Inspection on 28/05/10 for Rosewell Country Home

This inspection was carried out on 28th May 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rosewell Country Home 19/02/08

Rosewell Country Home 24/05/07

Rosewell Country Home 23/05/06

Rosewell Country Home 15/11/05

Rosewell Country Home 13/07/05

Rosewell Country Home 10/03/05

Rosewell Country Home 23/09/04

Rosewell Country Home 11/03/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 03/09/2010.

Key inspection report Care homes for older people Name: Address: Rosewell Country Home Church Hill High Littleton Bath & N E Somerset BS39 6HF     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: Justine Button     Date: 0 1 0 6 2 0 1 0 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 40 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 40 Information about the care home Name of care home: Address: Rosewell Country Home Church Hill High Littleton Bath & N E Somerset BS39 6HF 01761472062 01761479124 rw2europeancare@aol.com www.europeancare.net European Care (UK) Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Gillian Galloway Type of registration: Number of places registered: care home 94 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: 6 Beds may be for young physically disabled persons age 18-50 years. Manager must be a RN on parts 1 of 12 of the NMC register. May accommodate one named individual requiring nursing care in the `Farmhouse` until such time as her nursing needs increase to the point that the `Farmhouse` is unsuitable to meet those needs, or she chooses to move May accommodate up to 40 persons aged 65 years and over requiring personal care only, in the Main House. May accommodate up to 60 persons aged 50 years and over requiring nursing care, in the Main House. May allocate up to 34 persons aged 65 years and over requiring Personal Care only, in the Farm House Care Homes for Older People Page 4 of 40 Over 65 94 0 0 6 Staffing Notice dated 18/04/2001 applies. Date of last inspection Brief description of the care home Rosewell Country Home is an extended farmhouse situated in the village of High Littleton. The accommodation consists of an open style conservatory entrance area, which links the Farmhouse and Main house. The conservatory area provides a focal point for the home, housing the main reception, hairdressing salon, manager?s office, service user seating, a piano and a small bistro. The accommodation in the farmhouse consists of single and double en-suite rooms (WC & hand basin) with 3 stair lifts and is registered for social care (residential) service users. Not all rooms in the Farmhouse have level access from the stair lifts The main house provides accommodation over three floors. There is lift access to all floors and each floor has a separate communal lounge and dining facility. Bedrooms vary in size, most are ensuite (WC & hand basin) and there are assisted bathrooms and shower rooms on each floor. The home is registered for a maximum occupancy of 94 but the usual operational maximum is lower than this because few of the 12 double-sized rooms are in shared use at any one time. The home offers respite care subject to bed availability. Care Homes for Older People Page 5 of 40 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 focus of this inspection visit was to inspect relevant key standards under the Commissions Inspecting for Better Lives 2 framework. This focuses on outcomes for people and measures the quality of the service under four general headings. These are:- excellent, good, adequate and poor. This inspection was carried out by two inspectors over a one and half days. During this time we, The Commission, were able to speak with people living and working at the home, tour the building, view records and observe care practices. We were given unrestricted access to all areas of the home and all records requested were made available. The registered manager was present over both days of the inspection. Verbal feedback was given at the end of the inspection to both the home and regional manager Care Homes for Older People Page 6 of 40 Some of the people who live at the home are unable to fully express their opinions, therefore some of this inspection was spent observing care practices and interactions. Feedback was obtained from some people living at the home who were able to give it. This feedback has been incorporated into the report. The home received a full key inspection in 2008 and a review in 2009. At this time the home was two star good. We have recently received a number of concerns and complaints about the level of care and support people at the home are receiving. These concerns have been made by local healthcare professionals including GPs, district nurses and healthcare professionals. This inspection was carreid out as a result of these concerns. In addition we met with Bath and North East Somerset County Council, the Primary Care Trust and the European Care Limited under Bath and North East Somerset Safeguarding policy. At the initial meeting it was agreed that social workers and district nursing staff would be reviewing the care and support afforded to all people at the home. At the time of writing this report these reviews have been completed. The information obtained from these reviews have formed part of the evidence in this report. An additional meeting has been completed to discuss any actions that will be required as a result of these reviews and the findings of this inspection. European Care Limited have stated that they are taking the concerns raised very seriously and are working hard to address any shortfalls. European Care have submitted an action plan to address the shortfalls raised in this report. Progress towards meeting these shortfalls will continue to be monitored by both CQC and the County Council under their commissioning responsibilities. