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Inspection on 14/10/09 for St Georges Care Home

Also see our care home review for St Georges Care Home for more information

This inspection was carried out on 14th October 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There is clear information about the home, so people will know what the home has to offer in respect of services and facilities. People have access to the healthcare services that they need. Medication procedures are in line with good practice, but any significant events must be acted upon appropriately. People can participate in a range of different activities if they choose to and they can spend their time as they want to. St Georges Care Centre is a well equipped and comfortable nursing home where people will be looked after in a clean tidy and fresh smelling environment.

What has improved since the last inspection?

There were seven requirements issued after the random inspection visit in May 2009. Five were in respect of care planning and risk assessment processes and on the whole these have been met. One requirement was about the cleanliness of one specific bedroom. We toured the home and found all areas to be clean tidy and fresh smelling. The seventh requirement was in respect of people being protected from financial abuse. Some actions have been taken however this is not concluded yet. This requirement is therefore being carried over.

What the care home could do better:

Admission procedures are not consistently followed and this may mean that people will be admitted whose needs can not be met. Although care planning is on the whole good, the care provided to some people may often fall short of an acceptable standard. The meal time arrangements are not meeting every person`s needs and some people are dissatisfied with the meals they are given. The management of any concerns or complaints that people who live in the home, or their relatives have, are not being addressed adequately. Staff must ensure that they meet people`s needs at all times and safeguard those in their care. The numbers or skill levels of those staff on duty may not always be appropriate to meet the collective care needs of the people in residence and may mean that people will not receive all the care and support that they need. The induction training for new staff is not consistently in place and may mean that people will be looked after by carers who are not confident in their role. There is evidence to suggest that people who live in St Georges Care Centre may not always be receiving the best service because management and the staff team are not working together in the best interests of the home.

Key inspection report Care homes for older people Name: Address: St Georges Care Home Kenn Road St George Bristol BS5 7PD     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: Vanessa Carter     Date: 2 0 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: St Georges Care Home Kenn Road St George Bristol BS5 7PD 01179541234 01179542233 stgeorgecarecentre@tiscali.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): St Georges Care Home Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 68 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Manager must be a RN on parts 1 or 12 of the NMC register. May accommodate up to 68 persons aged 50 years and over requiring nursing care. Staffing Notice dated 22/06/2001 applies Date of last inspection Brief description of the care home St. George is registered as a Care Home for a maximum of 68 service users requiring nursing care. The home is situated in a residential area of St. George, with easy access to local community facilities and is less than 3 miles to the city centre. It can be accessed by car or bus, with a short walk. The home is purpose built, providing a mix of double and single en-suite rooms. Care is provided over two floors, the first being for the more dependent service users. Each floor offers bedrooms, communal lounge and dining room as well as bathroom facilities. There are also pleasant gardens to the rear and side of the property. There is a passenger lift providing access to all service Care Homes for Older People Page 4 of 32 1 4 0 5 2 0 0 9 0 Over 65 68 Brief description of the care home users areas. All parts of the home are accessible to the able-bodied as well as wheelchair users. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We were not due to inspect this service again until April 2010 because when we last inspected in April 2008, we decided that people were receiving a good quality service. Because of a number of events and complaints we had received we did a random inspection in May 2009 - seven statutory requirements were issued following this inspection. We have received further complaints about this service and have therefore brought forward this key inspection. The inspection was unannounced and took place over two days and a total of 14 hours were spent in the home. Prior to the inspection we received information from an anonymous caller who gave us some information that gave us cause for concern. We also received information from health and social care personnel. During our visit to the home we spoke with the home manager, the regional manager, registered nurses and care staff. We observed staff practices and their interaction with Care Homes for Older People Page 6 of 32 people who live in the home. We looked at care records for four people, and recruitment records for new staff members. We spoke with a number of people who live in the home and one relative who was visiting. We had a look around the home and saw most of the bedrooms and the communal living areas. As a result of this inspection a number of requirements and recommendations have been issued. An improvement plan will be requested with the aim of raising standards and stamping out bad practice. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: Admission procedures are not consistently followed and this may mean that people will be admitted whose needs can not be met. Although care planning is on the whole good, the care provided to some people may often fall short of an acceptable standard. The meal time arrangements are not meeting every persons needs and some people are dissatisfied with the meals they are given. The management of any concerns or complaints that people who live in the home, or their relatives have, are not being addressed adequately. Staff must ensure that they meet peoples needs at all times and safeguard those in their care. The numbers or skill levels of those staff on duty may not always be appropriate to meet the collective care needs of the people in residence and may mean that people will not receive all the care and support that they need. The induction training for new staff is not consistently in place and may mean that people will be looked after by carers who are not confident in their role. There is evidence to suggest that people who live in St Georges Care Centre may not Care Homes for Older People Page 8 of 32 always be receiving the best service because management and the staff team are not working together in the best interests of 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 9 of 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is clear information about the home, so people will know what the home has to offer in respect of services and facilities. Admission procedures are not consistently followed and this may mean that people will be admitted whose needs can not be met. Evidence: A copy of the homes Statement of Purpose and Service User Guide is kept in the main reception area - they are dated August 2009 and September 2009 respectively. A copy of the last inspection report dated April 2008 was also present. The home has a colour brochure that is given out to people who enquire about the home. These documents provide details about how nursing and healthcare needs will be met, the private rooms, the social environment, lifestyle and meal time arrangements, and visiting arrangements. People who want to know about what St Georges Care Centre has to offer will be provided with clear and detailed information. A service user guide is placed in each bedroom - one visitor was seen reading a copy and said it was good to be provided with the information. Care Homes for Older People Page 11 of 32 Evidence: The home last submitted their annual quality assurance assessment in February 2009. They told us that people will have their care needs assessed prior to admission. However, what we found was that not all admissions to the home will have been previously assessed. An elderly care Pre-admission Assessment form should be used to record details about a prospective person. We saw an assessment completed for a person who had recently moved in to the home. It recorded information about the persons significant medical history, significant social and psychological history and the current medication regime. The information recorded was detailed and provided a clear indication of the persons needs, including whether any specific nursing equipment was required. The decisions to admit some people to the home are made after telephone consultations only and we have been told on at least one occasion, a person has been admitted before local authority care plans had even been submitted in this instance this means that the home had no written information about the person admitted. We asked about one person who we were told was admitted for a one night unplanned stay, and were advised that a respite stay was cut short. No paperwork was shared to evidence this. During the inspection arrangments were being made to admit a person with highly complex care needs for a respite stay, and information was being gathered from the relative/main carer. No arrangments were being made for a home visit. These significant shortfalls have the potential to mean that people may be admitted whose needs can not be met. The registered provider must ensure that accommodation is not provided to any person before their care needs have been assessed by an appropriate person. Two of the beds in this home are contracted to be Safe Haven beds and people will be admitted in to these, from the community, by the Intermediate Care Team, in order to prevent hospital admissions. There has in the past been problems with decisions being made about who is admitted into these beds but there are now closer working relationships with the health assessment and review teams and the intermediate care teams. The home manager or registered nurses employed by the home have a say about who is admitted into these beds and we were told that they have made decisions that particular admissions were inappropriate. The home provides placement for those with general nursing needs or end of life care needs. They provide short term stays for people when they have vacant beds. Care Homes for Older People Page 12 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although care planning is on the whole good, the care provided to some people may often fall short of an acceptable standard. People have access to the healthcare services that they need. Medication procedures are in line with good practice, but any incidents concerning medications must be properly reported and acted upon. Evidence: We looked at four sets of care planning documentation to determine how the home organises the care delivery arrangements for each person. Following a