Inspection on 03/11/09 for Ranvilles Nursing & Residential Care Home

This inspection was carried out on 3rd November 2009.

CQC found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ranvilles Nursing & Residential... 23/02/10

Ranvilles Nursing & Residential... 28/01/10

Ranvilles Nursing & Residential... 14/01/09

Ranvilles Nursing & Residential... 26/02/07

Ranvilles Nursing & Residential... 07/10/05

Ranvilles Nursing & Residential... 23/06/05

Ranvilles Nursing & Residential... 01/10/04

Ranvilles Nursing & Residential... 18/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 03/06/2010.

Key inspection report Care homes for older people Name: Address: Ranvilles Nursing & Residential Care Home 5/7 Ranvilles Lane Fareham Hants PO14 3DS     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sue Kinch     Date: 0 3 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Ranvilles Nursing & Residential Care Home 5/7 Ranvilles Lane Fareham Hants PO14 3DS 01329842627 01329847743 ranvilles@brookvalehealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Visram Limited Name of registered manager (if applicable) Mrs Debra Mills Type of registration: Number of places registered: care home 53 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users to be accommodated is 53 The registered person may provide the following category of service: Care home with nursing (N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: Dementia (DE) mental disorder, excluding learning disability or dementia (MD) Date of last inspection Brief description of the care home The home offers nursing care to older people with mental health difficulties. It is a large converted house in a quiet rural area near Titchfield. The home offers accommodation in both single and double rooms. The house is set in its own gardens with car parking for visitors at the front of the house. The fees for the home currently Care Homes for Older People Page 4 of 32 Over 65 0 0 53 53 1 4 0 1 2 0 0 9 Brief description of the care home range from 695 to 800 pounds per week. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The site visit for this unannounced key inspection was carried out by two inspectors and took 8.5 hours. The inspection was brought forward due to recent safeguarding concerns and use of local safeguarding procedures. Therefore this inspection did not include information about the service in an Annual Quality Assurance Assessment (AQAA) or surveys. We spoke with people, relatives, nursing and care staff and the management and had feedback from the safeguarding procedures and a care professional.We also considered information received from the home and about this home since our last visit in December 2008. We observed aspects of care practices and staff organisation. We sampled some of the records including care plans and risk assessments and those relating to staff. We viewed most shared areas of the home and a sample of private rooms.We also checked some of the home systems and procedures. Care Homes for Older People Page 6 of 32 What the care home does well: What has improved since the last inspection? What they could do better: There are many areas in which the home must make significant changes and we have made requirements about these. The registered manager must ensure that care plans are sufficiently detailed to: include all social, emotional, health and nursing issues; include the wishes needs and preferences of people living in the home; ensure that risks have been taken into account; and to provide clear staff guidance and ensure that it is followed through effective monitoring. The manager must ensure that staff promote dignity and privacy at all times in care practices and that confidentiality is maintained. Medication procedures in the home must be reviewed and action should include steps to ensure that secondary dispensing stops, and that all creams and supplements are recorded when administered. The home must use the Royal Pharmaceutical Society guidelines to ensure that accepted practices are followed. The registered manager must ensure that action plans are put in place following nutritional assessments and a system is in place to ensure that they are carried out and the effectiveness monitored. The registered person must ensure that all staff are clear about their responsibilities regarding safeguarding through provision of training and supervision, that all staff are aware of their responsibilities regarding infection control and ensure that matters such as aspects of cleaning, unpleasant odours and ensuring bins have lids, are addressed promptly. A system must be in place to monitor staff levels and ensure that sufficiently skilled care and nursing staff are in place to meet needs. An effective system must be in place to monitor the overall skill mix of the care and nursing staff and ensure that regular training is provided to meet needs of people living in the home including health and safety matters. Care Homes for Older People Page 7 of 32 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A process for assessing peoples needs before admission including consulting other professionals is in place but this does not lead to a comprehensive plan of care ensuring that their needs are met. Evidence: The home has recently voluntarily suspended admissions whist it is reviewing the policies and procedures within the home following some safeguarding matters that have been addressed through local procedures. During the visit to the home we viewed and found evidence of pre-admission assessments including care management assessments and information from other sources being obtained prior to admissions to the home. In two of the records viewed we noted that statements about mental capacity had not been completed and did not indicate if there were any advanced decisions or people with lasting powers of attorney to represent them.The home has a policy of telling relatives that the home does not do resuscitation but calls for medical services and consults relatives at admission about their views but the forms are Care Homes for Older People Page 10 of 32 Evidence: confusing and unclear as to what is being agreed and do not state that decisions made about this rest with