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Care Homes for Older People Page 7 of 40 What the care home does well: What has improved since the last inspection? What they could do better: The concerns expressed to us included the number, skills and competencies of staff working at the home. This included the clinical skills of the registered nurses. During the inspection visit we confirmed these concerns. We were unable to ascertain the clinical skills of the nurses. Due to lack of clear documentation we are unable to see if adequate staff are on duty at all times. Although staff recruitment is satisfactory new staff, primarily the registered nurses were not receiving an adequate induction. Due to lack of staff with the necessary skills and competencies the health needs of people living at the home are not being met. This includes care of people at the end of their lives, those with wounds or pressure damage, people with mobility issues and those who require specialist diets. In addition we identified concerns with regard to the number of people who have or who are risk of loosing weight. The standard of meals at the home is satisfactory for the majority of people but not for those who require specialist or additional support . The care plans in place did not give clear guidance to staff on the needs of people at the home nor how these needs should be met. The home did not have suitable equipment to meet the needs of some people living at the home. This included pressure relieving equipment for the prevention of pressure ulcers. Although all required equipment has now been provided the management need to ensure that this continues to be the case. Some parts of the environment at the home is not of a high standard. One area of the home has a problem with recurrent malodours. There are no clear lines of accountability or responsibility from the registered nurses Care Homes for Older People Page 8 of 40 leading to a lack of leadership and direction within the home. The management has not been proactive in identifying shortfalls in the level of service and addressing any shortfalls. 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 9 of 40 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 10 of 40 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standards in this outcome group were not reviewed on this occassion. Evidence: The standards under this outcome area were not assessed on this occasion. At the last key inspection which was conducted in February 2008 it was reported that The home continues to do a comprehensive pre-admission assessment for each person who may be moving into the home. The manager and residential supervisor usually do the visits together; this enables them to make a joint decision about whether they can meet the persons needs. Information on the survey forms received from people living in the home were positive about this process. 14 people said that they received enough information about the home before moving in to make a decision about whether it was the right place for them, some people said on the forms that their families had helped to make a decision, and one person knew all about the home as they have lived in the area. On the homes annual quality assurance assessment form the manager Care Homes for Older People Page 11 of 40 Evidence: stated that they offer prospective service users/relatives various options to make them feel welcome. This could be a days trial free of charge, spending a holiday week with them so they could familiarise themselves with staff and the environment to see if it was right for them before they make a final decision, and also inform people about their website. The manager stated and staff confirmed that she informs them about anyone new who is moving into the home, and any difficulties they may experience. Care Homes for Older People Page 12 of 40 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. On the Residential side the needs of resident are being met. We could not confirm that the healthcare needs of people who required nursing care are being met. Medication Administration records do not meet with best practice guidelines. The care plans for people who require nursing care do not give clear guidance to staff on the needs of the individuals. Evidence: On the Residential side people are very satisfied with the care and support that they receive from staff. When we talked to people who live on the residential side of the home, they told us the staff are very helpful, kind and caring to them when helping them with their needs. Care Homes for Older People Page 13 of 40 Evidence: On the residential side of the home, there were many comments of satisfaction expressed by people living at the home and relatives about the care they receive and how they feel their needs are being met. Examples of comments made were ,the carers are brilliant, the staff are very good if you are incapacitated in anyway they do what they can to assist you, the staff are exceptional there is nothing they wont do to assist me, and the staff are doing very well, we have very good care. On the residential side of the home we observed care staff talk to residents in a warm and respectful way. We saw care staff supporting and helping people in a patient manner. The care staff we spoke to demonstrated that they had a good understanding of the needs of the residents who they were caring for. This show us that peoples needs are being properly met by the staff who are looking after them. Concerns have been expressed to us from district nurses social workers and relatives with regard to the care and support afforded to people living at the home. Although these concerns are extensive, the main concerns relate to the care of people with pressure ulcers. During the inspection visit we identified additional concerns with regard people who have or who are at risk of losing weight During the inspection we reviewed the care plans and care given to three people living at the home with nursing needs. In addition we reviewed aspects of the documentation (such as weight records) for a number of other people. We were also able to spend time observing staff interactions with people using the service and to speak with a number of people using the service. At the beginning of the inspection we observed one individual who was in bed. The individual looked very thin with a dry/dirty mouth. We reviewed a number of charts that were in place in the bedroom. These charts are used to record fluid dietary intake and positional change. The fluid charts showed that in the days preceding the inspection visit the individual had been supported to have between 270mls and 1,000 mls daily. 