comprehensive assessment, care plans were prepared for each person. The format and quality of the plans were generally good although one plan was not completed with as much detail as the others, and some information was incorrect. We saw examples where specific personal information was recorded in respect of peoples needs and how they wished those needs to be met - for example may be able to choose between outfits. Amendments needed to be made to one persons plan in respect of bed rails. This person was choosing to sleep in a recliner chair, but their plan referred to the need for bed rails, and each night the nurse recorded refused to go to bed. For another person their plan said they needed to be weighed on a daily basis - there were no Care Homes for Older People Page 13 of 32 Evidence: records to evidence that this is done and discussions with the nurses evidenced that this was not required. This does not evidence a full committment to providing person centred care. Care staff told us that they do not have time to read the plans, but the home manager told us that they are trying to overcome this by placing peoples care files in their bedrooms. Alongside the care planning documentation, risk assessments are completed in respect of the likelihood of developing pressure sores, nutritional needs, the probability of falls, and to identify the risks involved in any manual handling procedures. From the manual handling assessments a safe system of working is devised - these were detailed and gave clear instructions to staff on what they needed to do and what equipment is required. Care plans had in general been reviewed on a regular monthly basis. Where a review identifies a change in care needs these are reflected in an amended plan of care. A daily record is completed for each person - the quality of what was written was generally good and informative. A Collaborative Care record is kept for each person, of GP and other healthcare professional contact. We were told that the majority of people are registered with one doctor who works from the next door health centre - ward rounds are completed every monday, wednesday and friday morning and most people will be seen at least once a week. Other healthcare professionals will visit as and when necessary. People spoken with during the inspection were generally satisfied with the care that they get. I dont want to be here but I am well looked after, I couldnt manage on my own any more and it is nice knowing the girls are there to help me and I am happy here and my daughter sorts out everything for me with the staff. However, one person said that call bells are not always answered promptly and there were two occasions within a short space of time during the inspection, when staff needed to be asked to respond to call bells instead of standing around at the nursing station. We found one person using a tin to bang the table to summon help, as their call bell was left the other side of the room and tangled under the bed. Staff need to be more vigilant and ensure that people are not left without the means of calling for assistance. For this person it has already been raised as an issue that they had been left without their call bell and despite this it has happened again. Staff told us during the inspection that they are only able to provide basic care for people because they are so busy and some staff are inexperienced. This will be referred to again in the staffing section. Care Homes for Older People Page 14 of 32 Evidence: The medication systems are unchanged since the last inspection. During this inspection we reported that the procedures in place for the ordering, receipt, storage, administration and disposal of medications were safe and followed good practice guidelines. A planned meeting with the pharmacist has been held to sort out a few problems that the home were experiencing and we were told that the meeting was constructive. We were told that drug errors are not always reported via the regualtion 37 notification process. Two such errors (medication ommissions) that resulted in no adverse effects were confirmed as having taken place by the home manager who was dismissive about why they were not reported to us. The home manager must ensure that any medication errors, including where omissions have taken place are reported appropriately and action is taken to prevent a reoccurrence. People spoken with during the inspection had very differing views about how they were cared for. One said the girls are always rushed and may not always come and help me in time and other comments included some staff are better than others, Mustnt grumble, they all do their best and I do feel a nuisance if I have to ask for help as the regular staff are so stressed. A concerned family member wrote to us and raised serious concerns about how the staff team are being treated by the manager. This information along with what were were told by staff we spoke with, clearly indicates that the people who live in St Georges care Centre are being burdened with the anxieties of the staff team and that their care needs may be taking second place. St Georges Care Centre looks after many people who have end of life care needs and who may be funded by continuing health care funding. We were told that care staff and registered nurses are involved in the St Peters Hospice End of Life project and that nurses are competent in setting up and administering pain management medications. One such person said I can not fault the way I am being looked after. I am very comfortable. My family are very pleased that I am here as well. Care Homes for Older People Page 15 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can participate in a range of different activities