Inspection on 02/06/09 for Sheldon House

This inspection was carried out on 2nd June 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sheldon House 19/06/08

Sheldon House 15/01/08

Sheldon House 11/09/07

Sheldon House 20/09/06

Sheldon House 20/03/06

Sheldon House 29/09/05

Sheldon House 08/02/05

Sheldon House 09/09/04

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

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Sheldon House Sea View Road Falmouth Cornwall TR11 4EF     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Melanie Hutton     Date: 0 2 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 38 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 38 Information about the care home Name of care home: Address: Sheldon House Sea View Road Falmouth Cornwall TR11 4EF 01326313411 01326317902 sheldon@comfortcaregroup.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Anne Louise Libby,Mr Charles Barry Libby,Mr Darren Libby Name of registered manager (if applicable) Mrs Doreen Anstey Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home Sheldon House is a long established care home and is registered to provide nursing care for up to 34 people who experience dementia or enduring mental illness who are over the age of sixty-five years of age. The current owners have run the home since November 2000. The accommodation is a former hotel that was initially converted around 1994 and since then has undergone further structural changes. It is located on a quiet residential road close to the town and beaches of Falmouth. It is easily accessible on foot and by transport from the town, this results in frequent visits to the home by relatives and friends. There is a car park at the front of the home and an attractive garden area. 0 0 Over 65 34 34 care home 34 Care Homes for Older People Page 4 of 38 Brief description of the care home The accommodation is provided over three floors and is accessible to people who experience a disability by a shaft lift. The building is not the best design to provide the care and support required by residents. The layout does not easily lend itself to meeting the needs of residents. However, there is limited scope to improve this within the existing building. The bedrooms are for both single and shared occupancy. There are three communal areas provided on the ground floor. One of these areas is used as a dining room. There is a garden to the rear of the home, which is accessible to residents through the lounge. Fees charged for the service range from 500 to 850 pounds per week. Care Homes for Older People Page 5 of 38 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: one star adequate 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: This was an unannounced key inspection that was undertaken by two inspectors over one day, spending a total of twenty hours at the care home. We were also accompanied for part of the inspection by an expert by experience who provided us with verbal feedback and a written report on her views of the service. These views are included within this report. We looked at records, care documentation, policies and procedures and inspected the environment. As part of the inspection we spent a period of 2 hours observing the interactions with staff and service users in the lounge area. This is based on a recording tool known as a short observational framework for inspection (SOFI) and assists us to make judgments about services for people with dementia and the care that they receive. The findings from this period of observation are incorporated into the Care Homes for Older People Page 6 of 38 report. We met and talked with service users, registered provider, registered manager, deputy manager, staff and relatives visiting the home. We sent out surveys to service users, their relatives and staff prior to the inspection to seek their views of the service provided. We have received 7 surveys back from service users and their representatives and 4 from staff. Information from the surveys is contained within the report. An Annual Quality Assurance Assessment (AQAA) was sent to the registered provider prior to the inspection and returned informing us of the services provided within the home and any changes that have been made since the last inspection What the care home does well: During the inspection we observed that staff were kind, caring and patient to the service users. Whilst often very busy, they were seen to interact with service users in an unhurried manner and offered support discreetly where needed. Completed surveys that we received back from service users and / or their representatives prior to the inspection informed us the nurses and carers look after all the residents with very loving care. The carers dont stop and are always so kind to relatives of residents, nothing is too much trouble, Staff are so very caring and have always got a smile and cheery word for residents and visitors alike and they understand the needs of patients with severe dementia and show care and patience when dealing with difficult circumstances. Detailed care needs assessments are undertaken for service user prior to admission and again on admission. This ensures that the home is able to meet the assessed needs of the service user. People were positive about the meals provided to service users. We saw that service users are offered a choice of meal and that regular drinks, snacks and fresh fruit is readily available. Completed surveys sent to us from service users and their representatives informed us the home caters excellently for each residents likes and dislikes with meals. Nothing is too much trouble when it comes to getting their food and the home serves a very good variety of food. In my relatives case it is liquidised and well presented. The home has appointed 2 activity co-ordinators since the last inspection and the activities programme has been developed and includes arts, crafts and exercise based activities. The activities co-ordinator was observed spending time on a one to one basis with service users and good work is continuing in capturing service users life stories. The garden at the rear of the home is attractive and has prettily planted pots and beds. We were told that some of the service users assisted with the planting of seeds and flowers. Staff were positive about the support that they receive from the deputy and registered manager. Staff said I can go to Kate [deputy manager] about anything, she always has time and listens and If there is anything I am worried about or dont know about the office door is always open and I can always ask. Relatives also made positive comments about the support that they and their relative receive from the deputy manager. The registered manager is in the process of completing the annual quality survey of service users and their relatives. Not all have been returned as yet and once they are all considered