270mls in 24 hours is not sufficient and would leave the individual in a state of dehydration. The charts had not been totaled (or added up) each day so it is difficult to understand how the charts influence the care that staff provide. The individual had a dry dirty mouth. This may be due to being dehydrated but the individual toothbrush and paste were very dry this told us that they had not been used for some time. There was no evidence of mouth swaps or any other tools that could be Care Homes for Older People Page 14 of 40 Evidence: use by staff to complete oral hygiene. The lack of equipment leads us to believe that the individual had not been supported to maintain oral hygiene. The individual was on a pressure mattress (used to aid the prevention of pressure ulcers or bed sores.) In addition to the use of a pressure mattress a regular change of position is required to help in the prevention of pressure ulcers. People who are thin and who are unable to change position independently are at higher risk of developing pressure ulcers. Despite being on a specialist mattress and being thin on observation the records to demonstrate that the individual had been supported by staff to change position on a regular basis were spasmodic and not completed on a regular basis. For example when we entered the room the chart stated that the individual had been supported to change position at 03:00 onto their right side. The individual however was on their left side. The chart had not been completed to show this additional change. Staff would not be able to ascertain when this change of position had been completed so would subsequently not know when a further change would be required. Changes of position appeared to take place more regularly during night time hours. Those during the day appeared to be less regular and occurred only at meal times. Charts were in place to record the diet that the individual had eaten. The charts showed us that the individual was supported to have three meals a day. Breakfast, lunch and tea. The evening meal is served at around 17:30hrs. On some occasions the individual was not supported to have breakfast until 10:00 the following day. This is a period of fifteen hours. The charts did not record that any snacks or additional foods were offered. This is particularly concerning considering that the individual was of a low body weight. The diet charts in place did not give sufficient detail. For example the charts stated plate of pureed. This is not sufficient as it does not state the quantity or type of food. People who are at risk of loosing weight, have lost weight and have pressure damage should be offered small frequent meals which are high in protein and calories with snacks or possibly supplements offered in between. The charts did not demonstrate that this was the case for this individual. Given these findings it is difficult to ascertain how the charts influenced the care and support provided by the staff at the home and that the individual was receiving sufficient support from staff to prevent additional weight loss. We reviewed the care records for this individual. Despite records being available which showed that the individual had lost weight and at risk of pressure damage staff had not completed a nutritional assessment. A plan of care for this area had however been developed. This stated that the individual required supplemented drinks. These were not recorded on the diet charts kept within the room. We reviewed the Medication Administration chart for this individual which stated that a supplemented pudding had been prescribed by the GP. For the period 03/05/10 until 24/05/10 the chart had been Care Homes for Older People Page 15 of 40 Evidence: ticked as given for only four of the 21 days. The supplements ticked as given for these four days were not reflected on the diet sheets seen. It can not be confirmed given these findings that the supplements are being given as prescribed. This may place the individual at risk of additional weight loss. The assessments and care plans for this individual were ambiguous and did not give clear guidance to staff. For example the plan stated that the individual was nursed in bed. The plan stated that the individual required a two hourly change of position. This was not reflected in the charts seen in the room. The plan stated that staff should use a slide sheet to help support the individual to change position. A slide sheet was not observed in the room. Slide sheets come in differing sizes and should be used dependent on for example the weight of the individual. The plan of care did not state what size slide sheet should be used. The moving and handling assessment stated that a hoist and slide sheet should be used however the assessment was not stated nor signed so it is difficult to assess if the information contained in the assessment was still relevant. The assessment did not tell staff which hoist to use. Again slings for hoists come in various sizes. The moving and handling assessment did not tell staff which sling to use. This could place both the individual and staff at risk of injury if the incorrect sling was used. We reviewed the care records of another individual who was receiving respite care at the home. The care records were again ambiguous and did not give clear guidance to staff on the needs of this individual. The assessment sheet for this individual stated that he required assistance from staff with regard to his mobility. The assessment stated that the individual requires full hoist. Despite this, a full moving and handling assessment had not been completed. The records did not tell staff the hoist or the sling to be used. This may place the individual and staff at risk of injury if the incorrect equipment was used. The initial assessment stated that the individual required the assistance of care staff to complete personal hygiene and dressing. The plans however did not state what or how staff should provide assistance. The plans did not state any personal preferences or likes and dislikes for example toiletries the individual liked to use, what time of day they liked to get up or go to bed. The individual had a urinary catheter. There was no plan of care to inform staff how to care for the catheter, signs that may tell the staff that the catheter may need changing. People with urinary catheters often have a higher frequency of urinary infections. There was no information in the plan to tell staff how to recognize an infection or what to do if this occurred. This is even more critical as on reviewing the Medication Administration Record the individual was on a course of antibiotics usually used to treat urinary infections. People with catheters and infections need to increase the amount of fluid they drink. A care plan was in place for this aspect