if they choose to and they can spend their time as they want to. The meal time arrangements are not meeting every persons needs and some people are dissatisfied with the meals they are given. Evidence: The home has a full time Activities Organiser who works between the two floors and organises a range of diffent activities. The activity plan for the week was displayed in the main foyer and this included ball games, painting, decoration making, bingo and flower arranging. A church service is held on a fortnightly basis and a hairdresser visits the home on a regular basis. During the inspection we saw some people taking part in an arts and crafts session. Many people were in their own bedrooms - I do not feel well enough to join in and prefer to stay quietly in my room, I like to read my newspaper and do the crossword and I always go along to the church service were comments made by people during the inspection. We were told that they are always informed what is going on. People are encouraged to go out with family and friends and to continue with community activities if they wish. People are asked what time they like to get up, go to bed and where they want to have their meals served. A completed residents individual preference questionnaire Care Homes for Older People Page 16 of 32 Evidence: had been completed for some people - in addition they are asked what they would like to be called, whether they want to be involved in resident meetings, preference for a bath or shower, and their preference in respect to keyworker allocation. The home has a rolling menu plan and we were told that these are changed three times a year. An extra cook has been employed to cover the evening shifts and hostesses are employed to help serve out meals. There is a choice of two main midday meals and alternatives can be provided upon request. We were told that people can choose a variety of different cooked breakfasts. Some staff reported that the quality of food served has improved, meals are served at set times, but sometimes they are served late. There have been recent changes to the time breakfasts are served but people can still choose when to have their meals. Other concerns that have been raised with us about meals are that they are sometimes served cold, there may not be enough food to go around, particularly the tea time meals, and that visitors are not allowed to join relatives for meal times. This last fact has been followed up by health and social care colleagues who have been provided with mixed messages, including that visitors are discouraged at meal times. Care Homes for Older People Page 17 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of any concerns or complaints that people who live in the home, or their relatives have, may not be addressed adequately. Staff must ensure that they meet peoples needs at all times and safeguard those in their care. Evidence: The homes complaints procedure is displayed in the reception area and is included in the service user guide, kept in each bedroom. We were told that nurses will generally deal with any grumbles or concerns but formal complaints are referred to the home manager. Staff told us that there was a lot of dissatisfaction amongst relatives and that they are not listened too. This was discussed with the home manager who advised that a relatives meeting has been scheduled for the beginning of November to air concerns. Flyers advertising the meeting were displayed in the home with a note that specific care issues would need to be addressed separately with the home manager. The home manager holds an evening surgery but states that no-one comes to see her. We spoke with two visitors who did not raise any concerns about their relatives care. Although we did not receive any specifics complaints during the inspection, we are not assured that complaints are taken seriously by the home manager as some comments made, were very dismissive about the issues being discussed. We have been contacted on five occasions since the last inspection, by anonymous callers,relatives, health and social care colleagues and healthcare professionals. Care Homes for Older People Page 18 of 32 Evidence: Concerns have been raised about inadequate staffing levels or staffing skill mix, standards of care, food and mealtimes and the way in which staff are being treated. In our opinion some of these complaints are being generated by the staff themselves as we are being told that residents are distressed and extremely worried about what is going on around them. We are concerned that the people who live in St Georges and their relatives are being burdened with staff issues. The home has notified us of four events that have occurred where peoples welfare has been affected. One of these complaints was dealt with under Safeguarding of Vulnerable Adults (SOVA) protocols, one by the homes disciplinary procedures and the other two involved Police action. Each of these four events were handled correctly involving the appropriate agencies. The home needs to take further action to safeguard peoples belongings as this issue has not yet been concluded. People spoken with during the course of the inspection, who were able to express an opinion, felt that they could raise any concerns - the girls do their very best but I would ask my daughter to sort things out and it depends which staff are on duty. There are a lot of new staff and the care staff and nurses are very kind and thoughtful. Staff spoken with during the inspection said that complaints are swept aside, ignored and not acted upon. The complaints log that we were given contained only one complaint about loss of personal belongings and this was being dealt with. We discussed a recent complaint raised by