to have been returned a quality audit will take place. Some of the completed surveys we saw included comments: care of the patients form staff is second to none and their patience is wonderful, you are all so kind and friendly and me and my family appreciate it very much, nothing is too much trouble when we visit we are always greeted with a lovely smile and you all work so jolly hard and the staff are always friendly and polite they are a credit to their profession. Care Homes for Older People Page 8 of 38 What has improved since the last inspection? What they could do better: A requirement was made at the last inspection regarding the staffing levels. We were concerned that during the main meal of the day there did not appear to be sufficient staff to serve service users with their meals and assist everybody that need help with eating their meal. As a result, some service users had to wait a considerable period of time for their meal whilst others around them were eating. Also during the evening when people will be wanting to return to bed and require assistance with personal care the duty rota shows lower numbers of staff than at any other time in the day. Surveys that were completed by service users and / or their relatives prior to the inspection informed us the staff are very busy and get very tired but are always kind and patient. When asked within a survey what could the home do better staff replied making sure we have enough staff on a daily basis, sometimes there is not enough staff. This may be due to illness. The registered provider stated this would only happen when a member of staff went off sick at short notice and the gap would be filled as soon as possible. 2 recommendations were made at the last inspection that have not been met. These are regarding the floor of the laundry not being impermeable (the registered provider outlined the planned development for this area), secure storage facility for service users valuables and monies and supervision records. Some of the records held for service users are not complete e.g. moving and handling assessments. We discussed this with the deputy manager who has taken steps to address these gaps in order to fully protect service users and staff. Care plans are detailed and informative generally but within some we noted that there were gaps in the detail provided to staff and also that some needed reviewing and updating. Observation of the medication round in the morning identified that as the morning Care Homes for Older People Page 9 of 38 medication takes a longer period of time to administer, the lunchtime medications follow soon after. We discussed this with the deputy manager and whilst action appears to be taken by trained nurses to ensure service users receive medication in accordance with the prescription, written records should evidence this. During a tour of the premises, we observed that some areas of the home still need decorating and some damaged furniture replacing. In some areas of the home e.g toilets and bedrooms we noted there were odours and some carpets stained. In the bedrooms on the upper floor additional natural light is provided through velux windows. These do not have any blinds or curtaining so would not assist people to sleep in the mornings, particularly during the summer months. One member of staff commented within a survey that the building itself is not perfect compared to purpose built buildings and getting around. The induction, core and ongoing training records for staff show gaps and should be updated where necessary to ensure staff are trained and competent to provide care to the service users, including specialised training e.g. dementia care. We were not able to see the full investigation of complaints received although we were shown the outcome letter to the complainant. Full records of any complaints made to the home must be maintained and available for inspection. 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 set out 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 38 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 38 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered person ensures that the care needs of propsective service users will be met. Evidence: The registered person obtains information from the referring or commissioning body regarding the care needs of prospective service users, whenever possible. A care needs assessment is undertaken pre admission and also on admission to ensure that the home is able to meet the identified care needs. These assessments are undertaken by either the registered or deputy managers who are both registered nurses. The qualified nursing staff act as key workers for each resident and also participate in the assessment process. The pre admission assessments are undertaken with the prospective resident e.g. at home, hospital and representatives e.g. relatives / friends are invited to be part of the assessment process if that is the service users wish. Care Homes for Older People Page 12 of 38 Care Homes for Older People Page 13 of 38 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Gaps in care planning mean that staff are not consistently updated, informed or directed as to the action they must take to meet the individual needs of service users. The medication policies, procedures and systems in place protect service users. Service users are treated with respect. Evidence: Each service user has a care plan in place that has been developed by either the deputy manager or the named key worker for the person. Generally the care plans are detailed and inform staff of the action that they must take to meet the persons assessed care needs. Some, however, do not provide sufficient detail. We saw care plans that did not fully reflect the continence issues or oral care for people. Most of the care plans are reviewed and updated regularly although, again, there were some plans that needed to be updated and reviewed. We discussed these issues with the deputy and registered manager both of whom were aware and had taken steps to address the situation. Care plans were generally signed by the service user and / or their representative. Care plans evidenced that information from the risk assessments is Care Homes for Older People Page 14 of 38 Evidence: included and staff provided with instruction on the action they must take to reduce the risk. Separate moving and handling risk assessments were in place for most people, but again some were not completed or updated as necessary. A table with a key code is in place for staff to evidence how they have met the assessed care needs of people. For clarity the codes detailed on the form should be used consistently. Some forms had additional codes that were not explained on the form which did not make the information clear to the reader. An additional narrative is recorded that provides further information regarding the service users daily