of the individual care however this Care Homes for Older People Page 16 of 40 Evidence: again did it give clear guidance to staff stating only encourage lots of fluids. The plan should state the amount of fluid that should be given in any 24 hour period. The initial assessment stated that the individual was at risk of choking. There was no care plan or risk assessment in place for this aspect of the individuals care. This could place the individual at significant risk if staff did not give the correct foods or supported the individual to sit in the correct position to eat. The initial assessment stated that the individual was at risk of developing pressure damage. Again no plan or detailed assessment had been developed for staff to follow. This should have included signs to look for when pressure ulcers are developing and the frequency that staff should support the individual to change position. The lack of care plans could increase the risk that the individual would develop pressure ulcers if the correct level of care was not given. We reviewed the charts held in the individuals room. The charts completed for diet confirmed that the individual was on pureed diet. This sort of diet is given when people are at risk of choking. The pureed diet was not reflected in the care plans seen. The individual looked of a relatively low body weight. The weight charts confirmed that this was the case. Given the risks associated with this and the risk of pressure ulcer damage it would be expected that the individual was supported to have a diet high in calories, protein and potentially supplements. It would also be expected that the individual would have frequent meals and snacks. The diet charts kept in the individuals room did not reflect this for example on two separate days the charts showed that the individual was supported to have breakfast and lunch. No other meals or snacks were recorded. As previously stated people with urinary catheters and or urinary infections should be supported to have increase fluids. The fluids charts showed that on one day the individual was supported to have 350mls in 24 hours and on another day 290mls. This would not be sufficient and may place the individual at risk of dehydration and exacerbate the symptoms of the urinary infection. Given that no apparent action was taken by the Registered nurses in response to the information obtained from the charts it is difficult to assess how they impact and influence the care and support provide by staff. Prior to the inspection a visiting healthcare professional had raised concerns about people living at the home with nursing needs. The visiting professional told us that for individuals who had pressure damage, appropriate equipment was not being provided. On the day of the inspection visit we reviewed this and found that all equipment had been provided. This was provided however only when the visiting professional had Care Homes for Older People Page 17 of 40 Evidence: raised concerns. This is concerning as it would be expected that the home would complete robust assessment and care plans for people living at the home and would have identified the need for any specialist equipment. We reviewed the care records for one person identified by the visiting health care professional. This individual had three pressure ulcer. There was no clear plan of care in place for the treatment and ongoing evaluation of these wounds. No sizes, tracings or photographs were available. It is difficult to ascertain therefore if the correct wound dressing were being used and if the wounds were deteriorating or healing. Despite having pressure ulcers the waterlow assessment (used to determine the risk of pressure damage) had not been reviewed since April 2010. It would be expected that when people are at high risk that assessments such as these would be reviewed at least monthly. The care plans in place stated that the individual was nursed in bed. However we had been advised that the visiting professional had recommended a pressure relieving cushion for the chair. This would not be required if the individual was nursed in bed. During the day of our inspection visit the individual was observed sitting in a chair. The plans of care did not therefore reflect the Care needs of the individual. The individual had lost some weight recently. Despite this there was not a clear assessment or plan for this aspect of the individuals care. We were unable to ascertain therefore if the individual was receiving sufficient diet and fluids to address both the weight loss and that required to help in the healing of the pressure ulcers. The individuals care had been reviewed by the funding authority in December 2009. In this review it is clear that the individual likes help and support from her husband. This however was not always possible. The funding authority had recommended that a plan of care be developed by the homes staff to support the care that the individuals husband gives her. This plan of care was not seen in the individuals care records. It is clear from the review by the funding authority that the individual was not always able to make decisions which effect her life. As such it would be expected that the care home would have implemented a plan, required under the Mental Capacity Act 2005, showing what decisions the individual could make for herself, how staff could support the individual to make choices and decisions and who should be contact if the individual could not give consent or choices about the care and support she was to receive. Such guidelines were not in place for this individual nor where they evident in any of the care records seen. As part of the inspection visit we reviewed the Medication Administration Records Care Homes for Older People Page 18 of 40 Evidence: (MAR) on one of the nursing floors. It was identified that one person was on a relatively strong medication used for pain relief. There was a hand written entry on the MAR which stated give regularly. It could not be confirmed who this order had come from. It was noted however that the medication had not been given regularly. We reviewed the care records for this individual there was no plan of care in place for any issues with regard to pain. There were no guidelines was to when the pain relief should be given. There was no evidence in the document where professional visits are recorded that the GP had given any directions or guidelines as to the phrase give