Inspection on 28/05/09 for Ryland View

This inspection was carried out on 28th May 2009.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ryland View 27/08/09

Ryland View 25/11/08

Ryland View 25/06/07

Ryland View 11/09/06

Ryland View 10/01/06

Ryland View 20/04/05

Ryland View 18/01/05

Ryland View 18/01/05

Ryland View 18/01/05

Ryland View 18/01/05

Ryland View 12/01/05

Ryland View 21/04/04

Ryland View 21/04/04

Ryland View 20/04/04

Ryland View 20/04/04

Ryland View 19/04/04

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Ravenhurst

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Inspirations

Ashcroft Hollow Nursing 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 Name: Address: Ryland View Arnhem Way Great Bridge West Midlands DY4 7HR     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: Jean Edwards     Date: 2 9 0 5 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 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) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 40 Information about the care home Name of care home: Address: Ryland View Arnhem Way Great Bridge West Midlands DY4 7HR 01215201577 01215570859 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.bupa.com BUPA Care Homes (CFHCare) Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 140 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability terminally ill Additional conditions: One service user identified in the variation application of 29.11.04 may be accommodated on Manby Unit who is 56 years and over. This will remain until such time that the identified service users placement is terminated and whilst the home is able to meet her needs. That 14 elderly (OP) service users and 10 service users with a terminal illness (TI) be accommodated on Bloomfield Unit. That 26 physically disabled (PD) service users 18 years and over will be accommodated on Palethorpe Unit That 30 service users who are elderly and do not fall within any other category (OP) who are 58 years and over will be accommodated on Haines Unit. Care Homes for Older People Page 4 of 40 Over 65 60 44 0 0 0 0 26 10 That 30 service users with dementia (DE)(E) 58 years and over will be accommodated on Heronville Unit That 30 service users with demetia (DE)(E) who are 58 years and over will be accommodated on Manby Unit. That the variation granted on the 5 September 2005 for one male service user with learning disabilities who is over 65 years and will be accommodated on Palethorpe House, will only be for the lifetime of that identified service user and whilst the home is able to meet his needs. The variation granted on the 31 May 2006 for one male service user who is 54 years will only be for the lifetime of that identified service user and whilst the home is able to meet his needs. There will be two registered nurses on duty at all times between 09.00 to 21.00 hours on Bloomfield Unit Date of last inspection Brief description of the care home Ryland View is a large nursing home owned by BUPA, with ample car parking in the grounds. It is located near to Tipton and is accessible by car and public transport. Each unit has its own garden area. Care can be provided for up to 140 people in five separate, purpose built and spacious bungalows, called Bloomfield, Haines, Manby, Palethorpe and Heronville. Bloomfield can have up to 24 people, who are 58 years old and above, 10 of whom may require palliative nursing care. Haines can have up to 30 frail older people needing nursing care. Manby and Heronville can each have up to 30 older people who have dementia. All bedrooms are single occupancy and there are 4 en suite bedrooms on Bloomfield. There are toilet and bathroom facilities near to bedrooms on other units. Each unit has a large communal lounge, dining room and small quiet lounge. Bloomfield and Palethorpe have an additional lounge. Bloomfield has a large meeting room also used for teaching sessions. Each unit has a small kitchenette, which can be used to make drinks and snacks. There are aids and adaptations such as grab rails, assisted baths and hoists available on each unit. The administration offices, central laundry and kitchen are situated in a separate block. 2 8 1 1 2 0 0 8 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 last key inspection took place from 26 to 29 November 2008. We, the Care Quality Commission, (CQC), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. Three inspectors spent a total of two weekdays at the home, accompanied for part of the inspection by a CQC pharmacy inspector, who spent a day at the home. We monitored the compliance with all Key National Minimum Standards at this visit. The range of inspection methods to obtain evidence and make judgements included, discussions with senior managers from BUPA, the registered manager, a new acting manager, unit managers, and staff on duty during the visit. We spoke with people living at the home and made discrete observations of people unable to talk to us. We examined of a number of records. We also spoke to relatives visiting the home. This home had lacked clear direction and stability for some time and received a poor, zero star quality rating at the inspection in November 2008. Care Homes for Older People Page 6 of 40 Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the former CSCI. We looked around the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. The range of fees for the service was published in the service user guides for each unit. The weekly fees ranged between £470 to £1130, dependant on the assessed individual needs of each person, and the type of room occupied. Items that are not covered by the fee included toiletries, hairdressing, chiropody and newspapers. People are advised to contact the home for up to date information about the fees charged. Care Homes for Older People Page 7 of 40 What the care home does well: What has improved since the last inspection? Having looked all of the evidence from the previous inspection, we could see improvements in all areas, although there was still some work to do with the end of life planning for people. Where we identified areas for improvement in record keeping, the staff we spoke to were able to tell us about the missing information. This appeared to be an improvement since the last inspection. The organisation had implemented an improvement plan with more effective monitoring systems in place. A new experienced acting manager had recently been appointed and there was extensive senior managerial support to make sure improvements required at the last inspection were developed and maintained. The staff and people who had lived at the home for some time told us lots of things had improved. An example was more staff on Bloomfield, allowing more time for each persons care, though this was not demonstrated on Haines and Palethorpe units. There was improved access to activities, with activities organisers arranging in house activities and outings. These have been expanded and individual activities planners put in place for each person, which generally relating to their preferred individual activities. Care Homes for Older People Page 8 of 40 Social contact had also been improved for people being cared for in bed or in their bedroom, with records kept to show refusals and any alternatives offered. Though this is an area, which could improve further, for example we heard that some people were bored at times. The organisation had improved they way complaints were handled and there were improved records of investigations, outcomes and satisfaction levels. We made the management aware of someone who spoke to us and remained dissatisfied. We recommended that the home improved communication with this person. There were improvements to the protection of vulnerable people at the home, with more proactive safeguarding referrals made to the lead agency, Sandwell Safeguarding Manager and appropriate notifications to the CQC without undue delays. This meant that vulnerable people