the medical services. The home has been changing its procedures and in one of three new personal files in use we noted examples of changes being made to ensure that information is more person centred from admission and generally more detailed and addressing capacity issues in a more detailed way. We noted that initial care plans are written, using pre formatted sheets rather than person centred plans detailing how people may like their care to be provided, and have become the established care plan. In the sample viewed these did not adequately reflect the care needed by the people receiving the service from the beginning and identified in the assessments. The system to monitor and assess needs had not led to development of more detailed care plans. This is addressed in the section on health and personal care. Care Homes for Older People Page 11 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Through feedback from health and care professionals the management has recently realised the need to undertake a review of health and social care practises and training staff. But systems and procedures are not yet robust enough to ensure that needs are met consistently and risks minimised. Aspects of medication practises are not in line with national guidance meaning that there is a risk of errors and there is not always a clear record of medication administered. This leaves people living in the home at risk of not receiving all of the medication they need. Some practises in the home such as lapses of attention to confidentiality, mean that privacy and dignity are not always promoted. Evidence: Medication was observed to be held securely in the home and we were informed that the morning medication was carried out by two staff. The sample of records viewed of administration were completed. However, aspects of the medication system were Care Homes for Older People Page 12 of 32 Evidence: discussed with a nurse, nursing adviser and manager and we found some aspects of the medication procedures were not in line with national guidance. Named lidded pots were in use and it was confirmed that some medication is pre dispensed and then signed for by another nurse when administered. After this secondary dispensing was pointed out to the nursing adviser it was agreed that this would stop. This will reduce the risk of thicker elements of liquids settling in pots with the risk of some being left in the container and people not getting the full dose. A note was also seen in the medication storage cupboard to take care when pouring one persons liquids to ensure the correct dose was given as it was running out. This indicated that there was a risk of inaccurate doses being given. It was also noted that when additions are added to the medications sheet by nurses two signatures are not given to confirm the prescription. One person had been prescribed a supplement drink and this had not been signed for at all to show that it had been given. For another person it was recorded that regular moisturising was needed for their skin. On the medication sheet it was recorded as required twice a day. The records had not been completed except for on a couple of occasions meaning that the tasks may or may not have been completed and the effectiveness of the treatment could not be assessed. From conversations with staff, people living in the home, observations of practises, feedback from safeguarding procedures and a care manager, the management of the home and an observation of records, we note that recently the home has been reviewing the organisation, management and delivery of care. This has been prompted by safeguarding issues indicating that not all peoples needs in the home have been recognised and met by the homes systems. The home has subsequently had a lot of support and involvement of external health and care professionals to: review the way that care is delivered; to assess and review needs of some of the people with high support needs in the home; to recognise gaps in staff training, systems and levels; to revise the care planning process and increase the range of issues assessed and planned to be meet. Feedback from a care professional indicated the home has responded positively to the issues raised and is working on its improvement plan. The home has been supported to devise a new care plan format which is much more comprehensive but so far we were told that only three of the forty seven needed had been completed and the nursing adviser said that social services had required them to complete them by December 2009. However, we looked at the care and support provided to four people living in the home Care Homes for Older People Page 13 of 32 Evidence: and noted that for all of them the planned care was not sufficient to ensure that their needs would be met and we were concerned that they were at risk (this is referred to further in the section on complaints and safeguarding.)Their care plans were generic with little attention to individual needs. We also talked to staff about the care needed, met the people involved and talked with them where possible and viewed their rooms. Some examples of the issues we found follow. For one person there was no risk assessment or care plan for dealing with their aggression and behaviour that staff were challenged by and one aspect of the persons social and emotional needs were recorded to be ignored. A more recent record indicated that this need may now be followed up but it has not been met yet and the need was identified on admission to the home. The person had also been reported to have been concerned about how a staff member had behaved but this had not been followed up. For another person there was no clear plan for weight gain although the persons weight had dropped considerably since admission. Food and fluid intake charts were in place and a nutritional assessment completed but there was no clear plan of action for weight gain. Details of the pressure mattress requirements for this person were recorded but not in the bedroom for immediate access by staff and although there was a record of turning, clear guidance for this person was not in place.The records of turns indicated that the person may be left in the same position on some