regularly. Due to this it could not be confirmed if staff were giving the medication in line with advice from the GP, how to assess if the medication was required or how frequently the medication should be given. This could leave the individual concerned at risk and potentially in unnecessary pain. Creams and lotions are prescribed by the GP and therefore should be treated as any other medication. The creams and lotions seen in the majority of peoples bedrooms had not been prescribed for that individual. In some cases the prescription label had been torn off and in other a new name had been written by hand. As creams and lotions are prescribed a signature is required on the Medication Administration record (MAR) to confirm that they have been applied as per the prescription. This not seen on th day of the inspection visits. We reviewed the MAR for one person who had a pressure ulcer. The care plan described the dressing that was used however this was not seen on the MAR. Dressing for wounds are prescribed for the individual and should only be used for that individual. As there were no dressing on the MAR it is difficult to ascertain what dressing the care home staff were using. This may lead to a particular dressing not being available to staff. This in turn may impact on the healing of the wound if consistent dressing types are not used. Care Homes for Older People Page 19 of 40 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home can do a variety of social and therapeutic activities that are suitable for their needs. People living at the home are able to keep close contact with family and friends if they so wish. Evidence: There is an activities coordinator who works with the people in all parts of the home. We saw the activities co coordinator talking to people and engaging with them. We saw her engaging people with in a range of social as well as therapeutic activities that they looked to be very much enjoying. We saw people enjoying hand massages, having aromatherapy treatments and listening to classical music. We noticed that there were no obvious signs of therapeutic active taking place on the nursing side of the home. We were told that a second member of staff has just been recruited as a full time activities coordinator. This will ensure that residents can enjoy a full range of social and therapeutic activities thorough out the home We saw a game of Bingo take place in the afternoon of the second day of the inspection people looked as if they were enjoying the activity. Care Homes for Older People Page 20 of 40 Evidence: We saw the staff were welcoming in manner and were warm and friendly to residents and visitors on each day of the inspection. Mrs Galloway told us that there is a relaxed and open policy about visitors. We were told that resident can book in advance and enjoy a meal with their visitors in the Bistro area of the home .This is a good way for people living at the home to keep in contact with people who matter. We saw the flexible timetables of social activities for people throughout the home. The timetables help ensure people living at the home know what activities are taking place. We could see people can do a range of social activities. Recent activities included trips to the community for small groups. One person is regularly helped to get a Chinese takeaway delivered to the home as they really enjoy this food .This is a really good examples of supporting someone to enjoy what matters to them in their daily life. To find out about the quality of food that residents eat we sampled portions of both lunchtime meal choices. The meal choices were either chicken casseroles or quiche lorraine served with boiled potatoes, cauliflower and mixed vegetables. We saw people eating alternative meals who did not want the main meal options. The meals were tasty properly cooked and well presented. We saw a sponge and custard for dessert for the majority of people. We observed however that people who required a soft diet (usually those who have swallowing difficulties) received only custard for pudding. It could not be confirmed that this was the choice of the individuals. The manager agreed to review this at the end of the inspection. From the charts seen in some bedrooms it could not be confirmed that all people have meals or snacks at regular intervals. This is particularly noticeable between the evening meal and breakfast with long periods of time between the two. As previously stated a number of people at the home had lost weight or required a soft diet. We viewed the drinks trolley which was used to serve the morning and afternoon drinks. Biscuits were available on the trolley. These would not be suitable for those people requiring a specialist diet. The management need to ensure that a range of snacks are available. We looked at the menu and we saw a good range of meal choices that are balanced and varied. Care Homes for Older People Page 21 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are supported to make complaints about the service. There are systems in place to protect residents from abuse. Evidence: We saw an up to date copy of the complaints procedure on display in the reception area. The procedure includes our details for anyone who wishes to contact us directly. The contact details of the registered providers of the home are included if people at the home or their representatives wish to contact them to complain. People knew who to complain to if they were unhappy. We talked to the staff about how they support people if they thought they were unsatisfied or unhappy by the service. The staff demonstrated an understanding of their role in representing the views of people. We were told that there are residents meetings held regularly in the home .We saw a copy of the minutes of the last residents meeting. This is a good opportunity for people to complain if they need to. We looked at the record of complaints received to see how the home responds when complaints are made. There had been seven complaints received since the last Key inspection relating to care practices. We saw written information to show a senior Manager responds promptly to complaints. We saw a copy of the procedure in place relating to the issue of protection of Care Homes for Older People Page 22 of 40 Evidence: vulnerable adults from abuse. The procedure makes reference to the need to contact and be guided By the Local City Council Safeguarding team in the event of an