Inspection on 05/10/09 for Rushey Mead Manor

This inspection was carried out on 5th October 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rushey Mead Manor 07/04/09

Rushey Mead Manor 14/01/09

Rushey Mead Manor 10/09/08

Rushey Mead Manor 02/10/07

Rushey Mead Manor 12/12/06

Rushey Mead Manor 03/05/06

Rushey Mead Manor 18/10/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Rushey Mead Manor 30 Coatbridge Avenue Rushey Mead Leicester LE4 7ZS Lead Inspector Diane Butler Key Unannounced Inspection 09:34 5 and 6th October 2009 th DS0000064260.V377853.R01.S.do c Version 5.3 Page 1 This report is a review of the 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. 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. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.2 Page 2 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 Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushey Mead Manor Address 30 Coatbridge Avenue Rushey Mead Leicester LE4 7ZS Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0116 2666606 0116 2660708 Midland Healthcare Ltd Manager post vacant Care Home 40 Category(ies) of Dementia (17), Mental disorder, excluding registration, with number learning disability or dementia (17), Old age, of places not falling within any other category (40), Physical disability over 65 years of age (5) Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No one falling within category OP may be admitted into Rushey Mead Manor where there are 40 persons of category OP already accommodated within this home. No one falling within category PD(E) may be admitted into Rushey Mead Manor where there are 5 persons of category PD(E) already accommodated within the home. No person to be admitted to Rushey Mead Manor in categories MD or DE when 17 persons in total of these categories/combined categories are already accommodated in this home. No person to be admitted to Rushey Mead Manor in categories OP, PD(E), DE or MD when 40 persons in total of these categories/combined categories are already accommodated in this home. No person who requires nursing care are to be admitted into Rushey Mead Manor in categories OP, DE, MD or PD(E) when 20 persons in total of categories/combined categories are already accommodated in this home. 18th June 2009 5. Date of last inspection Brief Description of the Service: Rushey Mead Manor is registered to accommodate forty older people in need of residential or nursing care. The home has a multicultural service user group and the staff team is also multicultural. Both English and Asian diets are catered for. There is a small temple and chapel situated in the building. Accommodation is on three floors with a lift and stairs for access. There are thirty-eight single bedrooms and one double bedroom. Two of the single bedrooms and the double bedroom have ensuite facilities. There are five lounges, two dining rooms, and one smoking room. The home is situated close to Leicester City Centre with good transport links and other local amenities. Current charges range from £380.00 to £475.00 depending on care needs and additional charges are in place for personal items such as newspapers, toiletries, and chiropody treatment. Details of what additional charges people can expect to pay can be found in the service user guide, which is available to everyone living at the home. A copy of the latest Inspection report is available at the home, or it can be accessed via the CQC website: www.cqc.org.uk. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.2 Page 5 Further information is available from the registered provider or acting manager. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use the service experience adequate outcomes. This key inspection took place over two days in October 2009. We (the Care Quality Commission or ‘CQC’) arrived at the home on Monday 5th October at 9.30am and completed the visit on Tuesday 6th October at 17:00pm. The inspection was unannounced and this means the service was not aware that we were coming. When undertaking key inspections CQC focuses on the outcomes for people receiving a service. In order to do this we case tracked four people receiving care and support. This means we checked records held in the office, spoke with them, relatives who were visiting on the day of the visit and care workers providing the care and support. An interpreter joined us for part of this inspection to enable us to gather the views of the people living in the home and observation was also used to evidence whether care needs were being met. Surveys were sent to ten people living at the service and ten members of staff to gather further views of the home and the service provided. Six surveys were received from people living at the service and their relatives and five staff surveys had been returned prior to this report being written. Comments received in the surveys returned included: Users of the service and relative Comments The home provides good care; meets ethnic needs and families are kept up to date with anything that concerns the residents Communication skills are very good between carers and nurse in charge. At present I feel the standard of the home has improved and the whole place looks clean and fresh. We need more activities. The staff look after me very well and my day to day care needs are met. Looks after me well and assists me with all my care. Would like more activities and outings. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.2 Page 7 Staff Comments The acting manager takes time to communicate with us and tell us everything going on with each resident and involves us as a person and respects us and our qualities. Some clients are concerned that the vegetarian meals are prepared in the same kitchen where meat dishes are prepared. Accommodates all, is run like a real home which gives residents a feeling of belonging rather than being in an institution. They could clean the garden and tidy up the place. I have observed very good nursing skills by the care staff; I have seen them work hard to give good person centred care. The staff are doing NVQs and asking to attend courses and are willing to extend their knowledge and share it with each other and help each other as a team. Further planning for the inspection visit included checking the service history of the service and last Inspection report and looking through the AQAA document (Annual Quality Assurance Assessment), which was submitted to the CQC prior to the visit. The AQAA document is the main way that providers inform us of how well their service is delivering outcomes for the people using it. We checked all the standards that the CQC have decided are key standards during this inspection. The information below is based only on what we checked in this inspection. We have kept details about individual people out of the report to make sure we respected their confidences. What the service does well: People living in the home are treated with dignity and respect at all times and care and support is provided in a relaxed and friendly manner. Recruitment processes ensure that all required checks are carried out before a new member of staff commences work in the home. This protects the people living in the home from possible abuse. Two menus are offered on a daily basis, one Asian, one English. Both menus offer a choice at every mealtime and meals can be taken ether in the main dining area, one of the lounges or in the person’s own room. Visiting is strongly encouraged; visitors are always made welcome and made to feel part of the home. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? We noted improvements within the care planning and risk assessment documentation although work is still required to ensure that they are accurate, complete and informative to the reader. Not all of the documents seen included all the relevant information, but spending time reviewing these documents would ensure that they were fit for purpose. A number of improvements to the environment have been made since our last key inspection. New carpets have been laid in the reception area and downstairs corridors. The communal lounges and dining area have been decorated. The gentleman’s toilet on the ground floor has been decorated, as has the smoking room and staff room. Bedrooms on the ground floor have been decorated and we were informed that the decoration programme and carpet replacement programme is ongoing. A key worker system has recently been introduced. People living in the home are now allocated a member of staff who is responsible for ensuring that they have everything they need and that records regarding their care and support are kept up to date and are accurate. Supervision of staff has re commenced and the acting manager is hoping to provide each member of staff with supervision in the next few months. The acting manager meets with staff on a daily basis to discuss day to day operations and offer support and guidance where needed. A number of training courses have been provided since the last key inspection including, safeguarding of adults, infection control and moving and handling. Training courses in dementia care and challenging behaviour have also been sourced from ‘Skills for Care’, (an independent registered charity working with providers to ensure that care workers have the knowledge and skills they need to carry out their role effectively). This will help staff to understand and work with people who show signs of aggression and dementia type illnesses. A quality assurance system has been re introduced. Questionnaires have been sent to people living in the home, their relatives and members of staff to gather their thoughts on the service being provided. Information received has been collated and a copy of the comments received has been placed with the service user guide displayed in the reception area. A thorough health and safety audit has been carried out on the premises and recommendations made have been addressed. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.2 Page 9 What they could do better: 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. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5,6 People using the 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’s needs are assessed, but obtaining or completing this assessment prior to admission would confirm that people’s needs could be met before they make a decision. EVIDENCE: Information is available to anyone interested in living at Rushey Mead Manor. A statement of purpose and a service user guide are displayed in the reception area and a brochure is also available. These documents inform the reader of the services that can be provided, charges that will be made and who a person should contact if they were unhappy about something. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 12 The service user guide is available in large print, but has yet to be made available in other languages as recommended at the last two visits. If these documents were made available in other languages it would enable the provider to meet the diverse needs of the people living in the home and those interested in living in the home. The brochure is currently available in both Guajarati and English. People who are interested in living in the home are invited to look around to see what facilities are available and whether it would be the right place for them to live. One person explained: “My son came and looked around and said that it offered a good service”. We were told that people’s needs are assessed before they move in to ensure that their needs can be met. We checked the records for two of the most recent people to move in and found little evidence to show that an appropriate assessment had been carried out. One file only included an initial assessment received from the person’s social worker, whilst the other only included a basic assessment dated four days after the person’s arrival. The acting manager told us that she had visited both people in hospital before their discharge, but had used the hospitals/social workers paperwork rather than completing her own. We were told that an assessment of need is now completed on all prospective users of the service and the acting manager explained that no one would move in until all the necessary paperwork was in place and she was satisfied that their needs could be met. Intermediate care is not currently provided at Rushey Mead Manor. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the 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’s needs are currently being met, but the necessary paperwork is not always completed accurately or in a timely fashion. EVIDENCE: We looked at some care plans to see if they contained all the information the nurses and care workers needed to meet the needs of those they were caring for. On the whole those checked did include relevant information to enable the nurses and carers to provide the appropriate support but some did not correspond with other documents and some needed to include more information. In one persons care plan it stated that they needed to have their blood sugars tested once a week, whilst their risk assessment stated that they needed to have their levels checked once a month. We spoke with one of the nurses Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 14 responsible for this task and she was able to confirm that this task needed to be carried out once a week and records confirmed this. We discussed this with the acting manager as it is vital that all records correspond with each other to avoid any confusion for nurses or care workers. We looked at the records for a person with pressure care needs. A care plan was in place and it was evident that this plan had been reviewed following the successful treatment of a second pressure sore. The care plan stated that the dressing for the current pressure sore should be changed every three days. We checked the records held and found that there were gaps in the recordings of the dressing changes, with one gap of eight days. We spoke to two nurses responsible for the dressing changes and were told that the dressings had actually been changed and they must have omitted to record this. We saw that they had involved the district nurse within the treatment plan and following the nurse’s recommendation to commence changing the dressing twice a week due to the pressure sore improving, no further gaps were present in the recording. Consideration needs to be given to the current monthly evaluation system of the care plans as not all care plans had been reviewed in September. Some risk assessments were seen and some of these were completed more accurately than others. Not all of the assessments seen included the actions the nurses and carers need to take to minimise the risk to the person, this included a risk assessment for a person on a pressure relieving mattress. Nurses are responsible for ensuring that the mattress is set at the correct pressure, but details as too the correct pressure was not recorded in the care plan or risk assessment and actions to take should the mattress malfunction or details of daily checks that currently take place were also missing from the documentation. We found one care plan without any risk assessments even though the person had been identified as at high risk of developing pressure sores and at risk of malnutrition. We checked the individual care plans for this person and found that although a risk assessment hadn’t been developed, the actions nurses and carers should take to minimise the risk had been included in the care plan. We discussed the importance of accurate risk assessing with the acting manager as it is crucial that all risks are identified and nurses and care workers are aware of the actions they must take to minimise any risk to the people they are supporting. We saw that improvements had been made to the fluid and dietary records for those at risk of malnutrition. During the last visit a large number of errors were evident in the recording. During this visit we found the records checked to be up to date and include what the person had drunk and eaten throughout the day. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 15 We checked the medication records of two people living in the home. Medication records were in order with a signature for each medication given. The nurse on duty was observed giving people their medication at lunchtime, this was carried out discreetly and without interruption. Controlled medication was being appropriately stored, with accurate records being kept. We were able to speak with a number of people who currently live at Rushey Mead Manor and a number of relatives during our visit and we were told that overall they were happy with the care and support provided. Comments received included: “Yes they do look after me very well”. “They treat us well, I am happy”. “I don’t think she is cared for so well, she says she doesn’t have a wash, they say she does”. “Any problems, I ask them and they take me to the doctors”. “They ask me what I want to wear”. “We are very happy here” Throughout our visit nurses and care workers were speaking to people in a respectful manner and providing care and support in an unhurried, relaxed and friendly way. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the 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 enjoy a varied diet, which meets their individual needs. A more committed activity programme would provide more stimulation than currently being offered. EVIDENCE: People are offered choices daily; these include when to get up and when to go to bed, what to wear, what to eat and when and where they wish to take their meals. One person explained: “Generally we eat in the hall, but if we ask they will bring it to our room”. Another person told us: “At 10:00am they bring us tea, if I ask for Masalla tea they will get it for me”. Specific religious and cultural needs are met. A cultural needs assessment is completed and preferences in daily living are on the whole identified and supported. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 17 We were told that care staff provide activities twice a day. No real activities were provided during our visit but activities that can be provided include games of skittles and ball games. A ‘Pat dog’ visits once every two weeks and craft classes are run alternate weeks. People living at the home have access to Sky television, providing Asian channels in one of the lounges whilst English channels are available in another lounge. Those spoken with shared that they were on the whole satisfied with activities currently offered though surveys received prior to our visit did show that some people would enjoy a more structured activity programme. One person stated: “We need more activities”. There are two cooks, cooking two menus each day, one Asian, one English. Both menus offer a choice at each mealtime and the meals served during our visit looked nutritious, appealing and hot. The menu on the 2nd day of our visit offered, guvar curry, potato curry, mixed dhal, rice and chapatti or chicken casserole, potato and vegetables. People who require special diets such as diabetic, soft or liquidised diets are catered for and supplements are provided if needed. Visiting is encouraged. Relatives and friends were visiting throughout our visit and they told us that they were able to visit at any time and were always made welcome. One person said: “I am made welcome and I know I can come at any time”. We spoke to a number of people and asked them what it was like to live at Rushey Mead Manor, they told us: “The food is very good and we get everything we need”. “I get up and if I want to watch TV in my room I can and I have my religious pictures in my room so I can worship”. “They try to talk to me in Punjabi”. “Sometimes if the staff have time they take me round the garden”. “If I want breakfast or tea in my room they come and bring it to me, they look after me very well”. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the 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 in the home know who to talk to if they are unhappy and feel safe and protected from harm. EVIDENCE: People are informed of how to make a complaint, or share a concern, when they move into the home and a copy of the complaints procedure is included in the service user guide and is displayed in the reception area. This procedure is not currently available in any other language than English. To ensure it is widely accessible to all, it should be made available in alternative languages for those whose first language is not English. We were informed by one visitor that they had not received a copy of this document. Everyone we talked too knew who to go to if they werent happy about something and everyone told us that they felt safe within the home environment they told us: “We would talk to xxxx”. [acting manager] Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 19 “We’re not shouted at”. “They treat us very well”. “I would talk to the ladies”. “Yes I feel safe”. “I would talk to whatever staff were around”. “I have no worries”. Nurses and care workers have received training in safeguarding of adults and are aware of whom to go to if they had any concern of any kind. We were told, “I would tell xxxx” [acting manager]. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,25,26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Ongoing improvements to the environment will ensure that people are provided with a clean and comfortable place to live. EVIDENCE: Accommodation at Rushey Mead Manor is provided on three floors. Some parts of the home are currently not in use, including a second kitchen, lounge area and a number of bedrooms on the first floor. These areas are secure and only accessible by staff. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 21 Further work has been carried out since our last visit to improve the environment. The downstairs corridors have been decorated and carpets replaced. The gentleman’s toilet has been decorated as have the bedrooms on the ground floor. Covers have been put on the radiators in the communal areas and these have been painted. The ground floor areas of the home were clean and tidy although the curtain in the reception area was in need of attention as it was hanging off. We checked the corridor on the first floor and noticed a strong smell of urine. The acting manager acknowledged this and explained that the domestic cleaner was due to clean the carpet that afternoon. The question was raised as to how effective merely cleaning this carpet would be. Two bedrooms visited also had strong smells evident. The acting manager told us that she was in the process of purchasing equipment to hopefully eliminate these odours. The downstairs bathroom was still in need of attention and we were informed that as soon as they were in receipt of the replacement parts for the shower, redecoration will begin. An ongoing decoration and carpet replacement schedule is in place and the registered provider told us that he was confident that all necessary work to bring the environment up to standard would be carried out. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the 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 in the home are protected by current recruitment practices. EVIDENCE: We looked at the staffing rota and this told us that there is a registered nurse and four care workers on the morning shift, a registered nurse and three care workers on the afternoon shift and a registered nurse and two care workers on the night time shift. People living in the home told us that they felt there were enough staff on duty to meet their needs, although one person did say that they sometimes had to wait a while when they called the bell at night. We looked at two staff files to see whether recruitment practices were followed. Both files included references and the necessary police checks and all these checks had been obtained before the person started work. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 23 The provider also checks the personal identification number or ‘PIN’ of each registered nurse employed to ensure that they are suitably qualified to provide the nursing care required. All new staff work through both an in house induction and a formal induction to make sure that they know how to provide the necessary care and support to the people living in the home. We looked at the training files of two members of staff to see what training had been offered since our last visit in April this year. We found that training in safeguarding adults, basic first aid, moving and handling, infection control, health and safety and basic food hygiene had been provided. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all records required by regulation are up to date or accurate. EVIDENCE: The current acting manager has been in post since June 1st June 2009. She is a registered nurse and has many years experience in the nursing field. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 25 We were told that the acting manager was always available for help and advice should staff need it. One nurse explained: “xxxx is always available, even if she’s not in the home, she’s only a phone call away, I feel very much supported”. We checked money held on behalf of one person to see if this was held in line with company policies. Accurate records were being kept, receipts were in place and the signatures of those involved in any transaction were obtained. We were told that supervision sessions had been re introduced for care workers and nurses. We saw the records for two care workers who had received supervision recently and the acting manager told us that it was her intention to continue to provide this to all staff. The registered provider explained that surveys had recently been sent out to people using the service, their relatives and staff, to gather thoughts on the service being provided. Comments included in the surveys returned have been collated and are included in the service user guide which is displayed in the reception area. Comments received included: “Things are much better since xxxx [acting manager] took over”. “The place is a lot cleaner than before”. “Feels whatever she brings up the problems are sorted straight the way”. Care workers and nurses are provided with health and safety training and a health and safety audit of the home has been carried out since our last visit. We looked at a number of records during our visit, it was noted that although there were some improvements since our last key inspection, there are still short falls that need addressing. These include ensuring that care plans are accurate and up to date, risk assessments need to be completed and include all the risks associated with the task and ensuring that daily records and evaluations are completed. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 N/A 18 3 3 3 X X X X 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1) Requirement The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – (a) needs of the service user have been assessed by a suitably qualified or trained person. (b) The registered person has obtained a copy of the assessment. An assessment of need must be obtained and carried out for all prospective service users. The registered person must satisfy themselves that they can meet the person’s needs. The registered person shall: Keep the service users plan under review. The registered person must ensure that care plans and associated documents are accurate and up to date. Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 28 Timescale for action 05/11/09 2 OP7 15 (2)(b) 05/11/09 Nurses and care workers need to have up to date information to enable them to care properly for the people in their care. Previous time scale of 18/06/09 was not met. 3 OP7 17 The registered person must ensure that daily records accurately reflect the care given to people living in the home. This is to ensure that people’s health and care needs can be accurately monitored and updated when necessary. Previous timescales of 18/06/09 not met. The registered person shall ensure that – Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The registered person must ensure that risk assessments are completed, thorough, and include all the possible risks associated with the identified task/risk. Care workers need to be aware of all the current risks to the people they support and the actions to take to minimise those risks. 5 OP26 13(3) The registered person shall make 05/11/09 arrangements to prevent infection, toxic conditions and the spread of infection at the care home. DS0000064260.V377853.R01.S.doc Version 5.3 Page 29 05/11/09 4 OP8 13(4) 05/11/09 Rushey Mead Manor The registered person must ensure that the premises are kept clean, hygienic and free form offensive odours. 6 OP37 17 The registered person shall maintain in respect of each service user records specified in Schedule 3 and Schedule 4 and these are kept up to date. The registered person must ensure that accurate records are kept for all care and support given to those in their care. 05/11/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The service users’ guide should be available in different languages to meet the diverse needs of the people living in the home. A committed activities programme should be made available to provide people with more stimulation throughout the day. The complaints procedure should be available in different languages to meet the diverse needs of the people living in the home. 2 3 OP12 OP16 Rushey Mead Manor DS0000064260.V377853.R01.S.doc Version 5.3 Page 30 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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