turns. A third person was in bed, upset and with a thin nightdress and covered with a sheet. The person had lost weight. The fluid and food intake was monitored but there was no specific management plan for nutrition and supplements. The care plan stated that a catheter was in use but it was not. Many aspects of the care plan were out of date including mobility issues and mental state. Bed rails were in place but a risk assessment was not available indicating whether they were to be used or not. The fourth person was wandering around the home and persistently trying to leave. Other than the provision of as required medication the care plan did not offer any other way of addressing this persons wish to leave. An occupation therapist report in April 2009 stated that the person enjoyed some activities such as sport but the daily record did not indicate that activities had taken place. The person was thin and had not been weighed since September 2009. The person had been prescribed supplements but there was no evidence that they were receiving them. An observation of accident records and discussion with the manager and nursing adviser showed that these had not been reviewed since August 2009. In discussion Care Homes for Older People Page 14 of 32 Evidence: with an inspector about accident records they agreed that some of the skin tears and bruising noted may have been a result of poor moving and handling practises. An accident recorded five days before our visit had not led to a review of the risk assessment for that person. While in the home we observed some caring, sensitive and good approaches from staff and note comments from a care manager that they have been positive about receiving help from outside agencies. One staff member told as that now they had the training about nutritional needs it was being put into practise. However, we observed in shared areas: people with their legs dangling from chairs in the lounge: one person was seen with wheelchair plates provided but feet dangling: several people had only socked feet exposing them to feeling cold or to accidents: one person was upset at being moved backwards in a wheelchair with one foot dangling; adequate monitoring of agency staff was not taking place by staff and the manager intervened to prevent one using a standaid on their own: incorrect use of a blue belt and being moved without using the brake on the wheelchair: several people given bibs long before eating and details of personal information being passed to a doctor in the lounge in front of others. Thickeners were available on the drinks trolley but nurses were not able to say what individual needs were and there were no speech and language therapist guidelines. All of these incidents indicate that more attention is needed to respect, dignity and peoples individual needs. Care Homes for Older People Page 15 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some mental stimulation and activities are provided in the home on a daily basis but there is not enough attention to individual needs meaning that people may be at risk of lack of stimulation. Work that has been taking place on assessing the nutritional needs of some people in the home has not yet led to a robust system showing that supplements and dietary needs are being met. Evidence: We were told by the manager and staff that the deployment of staff is arranged so that during the day activities are provided in the two lounges. A staff member said that this was not during the lunch period when staff are needed for supporting people with lunch. Whilst looking around the home in the morning we noted that there were staff providing craft type activities in both areas for those who wished to be involved. In the afternoon we noted that these activities recommenced at about 3pm. There is a cupboard of craft and games equipment available. Music was also being played in the afternoon. However, when considering our sample of people whos care we were assessing we Care Homes for Older People Page 16 of 32 Evidence: found that there was not much in the care plans about their individual social needs. One person had emotional and social issues that were not addressed and little was recorded in the care plan or daily records. The person had difficult behaviours and a more in depth assessment of social and emotional needs and more stimulation may have had a positive effect on this. Another person was recorded as liking television and as sociable. This person was on bed rest with no television or revised plan of care for these needs. An Occupational Therapy assessment in April for another person identified activities they would participate in, however we did not observe them doing any during the day and none had been recorded in the daily notes part of care plan. We observed, lunch being provided which looked appetising. One person commented repeatedly that the food was very good. We have already made some comments in the health and personal care section of the report about dignity at mealtimes and the use of bibs and people having to wait for food. We discussed aspects of the arrangements in place for meeting nutritional needs with staff. We noted that recent training for some staff had led to some nutritional assessments. We noted that the kitchen staff on duty were aware of the specific plans in place for two people to be supported to gain weight. The recent assessments had indicated that at least 10 people had been losing weight. We were told that when food is provided this is taken into account with items of higher calorific content offered. We noted some evidence of this and, for example some people in the afternoon were being offered ice cream. However, we asked for and were not shown, a clear plan or record for all people losing weight. This showed there was not a comprehensive action plan for each individual. As identified in the previous section of this report. We also found a lack of recorded of supplements given and no clear plan about how much to thicken drinks. If drinks were thickened too much it can affect peoples appetite and the overall the nutritional value of their intake. Care Homes for Older People Page 17 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. After recent