healthcare visitors - this had not been recorded. This, along with other information does not evidence that the home view complaints seriously. The home has an adult protection policy and staff whistleblowing policy. We were told that because of recent issues amongst the staff there is dedicated whistleblowing telephone hotline - the regional manager and home manager stated that there have been no calls from staff working in the home since this was set up. Staff spoken with said that they had received safeguarding training and understood what constituted abuse. Because many of the staff are new, they referred to the nurses or the manager as those who they would report safeguarding concerns to. Registered nurses and the home manager demonstrated their awareness of their responsibilities to safeguard people from harm and of what actions to take to report concerns, but we were told of an incident when one carer reported that a colleague had been rough with a person, and no action had been taken. They must ensure that appropriate reporting is made to the local authority. The staff team must also ensure that at all times, their actions do not place people at risk from harm, and that peoples care and support needs are being met. There were two occasions during the inspection where the staff had to be asked to attend to people who were requiring assistance. Care Homes for Older People Page 19 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. St Georges Care Centre is a well equipped and comfortable nursing home where people will be looked after in a clean tidy and fresh smelling environment. Evidence: St Georges Care Centre is a purpose-built two storey home designed specifically around the needs of elderly people and those whose mobility is reduced or severely impaired. The home is surrounded by attractive gardens with well established shrubbery. Plenty of car parking is available to the front of the property and there is level access to the front door. The main entrance is locked and during office hours callers will be welcomed by a receptionist. There are two passenger lifts up to the first floor as well as a central staircase. Information boards are displayed in the foyer and main reception area. We were notified by an anonymous person that some of the information displayed in this area was not appropriate and this was discussed with the home manager and the staff team. We saw that staff rotas, information about social events, a relatives information board, and registration certificates were displayed in this area. There are several communal areas located throughout the home. The main lounge on the ground floor consists of three areas of seating all linked together. The main dining room on the ground floor is set out hotel style and has access out into the rear gardens. On the first floor there is a small dining room and a small lounge. There is a Care Homes for Older People Page 20 of 32 Evidence: hairdressing salon that relatives are able to use. On each floor there is a kitchenette where visitors are able to make refreshements. Toilets and assisted bathrooms are located throughout the home. Each floor has sluice room facilities, separate from the bathing facilities. The home has a sufficient range of equipment to enable staff to undertake their duties and to move people safely. The majority of beds are electric profiling beds or hospital type beds. There is a plentiful supply of pressure relieving mattresses and pressure cushions. A nurse call bell system is installed in each bedroom and the communal areas, although if people who need to call for assistance are not provided with a call bell, then this facility is no use to them. Reference to this has been made in section two (health and personal care). The corridors are wide and fitted with grab rails. There are two shared bedrooms and 64 rooms for single occupancy. Each of the bedrooms are well furnished, have fitted wardrobes, a chest of drawers and a bedside cabinet with lockable drawer. People are encouraged to bring in any items of furniture they want and to make their private bedroom their own. Some bedrooms have patio doors leading out on to the rear garden. All areas of the home are well decorated, were clean tidy and smelt fresh. The laundry room has two industrial washing machines and two large tumble dryers with appropriate specified programmes. The laundry is staffed each day until 2pm and then again from 4-7pm. Care Homes for Older People Page 21 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers or skill levels of those staff on duty may not always be appropriate to meet the collective care needs of the people in residence and may mean that people will not receive all the care and support that they need. The induction training for new staff is not consistently in place and may mean that people will be looked after by carers who are not confident in their role. Evidence: We have been contacted on several occasions about staffing levels at St Georges Care Centre and for this reason we undertook a random inspection visit in May 2009. At this visit we determined that the staffing levels were appropriate. Further concerns have now been raised so we decided to bring the next full inspection forward. What we found this time was that there have been many occasions when shifts have been worked with fewer staff on duty. On the 3rd October instead of 11 care staff there were only eight on duty until one additional staff member came on duty and on the 4th October there were only 10 care staff. At this time there were 64 people in residence. Staff said there were no events over this weekend, but the skill mix during these shifts was poor - there was a number of agency staff on duty, plus inexperienced