life e.g. health, emotional, social or other issues. These are legible, detailed and signed and dated. The expert by experience observed the staff going about their work and commented Staff came across as very caring, patient and considerate. Great respect and patience was shown to one resident. One member of staff helping people to eat their dinner was patient and considerate. The expert by experience was also able to speak with a relative of a service user who spoke very highly of the home and the staff and would not have wished for a better home for her relative and could not fault or improve the care. We sent surveys out to service users and / or their relatives before the inspection and asked if they always received the care and support you need. 5 people said they did and 2 that they usually did. People also told us that staff were always or usually available when they needed them. Detailed records are held regarding the involvement of external professionals e.g. general practitioners, district nurse and community psychiatric nurses. We were able to see that the dentist, optician and chiropodist visits when necessary. Continence assessments have been completed for the service users who need support with this and most care plans advise and direct staff about the care needed, including the type and frequency of incontinence pad needed and any specific assistance needed to promote the continence of individuals. Service users have a choice of using the bath or shower and where people have expressed a preference this is recorded in their care plan and records show that this preference is respected. We observed that throughout the home there is pressure relieving equipment in place and when we randomly checked records relating to individual service users, found that this is recorded within care planning documentation. The deputy manager told us that currently there are no incidences of pressure sores. Detailed nutritional assessments are in place for each service user and we observed people being given additional support and supplements to their diet. Service users are regularly weighed and the results recorded. We asked people within the surveys if the home makes sure they get the medical care they need. 5 people said they always did and 1 that they usually did. A qualified nurse administers all medication and a monitored dosage system is used. Medication administration records (MAR) were inspected and were observed to be completed appropriately, evidencing why and when any medication has been omitted. Care Homes for Older People Page 15 of 38 Evidence: We observed the morning medication round during the inspection. This medication round commences at approximately 8 a.m. and was still on going at 11.30 a.m. The MARs identified that lunch time medication is prescribed for 12.00. We discussed the potential risk for services users due to the limited time between the medication rounds with the deputy manager. We were told that the nurses are aware of who has morning and lunch time medication and administer it appropriately. The quantities of medication received into the home is identified and a separate record identifies any medication leaving the home. This does not accurately reflect who removed the medication as the signature on the form is attributed to the pharmacist rather than the company employed. Each service user has a photograph held on their medication sheet to ensure their protection during the administration of medication. A policy and procedure is in place regarding medication to guide and inform staff. There is a designated fridge for the storage of medication that require this facility and temperatures are recorded. An audit of the the controlled drugs showed that they are stored and recorded appropriately. Lockable facilities are available in service users bedrooms should they be able to safely self administer their medication, currently nobody self administers their medication. The staff were observed to knock on service users doors prior to entering. A relative visiting the home told us that the staff are very kind and caring to her relative and supportive in enabling family members having privacy during the visit with their relative. A tool has been developed to evidence the choices made by service users to share double rooms, although some were not completed or signed by the service user and / or their representative. Screening is provided within double rooms to respect privacy of the occupant. Peoples preferred names are recorded within their care plan and these were observed to be used by the staff. Records identify the preferred preference of the service user regarding the gender of carer, again these were not consistently completed. There are currently no people who use the service from ethnic minorities although it is understood the home would be able to accommodate people who use the service from other cultures. From our SOFI observation we were concerned that some people had to wait a significant period of time to eat their melas. While they were waiting they had to watch other people eat their full meal. This concern is discussed more fully in the Daily life and activities section of the report. Care Homes for Older People Page 16 of 38 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. Service users are offered a varied programme of activities that could be improved to provide more social interactions. Visitors are welcome in the home at a time convenient to them and the resident. Evidence: The home has appointed 2 activities co-ordinators, one of whom has recently commenced work at the home. Most of the service users individual records show a detailed life history that has been gained through discussion with the service user and / or their relatives or representatives. These provide information on previous occupations, likes and dislikes and family history. We were told by the activities coordinator on duty on the day of inspection that these are being further developed and provide useful information to help to provide meaningful activities and conversation topics for service users. A range of activities are available to service users including arts, crafts, board games, skittles and ball games and one to one time is also provided. This may include manicures, hand massage, reading to residents or chatting with them. Detailed records are maintained of the participation of the service user and comments made regarding their perceived enjoyment of the activity. An exercise programme is being developed and provided to service users with the use of a DVD. 2 Care Homes for Older People Page 17 of 38 Evidence: members of staff have attended training regarding this and have cascaded this knowledge to other members of staff. During the observational part of the inspection we noted that whilst a craft activity was provided for service users, this did not encourage people to join together in a group. The