safeguarding issues were brought to the managements attention they have attended meetings and recognised the need to ensure that staff are able to recognise and act on concerns. However, although changes are occurring not all staff are sufficiently aware of the action needed to be taken and need further supervision and training to maximise the protection of people living in the home. Evidence: We noted at our last inspection that the home has a complaints procedure. At this inspection the procedure was included in the contracts issued by the home although the address for CQC needs to be changed. We had information from some relatives who were not sure of the formal complaints procedure but said that they would speak with the manager if necessary. The home does usually routinely report events in the home to CQC. However since our last inspection a safeguarding issue arose through a complaint about the home and was brought to social services attention by a relative. Since then a further safeguarding matter arose from a visiting health professional after the investigating procedures had begun. The management of the home have been involved in addressing the matters raised and has attended safeguarding meetings. In response to matters arising the management have produced an improvement plan to address the many issues that the safeguarding process has identified as needing improvement to ensure that the people living in the home have their needs met and are in a safe Care Homes for Older People Page 18 of 32 Evidence: environment. This has included correcting or improving: use of pressure relieving equipment, management of pressure sores, care planning, meeting nutritional needs, addressing capacity issues and training in dementia and safeguarding. At the time of the inspection the management said that they had updated their action plan with some things still to be achieved. This plan also recognised the need to increase the nursing staff available to monitor the nursing needs in the home.However, currently evidence shows that insufficent action has been taken to ensure that that peoples needs are adequately met. We were also informed by a care practitioner from social services that the home was making a positive way forward following these safeguarding matters and that the home was willing to take support and guidance from the health and care professionals who had been involved. The safeguarding monitoring was still continuing at the time of the inspection and a deadline had been given by Social Services for compiling care plans for people with high needs by early December 2009. During our visit from observation, meeting a selection of people, talking about their needs and support with staff and viewing records, we identified a number of issues in the health and personal care section and subsequently informed the management of the home and made a referral about them to Social Services under the safeguarding procedures. One of the matters was raised as an immediate requirement and was followed up with a letter of serious concern. These matters are now being investigated. The registered provided has told us of action taken so far. The homes improvement plan included a recognition that the staff needed training in safeguarding. At the inspection when we asked to view training records we were told that these were not up to date. The area manager said that there had been some staff meetings since recent events and that this had included safeguarding. Also that three staff had received the training so far and that more was planned. In conversations with some nurses and staff during the inspection, although they identified the manager as someone to report to they did not have an adequate awareness of local reporting procedures so they could not demonstrate they knew what to do if they had concerns in the absence of the manager. Care Homes for Older People Page 19 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A rolling programme of upgrading and cleaning schedules are in place in the home but further attention to cleanliness and replacement of furniture is needed to ensure that people living there are in a clean and hygienic home and individual needs are met. Evidence: The external appearance of the home is of a well maintained house and garden. We viewed some of the internal private areas of the home and some shared areas. We were made aware of some of the changes to the internal environment that were ongoing and the manager said that there was a regular programme of refurbishment. An example of work planned was replacement of the dining room flooring to offer more resistance to slipping. Other changes were referred to as we viewed areas of the home and in the improvement plan. This showed that a number of the changes had occurred as a result of a review of the environment advised by professionals recently in the home. These included changes to the treatment area partitioned from one of the lounges. This now means that a dressing and treatment room is separated from another area used for consultation and hairdressing. Consideration is now also being given to extend privacy in this outer area which is only separated from the lounge by a net curtain. In some areas, including the lounge, there was evidence of stained carpets and some damaged walls and door frames. The hoists had created movement in the carpets increasing the risk of tripping. In the dining room the seats of chairs Care Homes for Older People Page 20 of 32 Evidence: were not clean. This was brought to the attention of the management. Cleaning staff are available in the home but not at weekends. Care staff said that they are allocated tasks by nursing staff but observation and discussion about a standaid which was dirty, and bins without lids in bathrooms, one of which contained clinical waste, indicated that current arrangements did not address all cleaning and infection control issues.We also noted, on the ground floor at the beginning and end of the day, an unpleasant aroma prevailed mostly in the corridor area. The management agreed to check this. We have been told of changes to some of the furniture including new pressure relieving mattresses and reclining chairs. We saw the pressure mattresses