living at the home were now generally better protected from risks of harm. There were considerable improvements to the environment on Bloomfield and Heronville, and 18 additional nursing profile beds, comfortable armchairs and other furniture had been provided as part of a rolling programme of refurbishment. We noted improvements to the analysis and evaluation of accidents. This meant that any trends or increased risks could be identified, and where possible be controlled and minimised. There were other significant areas of health and safety and fire safety at the home, which had been improved. These included safety checks for bedrails, fixed wiring and emergency lighting had been satisfactorily concluded, and all staff, especially night staff had received up to date fire training and participated in fire drills. The other agencies such as the West Midland Fire Service and Health and Safety Executive were also satisfied with the level of compliance. What they could do better: All of the people had care plans and risk assessments in place but the registered persons need to make sure that all of the information is easily accessible for staff to read. We looked at care files and found that people had care plans that were repetitive and recorded on at least two plans. The staff should not be afraid to remove care plans that were no longer relevant. We found evidence of some poor outcomes for people during this inspection, and there must be further improvements to make sure that all needs are being met. Examples were, one person was not receiving pain relief, there was no care plan for a person with a catheter, and there should be more detail in the plans for someone needing oneto-one monitoring. Despite these shortfalls there were positive aspects in that the staff on the units were aware of the peoples needs. At the last inspection there were a considerable number of areas of medication administration and recording, which we required to be improved so that there was assurance that everyone living at the home received their medicines as prescribed. Although there were improvements with the way peoples medication was being managed and administered, notably on Bloomfield, there were repeated serious failures, notably on Manby and to a lesser extent on Haines, where medication in the mornings was particularly protracted. There were also medicines, which were not available. This meant that some people were not receiving some of their medication as prescribed by their doctor at the right time. At the last inspection we received some comments, which indicated that soft diets and pureed diets were bland and repetitive and we recommended that improved meals Care Homes for Older People Page 9 of 40 should be introduced. However the food we saw presented and we sampled for soft and pureed diets was unpleasant and unpalatable. The new chef gave assurances improvements would be made. We will review the meals at the next inspection to test out the validity of the assurances given. We were told that there was a planned refurbishment due to take place but we were not given a timescale. A repair, renewal and maintenance plan had been put in place since the last inspection but there were some areas of the home, which needed prioritised attention. For example there were bathing and toilet facilities, with doors not closing properly and unguarded radiators, which did not provide privacy and safety on Palethorpe unit. The organisation had reviewed staffing levels on each unit, and whilst there were improved levels of care and attention on some units, on others, such as Haines and Manby we were aware of people waiting unacceptable times to get up or be assisted with meals and drinks. We discussed these concerns with the management, who acknowledged them and gave assurances they would monitor the deployment and management of staff time on these units. The registered persons must also make the recruitment of new staff more rigorous, exploring any anomalies in documents. Systems must be out in place to keep track of expiry dates of overseas staff work permits and visas to allow them to remain and work in the UK. The organisations must also implement systems to hold sufficient information about agency staff to safeguard people living at the home. We made the management of the home aware that a CQC management review would be held to consider what further action might be needed to make sure there is full compliance with all requirements. This relates particularly improvements to the management of medication to maintain the health and well being of people living at the home. 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 10 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 11 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is published information about the home and the home has comprehensive assessment tools. People wishing to live at the home can generally be assured their needs can be met most of the time. Evidence: We looked at copy of the homes statement of purpose and service user guides, which had been updated in August 2008. The documents contained comprehensive information and each unit had an individual service user guide. We recommended that the admission criteria for each unit should be included. This information was important because each unit accommodated and cared for people with very different needs and would give people comprehensive information about the service to help them make decisions about the choice of home. We saw that that each person living at the home had access to their own copies in the Welcome Pack in their bedroom. The organisation included information about the range of fees in the service user guides. Care Homes for Older People Page 12 of 40 Evidence: We looked at the care records for people admitted to the home since the last key inspection. The homes administrator provided us with evidence that the BUPA contracts, terms and conditions had been issued to everyone admitted to the home since November 2008 and there was a process to ensure that everyone living at the home would be given contracts with up-to-date terms and conditions and information about their individual fees. The contracts did not include reimbursement for the free nursing care element, Registered Nurses Care Contribution, (RNCC), as previously recommended. There was evidence that everyone, except the people admitted to Bloomfield unit for palliative care, had a detailed assessment of their needs before they came to live at the home. The records we looked at showed that whenever possible the person or their representatives were involved in the assessment of needs, risks and planned care. The QUEST, an assessment and care planning system, implemented by BUPA, encouraged staff and people receiving the service to take part in the assessment of their needs, and there was generally improved consistency with the information recorded, which meant that peoples needs were less likely to be misunderstood or left unmet. There was evidence that the staff were using the BUPA QUEST documentation more consistently completed. We also noted that generally as peoples needs changed appropriate referrals were made to multi disciplinary professionals for reassessments, guidance and support to meet their needs. We saw evidence that the previous recommendation, to provide additional specialist training for staff, had been actioned and the majority of staff on Palethorpe unit had received training in alcohol related dementia, mental health topics and learning disabilities. When we spoke to staff on this unit we noted that they were knowledgeable and confident in recognising and understanding the needs of people living in Palethorpe. There were improved mechanisms and evidence to show that staffing levels were generally monitored and revised proactively in accordance with occupancy and dependency levels of people living on each unit. For example we noted that there was an extra care assistant on duty for the early shift