member of staff supported individuals to make cards whilst remaining in their seats within the lounge. This type of activity could be developed further to encourage a social interaction with other service users participating in the activity. Service users are able to watch the television in the lounge and listen to music. During the day of inspection we noted that the television was put on at different times and that music was also played. The music playing was classical music. We observed one resident calling out for the music to be turned off and this was addressed immediately by a member of staff. The activities co-ordinator told us that service users have been involved in planting seeds and plants for the garden. On the morning of the inspection the weather was warm and sunny. The expert by experience noted that the garden door was locked and asked for it to be opened so she could view the garden. Her comments about the garden included the garden at the rear of the home is enclosed and secured so it would be possible for residents to sit there in safety but even though it was warm and sunny, the door was locked and all of the residents were inside. She further added Most of the area was covered in grass with two raised beds. Sweet peas had been planted against a wall and there were several pots containing herbs. I would have preferred to have seen the herbs in the raised beds giving the residents the opportunity to smell the wonderful fragrances and also for a display of coloured flowers to be planted for residents with impaired vision. I was told that residents were not outside as they would need to have a member of staff with them. The garden provided a bench and 2 chairs for people to sit down. The registered provider told us that people do not use the garden in the morning as it remains in the shade until the afternoon and can be quite chilly. We were also told that some medication taken by people who use the service can cause unpleasant reactions to too much sunlight. (We did not see this documented within care plans) We were also told that further development is planned for the garden and raised beds are due to be renewed. We asked people in a survey if there are activities arranged that they can take part in if they want to. 2 said always, 2 usually and 2 sometimes. One person made a comment that activities are getting better. Another relative told us The activities are now underway. The new co-ordinator is inventive and lively. I hope it continues as she has a vital role to play in the residents quality of life. Visitors are able to visit the home at any time, information about this is included in the service users guide. The visitors book shows that the home receives many visitors at varied times of the day. The front door of the home is locked for security purposes and none of the current service users have an electronic key fob to exit the building, although the registered provider stated that subject to a satisfactory risk assessment Care Homes for Older People Page 18 of 38 Evidence: individuals could be provided with this. We have been told by the registered provider that regular visitors to the home have been provided with an electronic key fob. Visitors attending the home on the day of inspection were observed to be greeted warmly by staff. We were able to speak with visitors to the home and they were positive in their comments about the home, the staff and the care that their relative receives. Comments made within surveys completed by representatives of service users were positive regarding the welcome that they receive from the staff. Additional comments made included the home welcomes friends and family - any time. It has an open lively attitude which is not rigid, the staff are always so kind to relatives of residents too, nothing is too much trouble and The staff have always got a smile and cheery word for residents and visitors alike. During the day of inspection we observed service users making choices about their daily lives. Service users are offered a choice of food. Whilst the choice of food is not completely meaningful for most of these service users, as it involves the service user being asked 24 hours ahead of the meal, we observed people being offered another alternative on the day should they require it. We saw people choosing to return to bed in the afternoon and we were told that times of getting up and going to bed were flexible, dependent on the service users wishes. Staff told us that where people have limited communication, the staff themselves recognise when the service user is ready to go to bed or needing the toilet. Care plans provide some information on the preferences and choices of service users regarding their daily lives. The home does not advocate managing finances for service users. Currently the registered provider manages the finances for one person but is actively seeing assistance from DACS for this person to be supported by an independent advocate. The kitchen was clean and orderly on the day of inspection. There were 2 chefs on duty, 1 acting as a kitchen porter. The home provides 3 varied meals each day with the menu operating on a rolling programme and providing a choice of food at each meal time. The current menu is due to change shortly and the chef told us it would be reflective of the summer season. We asked if service users were able to participate in the development of the menu and were told that generally people were not able to but the carers provided information of which food was popular amongst the service users. The registered provider told us that members of the Relatives Forum often discuss menus and attempts are made to incorporate what they believe will be enjoyed into the menu. 2 service users we spoke with told us that they had liked the lunchtime meal and a relative visiting the home said that her husband always seemed to enjoy his food. Between meals, additional drinks and snacks are offered to the service users including tea, coffee, juices, biscuits, cakes and fresh fruit. It was observed during the inspection that the offering of morning coffee was not Care Homes for Older People Page 19 of 38 Evidence: completed until 12.30 p.m, following which lunches started to be served at 12.45 p.m. We discussed this with the registered manager and provider as it is a concern that service users may not eat or enjoy their lunch fully following so closely after the morning snack. A variety of food is on offer at tea time and the chef told us that additionally sandwiches are made and left in the refrigerator for the care staff to use for anyone who is hungry throughout the evening or night. One of the alternatives for the main meal was vegetable and lentil bake. When asked by a service user what the meal was the staff were not aware and had to find out from the chef. A white board in the front lounge has on previous inspections identified the days menu, on the