allegation of abuse. In the last twelve months there have been three concerns that have been referred to the Safeguarding team. Two of the concerns were referred by Manager following their own internal concerns around specific care practice issues. One of the complaints we read about had been made in 2009 by a G.P. Concerns had been raised about an alleged lack of effective leadership form the registered nurse in the home. This complaint had been investigated at the time by a senior manager from European Care. It should be noted however that the concerns raised at this time are very similar to the concerns currently under investigation. Care Homes for Older People Page 23 of 40 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. People live in a home that is well designed for their specific needs. However the home is not fully clean and a part of the home has an offensive odour. Evidence: Rosewell is a purpose built care home that provides nursing and personal cares for up to ninety people. People who live on the ground floor largely have personal care needs. The first and second floor of the home is used for people who require nursing care. The building is wheelchair accessible and we saw that there are different types of adaptations in place to help assist residents and visitors with disabilities throughout the building. There is a lift for people to get to first floor and second floor. There are a variety of communal rooms. These include an activities room, a hairdressing salon, a spacious open plan lounge and reception area. We saw residents sitting in the communal areas looking relaxed and comfortable in the surroundings. Bedrooms on the ground floor look out onto either, the large central garden or a small garden by the entrance. We found that the bedrooms and communal rooms are spacious and the standard of fixtures and fittings are of a high standard. Care Homes for Older People Page 24 of 40 Evidence: We saw that the bathrooms have specially adapted baths to help people who may have reduced mobility to be able to bathe safely. We saw toilets are in close parts of the home near to communal areas and bedrooms. We found that the main kitchen being used to cook meals for residents was organised and looked to be well run. However we saw that the rubbish bin did not have a lid on it .The bin needs a lid for hygiene reasons, to reduce infection risks from rubbish in the bins. We also saw that the two fly extractors in the kitchen were not working. This meant there is an increased likelihood of flies getting into the kitchen area which can spread germs and infections. We saw that the kitchenette on the first floor in the dining room was not being maintained in a way that was fully hygienic. Specifically we saw a cloth that was dirty on the floor of the kitchenette; we saw a plastic tub of sugar with the top left of .We observed at least two flies in those areas. We saw milk that had been decanted into a plastic jug in the fridge with no label on it to say when it must be used by. We saw dirty cups and small dishes left in the sink in the kitchenette. The work surface in this area was in a poor state of repair being chipped and cracked. This would make the area difficult to clean and could harbour germs. We were aware on the nursing side on both days of the inspection there was a strong offensive odour in one area. We did see domestic staff cleaning that area during the morning and the odour slightly reduced. Concerns have been raised to us with regard to the supply of specialist equipment such as pressure relieving cushions and mattresses. These had been supplied by the home on the day of inspection. The management must, however, ensure that all people at the home have access to any equipment to meet their health care needs. This should be in line with assessed needs and the plan of care. Care Homes for Older People Page 25 of 40 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. Staffing levels may not be adequate to meet the needs of people living at the home. Staff at the home may not have the skills to meet the needs of people at the home. The induction of new staff is not always adequate Staff requirement procedures are robust. Evidence: The concern raised to us related to the homes ability to meet the healthcare needs of people who require nursing care. As such we reviewed the training files of the Registered Nurses employed at the home. In addition we were given a copy of the homes training matrix. The training matrix demonstrates which staff have undertaken mandatory training. We found that five of the registered nurses employed were not recorded on the training matrix. Some additional registered nurses had not completed all mandatory training. Registered Nurses are required by the Nursing and Midwifery Council to have regard to their own continuing professional development (CPD). The NMC guidance states that Care Homes for Older People Page 26 of 40 Evidence: Registered Nurses need to undertake at least 35 hours of learning activity relevant to their practice during the three years prior to the renewal of registration and to maintain a personal professional profile of the learning activity. In addition employers are responsible for ensuring that the staff that they employ have the skills, knowledge and competencies to meet the needs of the people for whom they provide support and care for. When we reviewed the files relating to the Registered Nurses it was very clear that none of the nurses have undertaken any clinical training for a significant period of time. As such it is unclear how the management ensure that the staff have the skills to support the people living at the home. The Registered Nurses may not be complying with the NMC guidance. The lack of recent training may have lead to the failing from some staff with regard to meeting peoples clinical needs. It should also be noted that a local GP surgery raised concerns to the management with regard to the ability of the staff. These concerns were made in 2009. At this time the management stated that they would review the concerns. The concerns with regard to the lack of clinical skills and training were expressed to the management of European Care at a safeguarding meeting following the inspection visit. It was agreed at this meeting that European Care would undertake an audit of the skills of the registered nurses and organise any necessary training required. We have been told that this training is