at Bloomfield and staff told us this had made a considerable difference to the way they were able to respond to peoples needs. However this was not the case on all units and our observations at Haines and Manby showed that the allocation and management of staff were disorganised. This meant that in some instances increasing needs and dependency levels resulted in people not receiving the care they needed. We received comments from discussions Care Homes for Older People Page 13 of 40 Evidence: with people living at the home, relatives, and staff that at times the home was short staffed and people did not always receive prompt attention. Care Homes for Older People Page 14 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. There are care plans and risk assessments, which provide staff with guidance and are generally adequate to met peoples needs. There are not always assurances that all individual needs will be met for each person. The arrangements for administration of medication do not ensure that every person at the home receives their medicines as prescribed by their doctor, which poses risks of harm to their health and well being. People are generally treated with respect and courtesy, with rights to privacy and dignity maintained. Evidence: We looked at of care records for a sample of people living in each of the five units. There were considerable improvements, especially at three units, in the way the BUPA QUEST documents had been used to assess and plan to meet each persons needs. The majority of care plans we saw were person centred and demonstrated people and / or their representatives had been involved in developing the plans for their care and Care Homes for Older People Page 15 of 40 Evidence: support. There were less variances in how well the healthcare screening tools, risk assessments and care planning were implemented, monitored and maintained. This meant that generally persons living at the home could feel assured that all their care needs were known about, understood and would be met. All units had a number of people with complex needs. Haines, Manby, Palethorpe and Bloomfield had a number of people needing to be nursed entirely in bed, and some of these people required end of life care. It was positive to note that the organisation had responded to the requirement made at the last key inspection in November 2008 and had provided 18 new nursing profile beds. This meant that people were being cared for in beds, which minimised some of their discomfort, especially when needing a change of position. The managers present at this inspection told us that additional nursing profile beds were on order. We were worried that not all units had made the same positive progress. Notably the care provided and care records on Haines unit were disorganised. For example, in one persons care file though we eventually found that all the information needed, it was difficult to follow and actions had clearly been overlooked, which resulted in her needs not being met. We noted that this persons condition had deteriorated in a short space of time, and this person had lost weight and had developed numerous pressure ulcers, despite pressure relieving equipment and involvement of the GP and tissue viability nurse specialist. Whilst it was positive that there was a revised plan nursed in bed, the lifestyle profile, was out of date and inaccurate, stating gets up at 10:30 a.m., breakfast in room, reads daily paper, watches TV, lunch in bedroom, goes to bed around 1700 hrs. We also noted in the records that on 11/5/09 the GP had requested (Methicillin Resistant Staphylococcus Aureus)MRSA screening, however there was no indication that this has been done or any evidence of the result in the records. The quality manager gave us information later in the first inspection day that the screening had been done and a bacterial infection had been identified. She assured us that the GP had been requested to visit and the appropriate antibiotic would be prescribed. We made it clear that it was not satisfactory that no action was taken until prompted by inspectors, this was acknowledged by managers from the organisation. Furthermore, this person had a recorded weight loss of 5.5 kg since May 2009, she still remained on nursing care plan A for eating and drinking, which did not prompt further intervention. We were told that there were records of change of position, but there were no food or fluid charts in place. We observed this person in their bedroom and noted a bowl of cornflakes congealed and not eaten on the over-bed table out of reach, with a beaker of cold tea, recorded as offered but nothing recorded as taken. The person with a very dry mouth, unable to reach the drink or breakfast was Care Homes for Older People Page 16 of 40 Evidence: observed crying in pain but could not say where. The medication records showed that this person had not received any pain relieving medication for at least four days, since the new (Medication Administration Record) MAR chart started. The quality manager told us later in the day that food or fluid charts had been put in place and the GP had prescribed soluble pain relieving medication. We again stressed that it was not satisfactory, that staff took no action until prompted by us. On the same unit we looked at the end of life care being given to someone being nursed in bed. We observed that the person looked very frail, with dry, flaky skin and we noted that there was a beaker of cold tea on the over-bed table. There were fluid balance records in place in the bedroom, with fluid intake and output from catheter recorded. However though the total fluid intake looked adequate there was only one entry for urinary output and no total or variance recorded for the 24 hour periods. This meant the monitoring of this persons condition was not effective and their needs were not being met. The accuracy of the records could not be relied on and other complications could have been missed. We discussed the implications with the quality manager and the acting manager who acknowledged that the incomplete information would result in the persons condition not being monitored or managed for their comfort. The care records and delivery of care on Bloomfield unit, which provided palliative care and care for frail older people were generally excellent. On the sample of care records we saw that the end of life care plan considered psychological, physical, spiritual needs. There was documented involvement of family with no restrictions, and arrangements for overnight stays as needed. There were also anticipatory prescriptions in place for symptom control and the advanced care plan documentation was in place for when needed. We looked at one persons daily records, which were generally well completed, however only 4 feeds, instead of the presribed 5 feeds, had been administered on 27/5/09 and there were three days where it was not recorded that the enteral feeding tube had been rotated 360 degrees. We discussed these omissions with the unit manager, who acknowledged the deficits in the records and gave us assurances that these omissions would be investigated and dealt with. We talked to a small number of people staying on Bloomfield unit for respite care, they told us that they were impressed with their accommodation, that they liked the food and that they found the staff wonderful, friendly and helpful. The care records and delivery of care to people living on Palethorpe unit, for younger Care Homes for Older People Page 17 of 40 Evidence: adults with chronic illnesses, were also very person centred and well organised. There were a small number of improvements we recommended. An example was actions in one persons review notes going to reorganise Caribbean get together like in the past and ask X to teach sign language. There was no written evidence these actions had been followed up. We discussed this with the unit manager who told us that the speech and language therapist had stated that