day of this inspection it only informed people of activities taking place. The dining room, located off the front lounge, is comfortably decorated and enjoys views across the sea. Limited spaces were laid for dinner and one table was not cleared at lunch time and appeared to be covered with arts and crafts material. A small number of service users used the dining area for their lunch, most remained seated in the lounge and their meal was brought to them. The lounge at the back of the house also has a dining table that was laid for 3 people, others remained in their lounge chairs and had lunch brought to them. Staff were observed to assist service users with their meal in a sensitive manner. We did observe one member of staff use terminology that was not fully respectful to people needing assistance with their food and we raised this issue with the registered manager. We also discussed with the registered manager that whilst people were helped to the dining area, they were seated prior to the tables being laid and food being ready which may not indicate to the service user with limited understanding, that it was a meal time. We also observed that some service users had been served with a main meal and desert whilst others were still waiting for their main meal. Whilst the meals began to be served at 12.45, 3 people did not receive their meal until 1.45. It appeared that whilst staff seemed to do their best to help people in a caring way and were patient and attentive during this period, there were insufficient staff available to meet everybodys needs. Staff use intercom radios to liaise with each other and the noise from these over the lunchtime period appeared to be intrusive. We discussed these issues with the registered manager and registered provider during feedback of this inspection visit. Care Homes for Older People Page 20 of 38 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users and their representatives are provided with information on how to complain should they need to do so. Service users are not fully protected from abuse Evidence: There is a complaints procedure displayed within the home. This is also included within the service users guide. We have not received any formal complaints since the last inspection although there have been 2 complaints made to the home. These were concerning a service users meal and cleanliness of communal areas. The registered manager keeps records of the investigation into any complaint. On the day of inspection the records of the relevant investigations were not able to be located, we were told this was due to the registered manager recently relocating offices in the building. We were shown outcome letters to the complainant. Residents and their relatives / representatives who completed surveys told us that there was someone at the home who they could speak to informally if they were not happy and 5 people knew how to make a formal complaint, whilst 1 person said that they did not. There is a procedure for the safeguarding of vulnerable adults that includes whistle blowing. This document provides information for staff on the types and symptoms of abuse and provides clear guidance on the action they must take should there be any suspected abuse. It was clear from written daily records and notifications completed Care Homes for Older People Page 21 of 38 Evidence: and sent to us that staff understand these procedures and safeguard service users. The 8 Staff records that we case tracked showed that these staff members have all attended safeguarding training. This has been provided internally by one of the directors of the company, who is also an external trainer for Cornwall County Council. The registered and deputy managers have recently attended a deprivation of liberty training and showed a good understanding of their responsibilities regarding safeguarding vulnerable adults and the processes they must follow should their be any suspected abuse. The home itself is an older style property with steep staircases to reach the upper floors. Parts of the house are inaccessible to service users and staff use electronic keys to access different areas of the house. The current service users do not have free access to all parts of the home. The registered provider stated this could be made available by the provision of an electronic key fob, subject to a satisfactory risk assessment based on the individuals physical and mental health. We discussed this with the staff on duty and were told that the service users would not be physically able to return to their rooms unattended even without the restrictions in place. Care Homes for Older People Page 22 of 38 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. Service users live in a clean home but some systems in the home do not promote infection control. A programme of refurbishment has started and is planned to continue throughout the home. Individual accommodation is homely and comfortable. Specialist equipment is provide based on individual need. Evidence: The home is a three storey building with the communal areas located on the ground floor. The layout of the home has significant limitations in providing good quality services and facilities i.e. restricted access of the service users to parts of the home as detailed earlier in the report. This has been recognised by the providers. The expert by experience made their observations of the home and reported The approach to the home has a circular drive with a wonderful garden and plenty of parking. The entrance hall needs some attention to make it more welcoming, the paint is chipped and there is a bare ceiling light bulb. Large colorful prints are on the walls but no fresh flowers - a flower arrangement always makes an entrance more homely. There were areas of the home that had a strong smell of urine. The registered provider responded to these comments by stating that the service users would be at risk from having fresh flowers in the reception area as they reach them, eat them, drink the water or damage Care Homes for Older People Page 23 of 38 Evidence: themselves on broken glass. We observed that since the last inspection several bedrooms have been decorated and refurbished. Carpets in some areas have been replaced. The home employs a maintenance person, shared with the sister care home and records are maintained of areas that need attention. Ongoing refurbishment and redecoration has been planned for the home. The grounds at the front of the home are neat and tidy and the secured area of garden at the rear of the home is accessible to service users as detailed earlier in the report. Fire risk assessments are in place and the home is subject to visits from the environmental health officer. Since the last inspection the bathrooms have been refurbished and now provide more homely bathing areas that are clean and tidy. Service users have a choice of assisted bathing in either