currently being organised. It was apparent from reviewing the staff files that not all the staff had completed an induction when they commenced employment. For those of the Registered Nurses who had completed an induction no reference was made to the clinical duties or responsibilities that the Registered nurse undertake. This was also raised to European Care at the Safeguarding meeting. European Care have told us that as a result of these concerns that they will review the induction completed by the Registered Nurses. We will review this at the next inspection visit. In addition to the concerns with regard to the clinical skills of the staff we were told that at times there does not appear to be an adequate number of staff on duty. This related particularly to the numbers of registered nurses. As a result of these concerns we reviewed the staffing rotas for the four weeks preceding the inspection visit. The duty rotas showed us that there are were sufficient numbers of Registered Nurses on duty. This did not however take into account the skills of the nurses. Staffing should also be calculated on the numbers and dependency of the people living at the home. We saw that each person living at the home had a dependency score calculated in their plan of care. When we asked the manager if she had copies of these or how she monitored the dependency scores it was apparent that no formal monitoring was completed. The manager told us that she received verbal feedback from the staff with regard to dependency levels. This calls in to question why dependency scores are calculated if they are then not Care Homes for Older People Page 27 of 40 Evidence: used as working data. The management need to review how they ensure that there are sufficient numbers of staff on duty. We observed that the care staff were kind, caring and appeared to be competent in what they were doing but were lacking in leadership from the Registered Nurses at the home. We reviewed the files of three staff who had recently been employed at the home. These showed that robust recruitment procedures were in place. All checks including two written references and Criminal Record Bureau checks. Care Homes for Older People Page 28 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run by a manager who is very experienced and has been running the home for many years. The health and safety of residents and staff is protected. However the checks on the fire alarms are not being carried out often enough to ensure that they work and to keep people safe. staff supervision arrangements are not in place and up to date. Evidence: Mrs Gill Galloway has been the manager for over ten years. She has a significant amount of experience caring for people with a range of needs and learning disabilities. She is registered with us as the manager of the home. Mrs Galloway is supported in her role by a Deputy Manager who is also qualified nurse. Since meeting with us and representatives from commissioning organisations. PCT and Adult Social care, Care Homes for Older People Page 29 of 40 Evidence: European Care have told the home is being supported from manager from other homes, regional managers and the companies compliance and standards team. This support should help to address the concerns raised. The home holds a number of peoples money for safekeeping. We checked the records and cash of several people. We found that the records were well organised. The two financial administrators who we met explained to us the system they us to keep peoples money safe. It is evident that money is being looked after safely. We checked the fire logbook record and we saw that the required weekly and monthly tests of the fire alarms and the fire fighting equipment are being done. However we saw a gap in the record of fire alarm tests of four weeks between February and March of this year. This means there is no evidence that the alarm was tested during this time and could have posed a significant risk to people in the home in the event of a fire if the alarms had not been working. One of the complaints we read about had been made in 2009 by a G.P. Concerns had been raised about an alleged lack of effective leadership form the registered nurse in the home. This complaint had been investigated at the time by a senior manager from European Care. It should be noted however that the concerns raised at this time are very similar to the concerns currently under investigation. The company has its own quality assurance systems to monitor the quality of care. Monthly visits to the home in line with regulation 26 and numerous monthly audits, based on the National Minimum Standards, are undertaken. It is however concerning that audits and visits have not highlighted the shortfalls in the service identified at this inspection. Or if issues have been highlighted that action has not been taken by the company to address the shortfalls. Various staff meetings are held regularly. Records seen confirmed that these are usually well attended by most staff. It could not be confirmed if staff receive formal supervision. The nurses supervise a group of care staff each and the manager supervises nurses and senior staff. We requested copies of recent supervision for staff. The manager told us that supervision had not been completed for any staff recently and that she knew that this was an area that needed to be adressed. Staff supervision would have been a tool that the manager could have used to monitor the training and the clinical skills of all staff but particularly given the recent concerns the Registered nurses. At the safeguarding meeting following the inspection visit European Care have told us that staff Care Homes for Older People Page 30 of 40 Evidence: supervision arrangements have been reintroduced. All of the Registered nurses have now had a supervision meeting to discuss their training requirements. We will review this at the next inspection visit. Care Homes for Older People Page 31 of 40 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 7 15 The registered person shall 30/06/2008 ensure that care plans detail the health, personal and social care needs of each service user. Repeated requirement The registered person shall ensure that ventilation is provided in all parts of the home which are used by service users. Repeated requirement 30/06/2008 2 25 23(2)(p) Care Homes for Older People Page 32 of 40 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 