it was not possible for this person to use sign language. We recommended that discussions and decisions should be fully recorded in the persons care notes. This person with no verbal communication had a very detailed communication care plan but we asked the unit manager whether a picture board or electronic device had been considered. She told us that they had pictures of food to assist making choices. We saw that it was recorded this person had refused to have blood tests. We discussed this persons refusal with the unit manager. As the person had been assessed as not having capacity under the Mental Capacity Act 2005, we strongly recommended that a review be held with the persons Independent Advocate, GP and Social Worker for decisions to be agreed in the persons best interests. We also recommended that more specific information relating to diabetic checks would enhance the care plans for this condition. Another persons care records indicated a referral had been made to a continence advisor but additional information should be recorded about what to do if the catheter comes out or needs replacing. This person also had a care plan in place for restless sleep, but the reviews of the care plan show that the person was sleeping well, staff also confirmed this. The home should feel confident to discontinue care plans if problems are no longer relevant. We looked at the care of a person on Heronville who was assessed as needing one-toone care. When we spoke to staff on this unit none of them knew what this meant. It was not indicated on the staff rota that there were extra staff in place. However there was funding from the placing authority for the one-to-one placement and we could see from the rota that an extra staff member was available. We stressed the importance of clear communication and guidance for staff so that they could provide the required care and monitoring for this person. It was positive that the unacceptable behaviour of this person had been reported to the CQC and Local Authority and we were told that since the extra funding had been agreed there had not been further incidents. We saw generally good evidence overall of referrals to GPs and other healthcare professions, such as the Speech and language therapists, dieticians, dentists, optician and chiropodists, though this varied from unit to unit. The sample of plans we looked at on other units, for the people with complex needs or Care Homes for Older People Page 18 of 40 Evidence: towards the end of their lives, generally did not consider all areas of the persons life including health, specialist treatments, personal and social care needs. We looked at the care of a people with diabetes, which was again variable across the units, with some generally well managed, with information relating to diet, medication, and heath care monitoring. On units such as Haines the diabetic care plans were not sufficient and did not give staff guidance to manage the condition to maintain or promote health and well being. We again highlighted the services offered by the diabetic nurse specialist service in Sandwell and recommended that contact be made with the diabetic nurse specialist team to provide additional support, information, and appropriate specialist diabetic training for the trained nurses and care staff. The pharmacist inspector visited the home on 28th May 2009 to check the management and control of medicines within the service. The pharmacist inspector visited three out of the five units. We found that there had been an overall improvement in the management of medication in two of the units, however it was disappointing that one of the units was found to be poor and was placing the health and wellbeing of the people who use the service at risk. Staff had undergone a Medication Administration Assessment. We were shown documentation to confirm this. Quality managers did the assessments in March and April 2009. We were informed that if there were any issues identified such as a gap in knowledge then the member of staff was re-tested. Further training was also done in a medication management workshop. This means that staff who administer medication have been assessed as competent to do so and ensure the safety of the people who use the service. The room temperature of the three medication storage rooms was below 25 degrees centigrade, which is the correct storage temperature for medication. The refrigerators in each unit were also within the correct temperature range of 2 to 8 degrees centigrade. We saw daily records for the room and refrigerator temperatures, which showed that medication was being stored at safe temperatures. We were concerned that the time period between the morning and lunchtime medication rounds had not been addressed since the previous inspection. For example, in Manby House we saw that the morning medication administration began at 9am but did not finish until 11.30am.We were informed that the lunchtime medication administration began at 2pm, which did not ensure that there was an adequate gap between doses to ensure the safety of people living at the home. Care Homes for Older People Page 19 of 40 Evidence: Medication records were seen and it was acknowledged that overall there was an improvement in two of the units with regard to recording the receipt, administration and disposal of medication. It was therefore disappointing that this was not seen in one unit. It was concerning that we saw that three people had not received their medication as prescribed. Two peoples medication had been out of stock for eight and five days respectively before a new supply was obtained. We spoke to the nurse in charge who could not give an explanation for this. A third person had not received medication on two evenings due to an error that was not clearly documented. The nurse in charge informed us that she believed it was an agency nurse. There was no record to show if a Doctor had been informed about any of these incidents. This increases the risk of harm to the health and wellbeing of the residents. The record of receipt of medication was not always documented. For example, we saw a new supply of tablets in a cupboard, which had not been recorded as received onto the residents medication chart. This means that the total quantity available in the home was not accurately documented and therefore increases the risk of incorrect medication supply. Medication was not always handled with care or safely and this increased the risk of harm to the people who live in the service. For example, we saw a medicine tot containing two white tablets placed in the door of a medicine trolley. We identified the medication and asked the nurse in charge why it had not been administered or destroyed. She could not offer an explanation. On further checking we found a medication chart with the two identified tablets. On 27th May 2009 the nurse in charge had documented the chart as RD, which was a code for refused and destroyed. We checked with the nurse in charge who agreed that the medication had been refused but it had not been destroyed in error. This was undertaken immediately. This poor management of medication increases the risk of a medication error. Medication was not always checked to ensure the person took it safely before the medicine chart was documented. For example, a care assistant found a tablet on the nightdress of a person nursed in bed. We checked the medication administration chart and saw that all of the morning medicines had been signed as administered by an agency nurse, however one of the tablets had not been taken. This means that people who live in the service are at risk of not receiving their medication as prescribed and this increases the risk of harm to their health and wellbeing. Information relating to medication was not always available. For example, one person was prescribed a painkiller to be given four times a day when required. We saw no Care Homes for Older People Page 20 of 40 Evidence: written information