baths or showers and there are available ordinary baths in the home. We were told by the registered provider that all hot water outlets that fill baths / showers e.g. where full body immersion takes place have restricted temperature valves in place. We randomly checked the temperature of the hot water and found that in one bath the water is delivered at a higher temperature than is recommended. We discussed this with the registered provider who assured us that all temperatures are checked monthly and will be re-checked and the restrictor valves adjusted accordingly. The provider also added that staff use a bath thermomenter to check the temperature of the water prior to immersing the service user. The communal areas and private bedrooms were noted to be clean and tidy on the day of inspection. The registered persons have attempted to utilise areas of the home for storage and we were informed of further plans to increase the storage areas in the home. A call bell system is in operation within the home. Some rooms were observed to use alarmed mats that will alert the staff if the service user either gets out of bed unattended or leaves their room, we observed that the use of such mats is recorded within the care plan. Other rooms did not have a call bell extension lead in place which means that the service user may not always be able to summons help. We discussed this with the registered manager who told us that not all service users would be able to use the call bell, this should be documented within the risk assessment and care plan information for each person. A large number of rooms appear to have a linoleum type flooring rather than carpet in bedrooms. The manager and registered provider told us that this dictated by the individual needs of the person occupying the room. We saw reference to this in some care planning documentation but not for all service users. Lockable storage facilities have been provided in private bedrooms since the last inspection, these are in the form of a metal medicines type cabinet. Some rooms have a locking facility on the door and this could be provided to any door if requested. Currently none of the service users appear to hold a key although one relative assured us that this is a facility that has been provided to them before and Care Homes for Older People Page 24 of 38 Evidence: that their privacy is assured. Bedrooms are personalised and since the last inspection as previously stated, a number have been refurbished which included the provision of new furniture. This needs to be an ongoing programme as it was observed that in some rooms repair is necessary to the fixtures and fittings. We observed that in the areas where bedrooms are located, there are few distinguishing features to assist service users in locating their rooms or exits to other landings. There are several notices on doors that inform staff not to wedge doors open. It is recommended that in order to promote the independence of service users that personalised pictures and names are displayed on their rooms. Emergency lighting is provided throughout the home and checked on a regular basis. Lighting in the communal areas and bedrooms is domestic in nature. We noted that in some of the corridors there is no natural light and electric overhead lights were turned off during the day leaving a darkened area which could pose a risk to service users and or staff. Most parts of the home are pleasant, clean and hygienic. Some private bedrooms had a distinct odour and 2 of the toilets were noted to smell strongly of urine. We noted that some of the commodes were in a poor condition e.g. frames rusted and seat covers ripped. This does not promote infection control within the home. We asked people in surveys if the home was fresh and clean, 4 said always and 2 said usually. An additional comment was made by a relative of a service user The home is always clean and smells fresh when you open the door. Sanitising hand gel is in place at the entrance to the home and throughout bathrooms and toilets. The laundry is located externally to the home. There are 2 industrial washing machines and 2 dryers. Red disposable bags are used for soiled laundry and all bed linen and towels are sent out to be laundered. The flooring and walls in the laundry are permeable and poses an infection control risk. This is being addressed by the registered provider and it is planned to paint both the floor and the walls. Systems in place in the laundry will not help to reduce the risk of infection e.g. dirty washing was observed to be placed on the floor while waiting to be laundered or sent out for laundering. The laundry assistant told us that the floor is not washed but brushed regularly. There is a designated member of staff working in the laundry every day of the week. Systems have been put in place since the last inspection to ensure that all personal clothing including underwear is returned to its rightful owner and not used communally. We received 2 surveys completed by relatives of service users, who made the following comments about the laundry systems in the home: The laundry service is very variable and sometimes clothes have not been treated well. Wash labels are not always observed, buttons are missing, ironing is not always done and clothes have Care Homes for Older People Page 25 of 38 Evidence: been torn and shrunk and more care should be taken with the laundry and appearance of the residents as shabby clothes can be so undignified. We did not evidence service users dressed in shabby clothes on the day of inspection, but these are comments the registered providers should be mindful of. The registered provider told us that people are fully reimbursed for any clothes damaged in the laundry. Care Homes for Older People Page 26 of 38 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 recruitment procedures are robust and protect service users. Training is actively encouraged and facilitated although there are gaps in the training profiles for some members of staff. Not all staff have undertaken specialised training to meet the individual needs of service users. A high percentage of care staff have achieved their National Vocational Qualification level 2 and / or 3. Evidence: On the day of inspection there were 3 trained nurses on duty, this included the registered manager and deputy manager. Also on duty on the morning of inspection were 6 carers. During the afternoon and evening there were between 5 - 9 members of staff. During the night the rota shows that there is 1 trained nurse supported by 3 carers. The activities co-ordinator arrived mid morning and was observed helping service users with their main meal of the day as well as encouraging them to participate in a craft session before lunch. Ancillary staff included 2 domestic members of staff who were meeting with their NVQ assessor during the morning, the chef was supported by a kitchen porter and