were in use. The chairs, on advice of the occupational therapist, are being bought gradually. Moving and handling equipment has also been bought to extend the range available in the home and to meet specific needs. On the advice of the Occupational Therapist foot plates are reported in the improvement plan to be in the process of being returned to wheelchairs. We noted an insufficient number of tables in the lounge for people to have drinks beside them. In bedrooms we noted that equipment is being provided to meet individual needs and but some matters need attention such as keeping information of the pressure required for pressure mattresses in each room. We noted that some beds had sides but these were not referred to in the care plans sampled. The nursing adviser said that all people in the home had them and agreed that whether they were used or not should be recorded to ensure that they are used safely. We also noted that staff did not provide one person with the call bell when planning to leave them alone in the room. The person was not mobile. The person subsequently rang the bell for some time requiring staff input but there was nothing in the care plan about how this person can access staff when needed. Care Homes for Older People Page 21 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recent safeguarding issues prompted the management to recognise that improvements were needed to the staff levels, including nursing staff, the skill mix and knowledge. Consequently changes are being made by increasing nursing staff and developing training systems but are not yet adequately established leaving some people at risk of their needs not being met. Recruitment procedures are still not robust enough meaning that people may be supported by staff not fully vetted. Evidence: Recent issues in the home has prompted the management to review staffing levels and they are recruiting more nursing staff including general nurses. The manager said that they are waiting for pre employment checks to be completed and that the aim is to have three nurses on duty in the day time and two at night. In meantime she said has increased nursing time on the floor including, at times, herself and the deputy. Rotas showed that over a two week period there has been an increase in nursing staff but three a shift has not yet been achieved on all days. The manager said that the home has an additional carer meaning that there are nine for each day shift in the short term until recruitment has taken place. This has meant use of agency carers until nursing staff is increased. Rotas supported this. Care Homes for Older People Page 22 of 32 Evidence: On the day of the inspection, in the morning, two nurses were on duty and one explained that they arrange to have one in the office dealing the doctors, visitors and so on and the other one is on the floor dealing with medication for about three hours and then time is spent on nursing duties. They will also be involved in improving care plans. From observation we noted this current arrangement when two nurses are on duty in the day time, does not not leave much time for informal supervising of staff and improving practises such as moving and handling. In addition changes needed in the administration of medication (noted in the section on health and personal care)will reduce the nursing time available on shift. Conversations and observations with the manager and staff indicated that carers are organised to work with specific people and this takes into account when people need support from two carers. One carer explained that they are given lists for each shift telling them who they should be supporting. We noted some sensitive and positive support from staff when supporting some people in various aspects of their care but other aspects of care noted in other sections of this report detracted from this. A requirement was made after the last inspection about recruitment of staff. The registered person must ensure that staff do not work in the home unless they have obtained all of the information and documents set out in schedule 2 of the Care Homes Regulations 2001, including two written references in relation to that person. At this inspection we looked at four files and noted that CRB and/or POVA First checks had been carried out before peoples employment commenced. However, but we found that for two people although references were obtained, they did not include one from previous employers which is good recruitment practise. For one of these people this meant that a reference had not been obtained from a care home previously worked in. A discussion about training was held with management who had identified training needs of staff in the improvement plan following the safeguarding issues raised. This included: ongoing training in the Mental Capacity Act issues and plans for all staff to gradually attend. Some initial training in tissue viability, moving and handling, care planning, nutritional assessments and safeguarding has been received.We were told that the training matrix is being updated identifying what training has been done and what is to take place. They said that a training programme was in place previously but the training scope has broadened to cover the gaps now recognised in training. This will take time to roll out and not all needs have yet been listed. An up to date record of training of all staff was not in place for use to view. Care Homes for Older People Page 23 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Lack of clear management arrangements and responsibilities and poor quality assurance had led to some health and care needs not being met and people put at risk. The management have started the process of change and improving health and safety but these are not yet fully embedded in practise to ensure that peoples needs are always met. Evidence: Since the last manager left in September 2009 the current manager has been managing the home and was registered in respect of it in July 2009. The registered manager has a Registered Mental Nurse qualification and therefore the deputy, Registered General Nurse, takes a lead in clinical nursing matters as required by CQC. Following serious safeguarding issues the manager