to inform staff under what circumstances the painkiller should be given. This was of concern because we witnessed the resident crying with pain and the records seen showed that no painkiller had been given since the start of the new medication chart. We saw no written review of the pain relief and no reason was documented to explain why the painkiller was not being administered. We discussed our concern with the quality manager and a doctor was contacted and a dispersible painkiller was prescribed. It was of concern that this healthcare need had not been undertaken by staff and therefore increased the risk of harm to the health and wellbeing of people living in the service. We spoke to some relatives, who were generally satisfied with the care provided. One relative was not satisfied and we were made aware of a complaint, which the organisation was trying to resolve. We heard from some staff who told us that there are sometimes staff shortages but they try their best to meet each persons needs. We saw that staff treated people living at the home with respect and courtesy, maintaining their privacy and dignity. People living at the home looked well presented and were appropriately dressed for the time of year. During discussions staff demonstrated a good understanding of how to people wished to have their care provided. Care Homes for Older People Page 21 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are generally more opportunities for activities and social stimulation for people living at the home. People are encouraged and supported to maintain important relationships and friendships. There are choices of generally nutritious meals throughout the day and night. Some people at the home may not consistently receive appropriate levels of support to maintain good levels of nutrition and hydration, which may pose risks to their health and well being. Evidence: We saw there were improved records of each persons preferred daily routine recorded in the sample of care plans examined, which provided staff with information to follow. There were improvements to the flexibility of routines on some units but the morning routines on Haines and Manby units were still disorganised. We saw evidence that not all personal preferences had been updated, as highlighted at the previous section of this report, and though staff were working hard, people were waiting unacceptable lengths of time for their personal care, breakfasts and medication on these units. We saw an example of a care assistant requesting the bank nurse to administer someones insulin at 11:20am so that this person could have their breakfast. Another person still lying in bed at 10:15am told us that they often had to wait for attention and though they did not mind waiting until about 10am, they disliked having to wait Care Homes for Older People Page 22 of 40 Evidence: longer. It was positive that when people had received assistance with their personal care they generally look well groomed, with appropriate clothing for the time of year, and attention to detail, such as wearing jewellery of their choice. Each unit had activities co-ordinators, who worked from 10:00am to 4:00pm, Mondays to Fridays. We talked to the activities co-ordinators on three of the units, who told us of increased opportunities to met with each other and develop activities. Each unit had activities notice board displayed in the reception area. A sample of activities advertised were, hairdressing, reminiscence, board games, quizzes, singing, Holy Communion Service, and one-to-one sessions for people in bed or in their bedrooms. There were designated activities rooms on some units, where we were told people could make cards, crafts, play skittles or have hand massages. The activities room on Bloomfield unit also had a supply of radios and CD players for people who were too ill to watch TV. We were told that there were entertainments such as singers and services at the home on various units and people who were able, were invited to attend from other units. We were told that Palethorpe unit had outings last year to the safari park and Blackpool and were planning for a trip Southport this year with about 18 or 19 residents plus staff and relatives in a 54 seater hire coach. The activities co-ordinator told us people are registered with Ring and Ride and there have also visited Sandwell Valley Park. There were plans to take residents buy bedding plants, and then help to plant them. We noted one person living at Palethorpe unit also attended the Beacon Centre for the blind. We were told this person loves to water the plants, and the unit bought an extended hose so that he did not water his slippers. The activity records were variable throughout the five units and some demonstrated people were offered more social stimulation appropriate to their individual needs, especially for people with dementia or sensory impairments. We noted that there were considerable improvements to the environments on Manby and Heronville to provide sensory stimulation for people with dementia. Whilst we were visiting Heronville unit the same piece of music was played continuously and we counted 15 repeats of the White cliffs of Dover. We pointed this out to the person in charge, it may have been that staff were so busy they did not Care Homes for Older People Page 23 of 40 Evidence: notice this but for people living in the home this could begin to be very annoying and cause agitation and distress. Once pointed out to staff, they changed the music. Staff spoken to said we do our very best, we can see that there are improvements being made and this makes us want to do our best. The environment on Heronville was much improved since our last visit. Small lounges have been sectioned off offering more choice quieter areas for people to sit. We saw a number of visitors during the two day inspection, though the majority of people told us that they felt generally felt welcomed, there were a variety of views. One relative told us she felt some staff worked very hard and were attentive to individual needs, but others did not. We discussed this persons concerns with the managers, who agreed to meet and discuss a way forward. The mealtimes observed on Haines and Manby units were protracted, and we were told significant numbers of people needing individual support to be fed, or assistance, support or encouragement to eat. Breakfast on Manby unit was observed. We saw there was a choice of hot breakfast, bacon sausage and eggs. We tasted the scrambled egg, which was unpleasant. We requested that the staff also taste the egg and they agreed it was unpalatable. On the second day of the inspection we noted that the poached eggs offered for breakfast were much better. During the two day visit we noted that the liquidised meals were thick and sticky and we saw staff adding water to loosen up the consistency. We were told that pureed meals were generally tasteless, which was confirmed when we tasted a small sample. We discussed our findings with the management of the organisation and with the recently appointed head chef. We were given assurances improvements would be introduced and monitored. Whilst on Manby unit we observed carers supporting people at meal times and saw staff offer people choices of drinks, such as tea, coffee or juice, which was positive. However one carer demonstrated this good practice, whilst wearing disposable blue plastic gloves and plastic apron. She stood at the side of one person, and although she spoke to them whilst feeding them she did not sit down, take her gloves off or give the person any eye contact during this time. This detracted from the positive aspects of the offers of choice. We noted that there was also music playing but it was competing with two televisions in the same area, demonstrating a lack of attention to peoples comfort and pleasure when eating. Care Homes for Older People Page 24 of 40 Evidence: In contrast the breakfast time observed on Bloomfield was a