the laundry assistant was also on duty. The deputy manager told us that this is normal staffing levels for the home and that if necessary additional members of staff will be brought in to meet the needs of the service users e.g. if someone is unwell and needing additional care. People we spoke with including Care Homes for Older People Page 27 of 38 Evidence: the service users and relatives were positive about the staff and said they are kind and caring, the staff work hard and are very patient and caring and I am very satisfied with the care my relative gets and the staff are kind and caring and Kate [the deputy manager] is just brilliant. Our concerns regarding service users having to wait for their meals may link to staffing levels. The registered manager stated that the staffing levels are reviewed regularly and would be adjusted as necessary. Comments were made in surveys from relatives of service users regarding staff are very busy and sometimes appear tired. The same people commented that the staff are very kind, caring and patient and one person said that nothing was too much trouble for them. One member of staff informed us within a survey that they would like more staff to be on duty as sometimes there are not enough. All staff are encouraged to participate in training including their National Vocational Qualification (NVQ) level 2 or 3 training. The Annual Quality Assurance Assessment (AQAA) informed us that 19 out of 26 care staff have completed the NVQ level 2 training. Staff are provided with induction training and the programme for induction training is in line with the skills for care foundation standards. Records inspected for recently employed members of staff show that induction training is in progress or has been completed with the exception of 1 member of staff. The training is provided to staff by resources purchased from an external training company. This consists of the staff member using the computer for e-learning modules and completing work books. The registered provider told us that the original module work books are checked by the manager or one of the directors and guidance given if necessary. The written paper is taken under examination conditions and sent for external marking and verification. Workshops are facilities by a director within the home to support staff with this form of training. The training includes moving and handling, First Aid, food hygiene, infection control and medication. One of the directors provides basic life support training in conjunction with the first aid training material provided by the external company. The home has 2 members of staff who are trained moving and handling trainers and provide practical training. Other training that some but not all staff have completed includes dementia care, tissue viability and Parkinsons. As this home is registered to provide care to people with dementia, it is advisable that all staff complete such training. Staff were asked within a survey if their induction covered everything they needed to know to do the job when they started work. 2 said always and 2 mostly. We also asked them if they are given training that is relevant to their role, helps them meet the individual needs of people and keeps them up to date with new ways of working - all 4 staff who completed surveys responded positively. The recruitment records for 8 members of staff were inspected. These records showed that many staff have been employed at the home for significant periods of time. The registered provider ensures that the applicant completes an application form and Care Homes for Older People Page 28 of 38 Evidence: attends an interview. Two written references and a criminal records bureau check are obtained prior to the person commencing employment. All staff receive a written contract. Care Homes for Older People Page 29 of 38 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users benefit from the ethos and leadership of the registered and deputy managers. Feedback is sought from residents and / or their relatives regarding the way in which the home is run. Evidence: Since the last inspection the manager has successfully registered with the Commission for Social Care Inspection - now the Care Quality Commission (CQC). The registered manager returned to the home to work in August 2008, having left for approximately 1 year to seek alternative employment. The registered manager is employed for full time hours and has many years experience working in care homes and is a registered nurse. We were told that the registered manager has attended regular training courses to keep updated in order to maintain her Nursing and Midwifery Council registration. Staff and relatives that we spoke with appeared to understand the organisations lines of accountability and know the registered providers. The registered providers provide Care Homes for Older People Page 30 of 38 Evidence: supervision and support to the registered manager. Staff were positive regarding the roles of the registered manager and the deputy manager and the support that they give. Staff meetings take place regularly and follow a planned agenda with the opportunity for staff to air their views. Written minutes are held of these meetings which we were able to access on the computer. The registered manager has recently sent out quality surveys as part of the quality assurance procedures of the home. There have been some returned and once all are returned we were told that an audit is to take place and the outcome of the survey will be published and available to all interested parties. We were shown the surveys returned so far and comments included the care of patients from staff is second to none, their patience is wonderful, you are all so kind and friendly and me and my family appreciate it very much, nothing is too much trouble when we visit and we are always greeted with a lovely smile even and you all work so jolly hard, you provide first class meals and staff are always friendly and polite, they are a credit to their profession. The registered providers visit the home regularly and on a monthly visit undertake a formal quality monitoring exercise in line with the National Minim Standards and Regulations for care homes. During this visit they speak with service users and staff and record the findings of their visits. Policies and procedures used within the home are regularly reviewed and updated where necessary as evidenced by the date recorded on each policy. The most recent inspection report is available in the home and within the service users guide for interested parties to look at. The home does not routinely hold money for service users. However, the registered provider does manage the financial account for one service user but is currently in discussion with DACS to make alternative arrangements for this person. The registered manager told us that should a service user require money for any