and nursing adviser told us that way the management of the home is organised has been reviewed so that liaison between the deputy and manager has increased to keep the manager informed about clinical matters. Previous management arrangements had not been adequate and led to a risk of harm to people living in the home.The supervision of them is also reported Care Homes for Older People Page 24 of 32 Evidence: to have increased and other nursing staff have been given individual responsibilities such as over seeing wheelchair maintenance, medication and pressure care. As reported in other sections of this report there are systems and practises in the home that are still to be sorted out including as medication, training, care planning, care provision and quality assurance. The nursing adviser said that it had taken a long time to change previous practises in the home, that the management had learnt a lot recently and that they were on a steep learning curve following recent events in the home and by having input from a variety of professionals. She said that said that the focus of improvement has covered four areas, training, equipment, systems and the underlying approach to care. We noted that these areas are addressed in an improvement plan that had been provided by the home in August 2009 following the safeguarding matters arising and updated for a meeting in November 2009. A care professional told us that positive progress was being made. The home is monitored by the Responsible Person regularly under regulation 26 but a record viewed by us did not show detailed monitoring of nursing or care received or how the quality of management is monitored. A discussion was held with the responsible individual and manager of the home about the homes quality assurance systems failure to maintain required standards of care and clinical practises. The Responsible individual agreed that this needed to be reviewed and said he would consider involving the nurse manager in the monitoring. Some money is held for people in the home and this is for personal spending and is managed by an administrator and we noted that records and receipts for spending are maintained. The home does not have a clear record of training for staff in the home and this includes the aspects relating to health and safety such as moving and handling, infection control, and tissue viability.Plans now in place in respect of this are referred to in the staffing section of this report. In the environment section of this report we refer to further work needed to ensure that practises are safe and dignified. Care Homes for Older People Page 25 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 18 13 The Registered manager was 16/11/2009 required to make an immediate referral through the safeguarding procedures. This was to ensure that a specific matter was followed up. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 The registered Person must ensure that care plans are sufficiently detailed and supported by adequate risk assessments to ensure that needs are met. This is to ensure that peoples needs are met consistently 16/12/2009 2 8 12 The Registered Person must 16/12/2009 ensure that health needs are met through effective care planning processes which are monitored for their effectiveness. This is to ensure that health needs are routinely met. Care Homes for Older People Page 27 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 9 13 The Registered Person must ensure that proper arrangements are made for the recording, safekeeping,safe administration and disposal of medicines received into the care home. This is to ensure that people are receiving all prescribed medication. 16/12/2009 4 10 12 The Registered Person must ensure staff promote dignity and privacy at all times in care pratices and maintain confidentiality. This is to ensure that the dignity and privacy of people living in the home is respected. 16/12/2009 5 15 12 The registered manager must ensure that action plans are put in place following nutritional assessments and that a system is in place to ensure that they are carried out This is to ensure that all special diets are followed and fully monitored. 16/12/2009 6 18 13 The registered person must 16/01/2010 ensure that all staff are clear about their responsibilities regarding safeguarding Care Homes for Older People Page 28 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action through provision of training and supervision. This is to ensure that concerns are promptly followed up. 7 26 13 The registered manager 16/12/2009 must ensure that all staff are aware of their responsibilities regarding infection control and ensure that matters such as aspects of cleaning, unpleasant odours and ensuring bins have lids, are addressed promptly. This is to ensure that people are living in a clean environment 8 27 18 The registered manager 16/01/2010 must ensure that a system is in place to monitor the overall skill mix of the care and nursing staff and ensure that sufficient regular training is provided. This is to ensure that Staff are provide with the skills to meet needs. 9 28 18 The registered manager must ensure that a system is in place to monitor staff levels and ensure that sufficiently trained care and 16/12/2009 Care Homes for Older People Page 29 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action nursing staff are in place to meet needs. This is to ensure that sufficient staff with the appropriate skills meet needs. 10 29 19 The registered person must 16/12/2009 ensure that pre -employment checks include references from most recent employers and recent previous care employers. This is to ensure that people living in the home are protected by the homes recruitment checks. 11 31 24 The registered persons must 16/01/2010 use an effective quality assurance system to monitor care and nursing needs. This is to ensure consistency in meeting needs is maintained. 12 38 18 The registered manager must ensure all aspects of health and safety is implemented and monitored . This is to ensure that needs are routinely met. 16/01/2010 Care Homes for Older People Page 30 of 32 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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