leisurely, relaxed social occasion, with people who were able to sit at tables, enjoying conversation. The people we spoke to on this unit were complimentary about the food in general and enjoyed their breakfast of a choice of cereals, toast and conserves, poached eggs on toast or bacon sandwiches, with fruit juice and plentiful hot drinks. It was positive that in the units dining tables were attractively laid with table clothes, placemats, condiments and attractive table decorations and efforts had been made for social interaction and for mealtimes to made special. We noted whilst on Heronville, the housekeeper had cleared the hot breakfast away at 10.50 am, then at 11.10 am carers bought one person into the dining area for breakfast, he was only offered toast because there was nothing left for him to eat. We observed lunch on this unit and noted that the same person was still sitting at the table at 12:30pm and was not eating his meal. We saw, as at the previous inspection in November 2008, that there were a lot of people who needed assistance with eating and drinking on Heronville, We spoke to staff about this they said, we manage but it is very hectic at times. One person served meals and checked that people were given what they had chosen. We observed the lunch served on Palethorpe unit observed lunch on the second day of the inspection and tasted the food because staff had said that it was boring and always the same for those people who needed soft diets. The mashed potato and peas were salty, and the liquidised food was abysmal, watery and lumpy at the same time. Some of the people on the unit said, the food is very nice, one person used to be a chef and said that the food is generally very good, and especially liked the coffee mousse on offer this day. We discussed the issue of food and the reduced quality of it for some people. We were told that the home had already consulted with residents about this, and had received their comments. A new chef had been appointed and during discussion he told us he was well aware of the concerns that people had about the food and was planning a meeting with residents and relatives to address these concerns and put a menu in place that meets all peoples choices. Care Homes for Older People Page 25 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 can generally have confidence their concerns or complaints will be listened to and investigated and the management practices generally protect people from harm or abuse. Evidence: The complaints procedure was displayed on the main notice boards in the reception areas of the home and was also included within the Welcome Pack and within the service user guide. This helped people to understand who to approach if they are unhappy or wish to express concerns. There had been no change to the organisations complaints policy since the last inspection in November 2008. There have been eight complaints since January 2009, and there were recorded investigations and responses. We noted that in January 2009 there was one complaint about the nurse call system not working, this had been addressed by the handyman and the bleep system was sent away for repair. We checked the handymans audit of the home and he had written nurse call system is in urgent need of upgrade this has yet to be done by the home. On a positive note we saw many cards of thanks and compliments from relatives, displayed on the notice boards in the reception areas of each unit, complimenting the staff and care at the home. We noted that the home had received 38 compliments for the service it has provided since the beginning of the year. Care Homes for Older People Page 26 of 40 Evidence: There are better systems in place for the protection of vulnerable people. We have seen the home was reporting issues to safeguarding team as they should. We followed up a Regulation 37 notification in relation to a male living at the home inappropriately touching a female living on the same unit. We referred to this issue in the personal and health care section of this report. The management of the home had worked with the Local Authority and health professionals and had secured one-to-one funding for the person. We noted the involvement of the community mental health team and that they were looking for another more appropriate placement for this person. The other person involved in the incident did not appear to have been upset. We spoke to a number of staff and they were all aware of who to report concerns to and when they should do this. We were given confirmation that staff had been given training in relation to safeguarding vulnerable people. The organisation needed to put in place more robust measures when recruiting new staff and using agency workers to improve safeguards for people living at the home. This is detailed at the staffing section of this report. Care Homes for Older People Page 27 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. The incremental changes to the decor and furnishings contribute to creating a pleasant environment for people to live in. The grounds are generally maintained to provide a safe and interesting outdoor environment for people at the home. Evidence: We looked at each of the five units, which accommodated the people living at the home. We looked for evidence that improvements, which were needed at the last inspection, to see if they had been actioned. We saw some evidence that the home was now being proactively maintained to more acceptable standards with an ongoing repairs, maintenance and renewal programme. The units had been redecorated to offer more stimulation for people on Manby and Heronville. We saw reminiscence pictures in the corridors, musical instruments, and grab rails had been painted red to aid recognition for people and provide guidance. The courtyard garden on Heronville was very inviting and gave people somewhere pleasant to visit. Seating, scented plants and ornaments made it a pleasing place to be. During the tour of Bloomfield unit we spoke to people staying for respite care who were all very complimentary about their environment and the garden area, called the garden of joy was particularly attractive and relaxing. We saw that the garden area on Palethorpe unit was in use during the inspection, Care Homes for Older People Page 28 of 40 Evidence: people on this unit had taken time to plant and take care of the garden themselves. There was a lovely patio area for people to enjoy and raised beds for those people who were unable to manage gardening any other way. However we noticed that people on Palethorpe who needed to use wheelchairs were not able to get into the building unaided because of a raised step on the patio door. This was bought to the attention of the person in charge and they immediately agreed to take action to create better access. On another unit, where we identified areas, which needed improvements at this visit, the management of the organisation were swift to act. An example was on Haines unit in bedroom 28, where there was someone, who was very small and frail and had bedrails with bedrail bumpers in place, but we noted a gap at the top of the bed between bedrails and headboard. When the gap was measured it was within permitted dimensions but the quality manager and acting manager acknowledged that this needed to be managed with more safety. We were told by the quality manager during the first morning of this visit that a nursing profile that had been ordered and would be delivered as soon as possible. This demonstrated very proactive and positive practice. We were shown some of the eighteen new nursing profile beds provided since the last inspection and we were told there were more on order. We saw that there were new comfortable chairs, dining tables and chairs on Heronville. During our tour we noted that bathrooms throughout the site were generally clean, though some were very clinical and on Manby, Heronville and Palethorpe, storage was still a problem. Some people had