reason this could be arranged and the representative of the service user invoiced at a later date. We noted that some valuables belonging to service users are stored in the registered managers filing cabinet. We were told that some of these were lost property that was unable to be traced to the owner and some belonged to previous service users. Insufficient records were maintained of these valuables and the the system for storing valuables for the service user is not robust enough to protect either service user or the staff. Staff records identify that supervision takes place regularly by the written evidence of the date on which it happened - no further detail is recorded in staff records. On discussion with the deputy manager it appears that the supervisor holds the records. This means that they may not always be readily available to the registered manager or for inspection. Annual appraisals have been undertaken, records of which are held securely in staff files. Staff who completed surveys informed us that they are regularly provided with support from their manager and also meets with the manager to discuss Care Homes for Older People Page 31 of 38 Evidence: how they are working. The registered manager is responsible for health and safety within the home, with other members of staff having specific roles e.g. fire safety is manage by a senior carer. A health and safety audit of the home was been completed at the end of last year by an external company. As a result of this audit 2 recommendations were made. Fire risk assessments are in place and fire safety checks take place as required by legislation. We observed that one fire door did not fit the frame and this should be rectified as a priority. We saw environmental health and safety risk assessments that have been reviewed since their implementation, the last review was as recent at 20/05/09. These included the use of portable heaters in some of the rooms. Evidence of maintenance and servicing checks were available for inspection including Gas safety, legionella testing and the lift and hoists. Portable appliance testing has been carried out this year with the results held on file. The 5 yearly hard wiring test certificate stated that the system was unsatisfactory. We discussed this with the registered provider who told us that the remedial work recommended by the electrician has now been carried out and they are waiting for a certificate to be issued to identify this. There are 2 designated moving and handling trainers and staff we spoke with have received moving and handling training and were confident with providing care to the current service users. COSHH assessments are completed and available to staff. Areas where COSHH substances are stored are locked securely to protect service users. Care Homes for Older People Page 32 of 38 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 19 23(2)(b)(d) The registered person shall ensure that all parts of the care home are reasonably decorated. 14/08/2008 Care Homes for Older People Page 33 of 38 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 It is required that the 11/08/2009 registered person shall consistently ensure that the service users plan of care is kept under review and where appropriate after consultation with the service user or a representative of his, revise the service users plan and notify the service user or his representative of any such revisions. This is so that staff are provided with up to date and accurate information to inform and direct them of the action they must take to meet the service users assessed care needs. 2 15 12 It is required that the 11/08/2009 registered person makes proper provision for the health and welfare of service users and ensures that the home is conducted in a manner which respects the Care Homes for Older People Page 34 of 38 privacy and dignity of service users. Meal times should be organised and conducive to relaxed and enjoyable eating experience 3 16 14 It is required that the registered person maintains a record of all complaints made by the service users or their representatives and the action taken by the registered person in respect of any such complaint. This is to ensure that all complaints are investigated thoroughly with written records to identify the action taken. 4 26 16 It is required that the 12/08/2009 registered person keep the care home free from offensive odours and maintain satisfactory hygiene standards within the home. This will assist the promotion of infection control. Commodes should be in a condition that enables them to be cleaned thoroughly. 5 35 16 It is required that the registered person provide a place where the money and valuables of service user may be deposited for safe keeping, and make arrangements for service users to acknowledge in 12/08/2009 11/08/2009 Care Homes for Older People Page 35 of 38 writing the return to them of any money or valuables so deposited. This is to ensure the security of money and valuables belonging to service users and offer protection to both service users and staff. 6 36 18 The registered person shall ensure that staff are appropriately supervised with written records maintained that evidence this. Written records must be made available to the registered manager and for inspection if required. 7 38 13 It is required that the registered person ensures that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. All fire doors must be able to shut completely and not remain ajar. 13/07/2009 12/08/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 It is recommended that daily records show clearly the personal care provided to service users e.g that the meaning of codes used are reflected on the form so that there is clarity to the reader. It is recommended that the programme of activities is Page 36 of 38 2 12 Care Homes for Older People developed to encourage group work providing social interactions amongst the service users. 3 22 It is recommended that where an assessment has been made that the service user would not be able to use a call bell extension lead or would be at risk from having such a facility, this should be recorded within the risk assessment or care plan. It is recommended that the use of linoleum flooring in private bedrooms should be assessed and recorded within care planning documentation. It is recommended that furniture is repaired or replaced where necessary in service users bedrooms. It is recommended that in order to promote the independence of service users that personalised pictures and names are displayed on their rooms. It is recommended that where there is no natural lighting to communal areas e.g. corridors, arrangements are made to ensure that these areas are lit and safe to use for service users and staff. 4 24 5 25 Care Homes for Older People Page 37 of 38 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 38 of 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!