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 All people living at the home 19/07/2010 must have plan of care that reflects their current care needs and gives clear guidance to staff on how to address these needs This will ensure that the healthcare needs of people living at the home are met. 2 8 12 People who have wounds or 21/07/2010 pressure ulcers should have a clear plan of care detailing the treatment, care and support required. This should give clear updates on the progression of the wound and the response of staff to this. This will ensure that people with wounds and pressure ulcers receive appropriate treatment and care. 3 8 12 People who require staff support with regard to mobility should have a clear 21/07/2010 Care Homes for Older People Page 33 of 40 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 risk assessment and plan of care detailing the support required and the equipment to be used and the frequency of positional change . This will ensure that people are supported appropriately. This will help reduce the risk of injury to both people living at the home and staff. 4 8 12 People who are risk of choking are supported with diet and fluids in line with a completed risk assessment and up to date care plan This will ensure the safety of people living at the home and ensure that people receive the correct support and care 5 8 12 People at the home should be supported to complete oral hygiene in line with the assessed need and plan of care This will ensure that peoples preferred level of personal hygiene and maintains peoples comfort 6 8 12 Charts and records used to monitor care such as fluid charts, positional change charts and nutritional charts 21/07/2010 21/07/2010 21/07/2010 Care Homes for Older People Page 34 of 40 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 are completed accurately where applicable This is required so that the health care needs can be monitored and appropriate care and support provided 7 8 12 Staff at the home should 21/07/2010 ensure that all people have a nutritional assessment and are provided with diet and fluids in line with this assessment. This will ensure the healthcare needs of people living at the home 8 9 13 Action must be taken to 21/07/2010 ensure that medicines are given as prescribed and that accurate records are kept of all medicines given by staff, including creams and ointments. If regular medicines are not given a reason must be recorded. This is to safeguard peoples health and ensure that medications are given as required. 9 15 16 Snacks should be available to all people at the home. This should include those on specialist diets. Snacks should be given in line with the plan of care 21/07/2010 Care Homes for Older People Page 35 of 40 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 This will ensure that people on specialist diets have access to a range of snacks. 10 15 16 People should be supported 21/07/2010 to have meals and snacks at regular intervals. This will ensure that people have access to sufficient amounts of diet and fluids 11 22 13 The management must ensure that the home is adequately equipped to meet the needs of people living at the home. This should include pressure relieving equipment This will ensure that staff can meet the needs of people at the home. 12 26 16 Food and beverages in the kitchenette must be stored hygienically. . This will reduce the risk of cross infection and ensure hygiene levels are maintained 13 26 16 Any environment within the home used to cook and prepare or serve food must be safe and suitable and hygienic . This requirement relates to 02/07/2010 02/07/2010 21/07/2010 Care Homes for Older People Page 36 of 40 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 the need to ensure the risk from flies and insects are minimised and the need for a bin that hygienically stores rubbish. 14 26 15 The kitchenette on the first floor nursing area must be updated and refurbished This will ensure it is easy to clean and reduce the risk of cross infection. 15 26 16 Action must be taken so that 30/06/2010 the home is free from offensive odour This will ensure that the home is pleasant place in which to live and work. 16 30 18 All staff should receive all mandatory training according to their job role. This may include moving and handling, fire training, Abuse prevention, health and safety and Control of Substance Hazardous to Health (COSHH). This will ensure that staff can safely meet the needs of people living at the home 17 30 18 All new staff employed should complete a robust induction in line with best practice and the position to which they are employed. 21/07/2010 21/07/2010 19/07/2010 Care Homes for Older People Page 37 of 40 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 This will ensure that all new staff are adequately supported and develop the skills to meet the needs of people at the home. 18 30 18 The management should complete an audit of the skills of the registered nurses. Where training needs are identified the management need to develop a plan as to how these training needs will be addressed This will ensure that staff at the home can meet the needs of people living at the home. 19 33 24 Quality Assurance systems must be more robust. The quality assurance systems must review care planning, staff supervision, staff training and dependency levels. To ensure that shortfalls in the service are identified and action is taken to address them. 21/07/2010 21/07/2010 Care Homes for Older People Page 38 of 40 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 1 7 The care plans should demonstrate that due consideration to the mental capacity act has been given. The plans should detail if the individual has capacity to make decisions which may effect their lives. If people have been assessed as lacking capacity then the plan should clearly state who will make decisions on their behalf. People who have nursing needs should be supported to undertake social and recreational activities according to their assessed needs and wishes. A system of staff supervision should be in place to support the staff and to help to ensure that staff have undertaken adequate training. The management must ensure that the fire alarm system is checked as and when required in line with the homes fire assessment . 2 12 3 36 4 38 Care Homes for Older People Page 39 of 40 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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