been able to individualise their bedrooms with personal possessions. However on units such as Manby, Haines and Palethorpe the majority of bedrooms needed to be redecorated and refurbished. We noted that all of the people whose care we looked at closely had the equipment in place that they needed such as pressure mattresses and cushions. We found throughout the home that there was generally a satisfactory supply of gloves and aprons and liquid soap. These items were available to help to reduce the risk of cross infection to people living at the home. We identified some additional areas, which needed to be improved at this visit, such as: Care Homes for Older People Page 29 of 40 Evidence: Bloomfield, room 37, shower room, we noted that the base of the assisted bath was very worn and in need of renovation, to maintain good infection control measures. Bloomfield, bathroom 16. We noted a new bath panel was required, the existing panel was cracked and ill fitting. Palethorpe, WC room 23 the door would not close into the rebate. WC room 24 door not closing at all and plinth with WC was not able to be cleaned effectively and was causing a malodour. Bathroom 31 there were similar problems with plinth and flooring causing a malodour. The Arjio bath not working, awaiting parts. Radiators and pipe work were not guarded, these must be risk assessed and guarded to avoid risks of harm to people using this facility. These issues pose risks to peoples safety and did not demonstrate their privacy and dignity was being maintained. Palethorpe, some of the furniture needed replacing, there were at least six chairs that were ripped, with exposed foam and in need of replacement. The unit manager told us that they were on order. The whole environment on Palethorpe needed upgrading, walls were battered from wheelchair use, wallpaper ripped in places. Manby the garden was overgrown, with grass and plants approximately 12 inches high making access impossible for people living at the home. Heronville, staff were completing an audit of all the beds and bed rails that need replacing, we noticed that pillows needed replacing and duvets were thinning. Towels were also frayed. Care Homes for Older People Page 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skill mix of staff generally meet the needs of people living at the home. Recruitment and selection procedures are not sufficiently robust to safeguard vulnerable people. Evidence: The staffing rotas demonstrated there were usually sufficient numbers of nurses, carers and ancillary staff and we were told that managers now regularly monitored residents dependencies and occupancy levels and reviewed and revised staffing levels, and made adjustments accordingly. We noted that additional care staff had been allocated to the early shifts on Bloomfield unit and staff told us that it had made a considerable difference. However we saw and heard about people waiting for attention, especially medication, assistance with feeding and to be taken to the toilet. We discussed our observations with the BUPA management, present at this inspection and we received assurances that they would be evaluating the deployment and effectiveness of staff to make sure that people were not put at risk with inappropriate timings of medication administration or unacceptable waiting times for attention. There is a recruitment and selection procedure in place. We spoke to one staff member who felt that their recruitment had been done fairly. We looked at the files for six members of staff. We did this to check the recruitment practices. Generally files were well ordered and sub-divided. This made it easier to look through the files. We Care Homes for Older People Page 31 of 40 Evidence: found evidence of application forms, references, proof of identity and criminal record checks. Staff were occasionally started on a (Protection of Vulnerable Adults) POVA First basis whilst waiting for their full check to come back. Where this is the case, we saw evidence of an existing member of staff to be buddied with that person for each shift. We found interview records for care assistants and panel interview records for nurses. Good practice would indicate a panel interview for all potential candidates to show fairness and equity. On three files we saw references, which either gave us cause for concern or said that the referee would not re-employ the person. We found gaps in employment histories on the application forms for two people. We could not find any evidence of how these issues had been explored. The agency employs staff who required work permits. We saw evidence that two work permits had expired but the registered persons were continuing to allow the staff to work. Additionally we found that the home uses agency staff from an external organisation. Although the organisation has an agreement to use this provider, we could not see how the home has checked the individual information for each agency member of staff they use. These systems need to be improved to show how the service is fully safeguarding people through its recruitment practices. There are two separate inductions, one for nursing staff and one for care assistants. Both have booklets, which they can work through. The care assistants receive a twopart induction. The first part focuses on the home and key policies and procedures. We saw evidence on all but one file of these being completed. The second part focuses on the specification laid down by Skills for Care. Although given verbal assurances that these had been completed, the home had no audit trail of this. This is because the staff can keep their workbooks and take them off site. There is an opportunity for each standard to be signed off and we have asked the manager to look at how they can show the work undertaken. There have been improvements in the level of training since our last inspection in November 2008. There is a centralised training and development matrix. There was evidence that staff were encouraged to undertake NVQ qualifications. Certificates and individual profiles are held on each file. Since then, there has been a home relief manager working on a rolling programme of training. Staff had attended a range of training to include safeguarding, moving and handling, infection control and health and safety. Additionally nursing staff are encouraged to attend training which they can use as evidence of their learning for their nurse registration. Whilst we did see some gaps, we are encouraged by the work undertaken to date and hope to see this continuing. Care Homes for Older People Page 32 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. People who live at the home cannot always be assured that the management arrangements make sure that their health, well being and safety of will be safeguarded. Evidence: This home had not had the stability of a consistent registered manager in post for some time. The current registered manager, Ms Kalmit Jagpal had been in post since September 2007. We were informed during the inspection visit that the current registered manager had co-operated fully with the improvement plan for the home but she would be moving to another home in the organisation in the near future. We were introduced to the new acting manager, who took an active part in the inspection. She told us that she had completed the BUPA corporate induction and was undertaking the on site home induction. We had the opportunity to speak to the new acting manager for the service. She has had some experience of managing large homes and is aware of the shortfalls in the service provision at Ryland View. Care Homes for Older People Page 33 of 40 Evidence: We were told that the home had a quality plan, which reviewed all areas of the home at least annually. There were regular audits of the care plans and risk assessments. There were also medication audits, though these had not identified the failures identified at this inspection. There were minutes to show that unit