carers and only a few competent care staff. One of the new staff members said it was like the blind leading the blind whilst another felt very unsupported and overwhelmed. Staff reported that this was a significantly bad weekend, there have been many occasions where they are short staffed and the Care Homes for Older People Page 22 of 32 Evidence: numbers of shifts worked like this is increasing. Since the beginning of 2009 there has been a large number of staff leave - this may be because they have been dismissed, or resigned, but means that there is currently lack of a stable staff team. Long-term staff have left their jobs and been replaced with workers some of whom have little experience in caring. The home manager told us that they have recruited new staff and therefore the use of agency workers will now diminish. A stringent sickness management policy has been introduced as last minute sickness is always the reason for short shifts. There is a very low morale and unsettled feel amonsgt the staff team who it seems are generating anxieties with people who live in the home and their relatives. This is not acceptable. It is our opinion that staffing levels are not arranged to take into account the dependency levels and care needs of the people who live in the home. There is also no thought about the skill mix, rather just a case of numbers on duty. The regional manager and home manager talked of a dependency tool they use to look at peoples collective needs, but no evidence was shared with us to confirm this. Nurses and care staff are supported in meeting peoples daily living needs by a team of administrative, housekeeping, catering, laundry and maintenance staff. We were told by the home on the AQAA that of their 36 care staff, 12 of them had achieved a National Vocational Qualification (NVQ) Level 2 in health and social care. This would mean that a third of care staff are trained. As this standard was not a focus of this inspection we did not ask what percentage of staff now hold an NVQ qualification - the changes in the staff team may well have altered these numbers. We looked at the recruitment files for four of the new staff who have been recently recruited. All four people were interviewed by the home manager but the interview assessment record only showed very brief notes. Two written references are obtained - these may be from previous care employers, character references or from other types of employment. POVA1st checks had been received on three people before they started employment but for the forth member of staff, the home did not have verification of a clear POVA1st check until after they had started working in the home. This shortfall is not acceptable and could potentially place the people who live in the home at risk of being cared for by unsuitable workers. It is policy that new staff complete an induction programme of training at the start of their employment and we were told that much of this is done via an e-learning programme - work is submitted to the Caring Homes training department and is assessed and marked. Those staff we spoke with during the course of the inspection, gave a very mixed response about induction training. One staff member confirmed Care Homes for Older People Page 23 of 32 Evidence: there was a programme to be completed but thought this had to be finished within 26 weeks. Two other staff members said they were unaware of an induction programme. Overall, the view was that new staff did not have long enough to orientate, were getting thrown in to the job too quickly, I am not being looked after, I sometimes have to work with other new staff who know no more than me and I have not been a carer before and I feel unsupported. More competent care staff and registered nurses are concerned that they are not able to train new staff properly. Two new staff told us that they had not done the practical manual handling training despite working for several weeks. The home manager told us that the deputy manager will be taking over the monitoring of staff training and therefore this will be followed up in the next inspection. The training plan for the home and the training opportunities each member of staff has taken up, was not a focus of this inspection and will be followed up at the next full inspection. We will want to see evidence of induction training programmes being completed within 12 weeks of employment, mandatory training and any other relevant training and development courses attended. Care Homes for Older People Page 24 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is evidence to suggest that people who live in St Georges Care Centre may not always be receiving the best service because management and the staff team are not working together in the best interests of the home. Evidence: The home manager has been in post since March 2009, having previously been a registered manager at other nursing homes in the South West region. She is a Registered Nurse, has completed the Registered Managers Award and has already made application to the Commission to be the registered manager for the service. Prior to March a number of interim home managers were in post as a stop-gap measure, after the departure of the registered manager who had held the post for many years. There was an over-riding view expressed during this inspection that staff are not listened to, relatives are unhappy and their complaints are ignored and people are Care Homes for Older People Page 25 of 32 Evidence: being cared for by staff who are disillusioned about their jobs. There has only been one relatives meeting since the manager took up post, although the next one is already planned for the beginning of November. Staff meetings are not held on a regular basis and some meetings have been replaced with letters of instructions to staff. This does not evidence a two way exchange of ideas. In view of the level of dissatisfaction expressed by the staff, and the alleged dissatisfaction of relatives and people who live in the home, it would be a good idea for Caring Homes to complete a full quality assurance survey in order to assess the satisfaction rate, and then devise an action and development plan to improve the quality of their service. We were told that the regional manager completes monthly Regulation 26 visits and records are kept of these in the home - we did not see these during this inspection. We were also told that a monthly audit is conducted by a different manager from another Caring Homes home. We did not see these records either. The home will be asked to prepare an improvement plan as there are many shortfalls in meeting the national minimum standards and regulations of the Care Standards Act. The home looks after personal monies for some people and we were told that new procedures are being put in place to account and audit arrangements. The records were not checked during this inspection as this was not a focus of our inspection. During the inspection safe moving and handling procedures were observed. However some staff told us that they have not yet received practical training in moving and handling tasks. We were also told that care staff do not tend to spend time reading peoples care plans and therefore do not read the safe systems of work devised following a moving and handling risk assessment - I would ask other staff how to move someone if I did not know was however an encouraging comment. The home manager has already identified this as a problem and it is now practice for care planning documentation to be kept in each persons bedroom. Environmental audits of the home are completed on a regular basis but the records were not checked during this inspection. There were no health and safety concerns raised during this inspection. We are not always informed of significant events that have occured in the home via the regulation 37 notification procedure. This is the second time this has been discussed with the home manager. Care Homes for Older People Page 26 of 32 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 37 Notify the Care Quality Commission of circumstance that affects the health and safety of the residents To meet the regulation 30/06/2009 Care Homes for Older People Page 27 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 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 3 14 The registered person must ensure that a full assessment of needs is completed prior to offering placement in the home. This is so that people can be assured that their needs can be met and the home is the right place for them. 20/11/2009 2 7 15 The registered person must ensure that a plan of care is prepared for each person that sets out their individual needs. This plan is to be reviewed and revised monthly or as often as is necessary. This is so that people are cared for in the way that they wish and their care needs will be met 20/11/2009 Care Homes for Older People Page 28 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 8 12 The registered person must ensure that people receive the care and support that they have been assessed to need. Call bells must be answered in a timely manner and people must not be left without the means of calling for assistance 20/11/2009 4 9 13 The registered person must ensure that any medication errors are reported and actions taken accounted for. This is so that lessons can be learnt from events and people will not be harmed by unsafe medication practices 20/11/2009 5 16 22 The registered person must ensure that all complaints are handled seriously and a record kept of all investigations and actions taken. This is so that people can be assured that any complaints they have will be taken seriously and they can demonstrate what actions are taken. 20/11/2009 6 18 13 The registered person must ensure that people are safeguarded from harm. 20/11/2009 Care Homes for Older People Page 29 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is so that people are safe and any relevant events are investigated to a conclusion. 7 27 18 The registered person must ensure that peoples needs are met by the appropriate numbers and skill mix of staff. This is so that people receive the support that they need from staff who are competent and able to meet their needs 8 28 18 The registered person must ensure that staff have the necessary skills and confidence to be able to carry out their jobs. This is so that people are in safe hands at all times 9 29 19 The registered person must ensure that full recruitment checks are always completed before new staff are taken on. This is so that people will not be cared for by unsuitable workers. 10 33 24A The registered person must complete an improvement plan as a result of this inspection. 20/01/2010 20/11/2009 20/11/2009 20/11/2009 Care Homes for Older People Page 30 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is so that an action and development plan can be devised and standards can be improved. 11 38 37 The registered person must 20/11/2009 ensure that we are informed about all notifiable events This is so we are kept informed and are aware of the actions the home is taking to deal with different situations. 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 33 A full quality assurance survey including the views of service users, relatives, staff and other stakeholders should be undertaken as part of the improvement plan. Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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