manager meetings and staff meetings were held. We also saw reports of the Regulation 26 monitoring visits undertaken by the organisations representative. These were generally more robust, and though some shortfalls had been identified at monitoring visits, these had not been rectified at the time of this inspection, such as the management, storage and administration of medication, as identified by the CQC Pharmacist. The results of the recent annual survey completed showed that there had been deterioration in the satisfaction of the catering service, there was only a 61 per cent satisfaction rate. The home had responded by surveying people again about the food and catering service. The results were being collated and we spent time talking to the chef about the comments people had given to us about the food being vile and tasteless and our own findings confirmed these views. The chef was planning a meeting with families and people to discuss these issues and get to the bottom of the problem. Seventy five per cent of people surveyed said that they were happy with the activity the home provides but more activity was needed. Relatives were also surveyed with the same findings, the largest area of concern noted. We were told that managers on each of the units undertook staff supervision sessions. The registered manager in turn supervised them. The home told us that the level of supervision has slipped on some of the units. We spoke to one member of staff who had been employed for nearly 12 months. They told us they had not received a supervision session since they started employment. They said, no supervision and I think it is ridiculous they continued, they [supervisions] need to be done on a regular basis. On a more positive note we spoke to some staff on Bloomfield unit who told us they received regular supervisions sessions from the unit manager and found this to be supportive and helpful. Maintenance records had been kept up to date. We checked hot water, air conditioning, emergency lighting, and nurse call system. Health and safety training was in place, and though there were gaps in the training matrix, remedial arrangement had been made. We were told that the handyman carried out and recorded monthly bed rail checks, and included measurement of gaps and permitted dimensions. The observations of Care Homes for Older People Page 34 of 40 Evidence: bedrails during our tours of the premises showed that they were fitted and maintained safely. However some areas of the home notably the bathing facilities were not maintained to standards, which protected people at the home from risks of harm. These areas were highlighted at the environment section of this report. We noted from our records and records held at the home that reporting Regulation 37 notifications was much better, and generally incidents had been appropriately reported to in accordance with safeguarding procedures. We looked at the accident records since the last inspection and noted that accident reporting was better. We noted through case tracking that when people were having falls and they had been reported appropriately. Reviews of falls risk assessments for people included any falls that had occurred during the previous month and any action the home had taken to address this. For example referrals to the rehabilitation team for falls prevention advice, and ordering low profiling beds and crash mats. Care Homes for Older People Page 35 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 9 13 The records of the receipt, 02/03/2009 administration and disposal of medicines for the people who use the service must be robust and accurate to demonstrate that all medication is administered as prescribed. This is to ensure residents health and well being is safeguarded. 2 9 13 Appropriate information 02/03/2009 relating to medication must be kept, for example, in risk assessments and care plans to ensure that staff know how to use and monitor all medication including, when required medication, to ensure that all medication is administered safely, correctly and as intended by the prescriber to meet individual health needs. This is to ensure residents health and well being is safeguarded. Care Homes for Older People Page 36 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 8 11 The registered persons must 01/07/2009 ensure that special care records such as food, fluid balance charts and turn charts are diligently completed with care provided accurately recorded and vigilantly monitored, and with care records updated as changes occur. This is to ensure each persons health and well being is maintained. 2 37 13 The registered persons must 01/07/2009 ensure any radiators and hot water pipes, which are not low surface temperature or unguarded, are risk assessed with remedial measures implemented as a priority. This is to safeguard people living in the home from risks of harm. Care Homes for Older People Page 37 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 1 It is recommended that the admission criteria for each unit should be included. This information was important because each unit accommodated and cared for people with very different needs and would give people comprehensive information about the service to help them make decisions about the choice of home. Each person living at Ryland View should be given a statement of terms and conditions detailing their fees, including the free nursing care element, Registered Nurse Care Contribution (RNCC) element, the provider responsibilities and their rights and obligations whilst they are resident at the home. That each persons last wishes in respect of death and dying should be explored and be recorded within their end of life care plan. This is a previous good practice recommendation, which was not met. It is recommended that more specific information relating to specialist diabetic checks should be recorded in the care plan for this condition. That manufacturers guidelines for use and maintenance of pressure relieving mattresses should be available on each persons risk assessment and care plan to ensure that they are maintained that the correct pressure for the persons individual care. It is strongly recommended that where people assessed as lacking capacity refuse planned treatment or care, recorded reviews should be held with the persons Independent Advocate, GP, social worker and significant others for decisions to be agreed in the persons best interests. The garden area on Manby and Palethorpe should be made accessible to ensure that all people living on these units are able to have independent and safe access. The menus should be reviewed after consultation with people using the service. That the action is taken to rectify defective bathing and toilet facilities, which could pose health and safety risks to people living in the home. 2 2 3 7 4 7 5 8 6 8 7 12 8 9 15 21 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 10 27 It is strongly recommended that staffing levels should be kept under review to ensure that each persons needs are met timely and consistently. It is strongly recommended that more robust procedures should be implemented for checking and validating peoples permits to work in the UK. It is strongly recommended that the organisation implements processes to provide documentary evidence of validation and induction for agency staff employed to work at the home to safeguard the people living there. It is recommended that induction elements should be signed off to provide an audit trail. It is strongly recommended that recruitment and selection processes should be robust and procedures must be in place to explore information provided by candidates, such as documented investigations of any gaps in employment histories. 11 28 12 29 13 14 29 29 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. If you would like a summary in a different format or language please contact our helpline or go to our website. 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