Inspection on 17/02/10 for Sunrise Operations Southbourne Limited

This inspection was carried out on 17th February 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sunrise Operations Southbourne... 21/09/09

Sunrise Operations Southbourne... 17/07/09

Sunrise Operations Southbourne... 13/08/08

Extracts from inspection reports are licensed from CQC, this page was updated on 16/05/2010.

Key inspection report Care homes for older people Name: Address: Sunrise Ops Southbourne Ltd (Reminiscence Neighbourhood) 42 Belle Vue Road Southbourne Dorset BH6 3DS     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: Gloria Ashwell     Date: 1 8 0 2 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 40 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 40 Information about the care home Name of care home: Address: Sunrise Ops Southbourne Ltd (Reminiscence Neighbourhood) 42 Belle Vue Road Southbourne Dorset BH6 3DS 01202437600 01202437601 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Sunrise Operations Southbourne Ltd care home 33 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: The maximum number of service users who can be accommodated is 33. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Dementia (Code DE) Date of last inspection Brief description of the care home The first Sunrise Community opened in the USA in 1981 and the Company has expanded both in the USA and, more recently in Europe. Sunrise provides care services to older people and has developed in the UK along the lines of the model operated in the USA. The first Sunrise community opened in South East London in 1998. Sunrise Operations Southbourne Ltd is a large purpose-built building set in its own grounds in a residential area of Southbourne, relatively close to a wide range of local amenities and the sea front. There is extensive vehicle parking to the side and a large Care Homes for Older People Page 4 of 40 Over 65 0 33 1 7 0 7 2 0 0 9 Brief description of the care home landscaped garden with patio areas to the front and rear, and a roof garden exclusively forthe use of residents of the Reminiscence Neighbourhood (the subject of this report). Access to all parts of the building is via the reception area on the ground floor. The Reminiscence Neighbourhood specialises in the care of elderly people with dementia and comprises the second (top) floor of the building. On the ground and first floor levels is the Assisted Living Neighbourhood being a separately registered service operated by the same provider organisation. Private accommodation is provided by a variety of suites for single and shared occupancy. In total there are 18 rooms/suites for single occupancy and 8 suites potentially for shared occupancy. Every bedroom has en suite hygiene facilities including a toilet. All double suites are designed so that each of the two residents can have his/her own bedroom or share the bedroom and have a lounge. The home provides all meals, laundry and domestic services. Care Homes for Older People Page 5 of 40 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This was a statutory inspection required in accordance with the Care Standards Act 2000. Throughout the report the term we is used, to show that the report is the view of the Care Quality Commission. During July 2009, in response to concerns regarding the safe handling of medicines, our Pharmacy Inspector visited the home and carried out a random inspection resulting in requirements for improvement. On 17 February 2010 a key inspection commenced and took place over two days. Two Care Homes for Older People Page 6 of 40 inspectors attended the home unannounced, toured the premises and spoke to residents, staff, observed staff interaction with residents and the carrying out of routine tasks and together with the manager discussed and examined documents regarding care provision and management of the home. During the inspection, particular residents were ;case tracked; for example, for evidence regarding Standards 3, 7 and 8, records relating to the same residents were examined and the residents spoken with. During 2009 an Annual Quality Assurance Questionnaire was completed by the manager and returned to the Commission; the information it contained has been used to inform the findings of this inspection. For this inspection compliance with all key standards of the National Minimum Standards was assessed. Following this inspection we notified Social Services of a number of safeguarding referrals for the protection of vulnerable people accommodated in the home. Care Homes for Older People Page 7 of 40 What the care home does well: What has improved since the last inspection? What they could do better: 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 8 of 40 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 40 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Service User Guide does not provide sufficient detail of the fees which may be payable in respect of care and other aspects additional to accommodation and so is failing to give service users clear and comprehensive information. Prior to admission, the needs of each proposed resident are assessed to ensure the home will be properly able to meet them. Evidence: Shortly after arriving in the home on the first day of this two day inspection we requested a list of all currently accommodated residents. Registered manager Mrs Cockwell gave to us a Client Rates Overview list which included the names of all residents, and the varying amounts each was paying for accommodation. The list also included additional fees charged for Care to 6 of the 23 residents currently accommodated. For 5 of these people the additional fee for Care was £19 per week, but for one person the additional fee was £106 per week. Care Homes for Older People Page 10 of 40 Evidence: At intervals throughout the two days of inspection we requested Mrs Cockwell to provide us with written evidence of the particular assessments supporting the additional charges. On the second day of inspection a Family Liaison staff member came to us to explain the additional charges and told us that they were to fund a Silver Service for excursions, activities, entertainment and alcohol with meals, for people who were funded by the Primary Care Trust because the fees paid by the PCT did not include provision for these aspects. This person agreed to provide us with written details of the Silver Service and in due course we were given a document which we found to be the policy for continuing care of a PCT in Buckinghamshire. Part of the document had been marked with a tab to bring it to our attention. The relevant paragraph stated that the particular PCT allowed for circumstances whereby The client or family may fund the additional silver service e.g. ensuite bathroom, double bedroom or room with a view. We thereby found that the document did not provide the clarification we had requested so again asked Mrs Cockwell to obtain for us the necessary details. We were shown the Statement of Purpose, last updated during July 2007, and noted it to state the following. Reminiscence Plus Care Services. For those residents requiring a greater level of support or extensive staff input we offer a Reminiscence Plus Care service for which an additional fee will be charged. The decision to place the resident onto this higher care level will be taken together with the family of representatives after discussion. During examination of a sample of care records we noted that some residents were recorded to be receiving Reminiscence Plus care services, and also saw that at least one person was receiving a Reminiscence Plus Plus care service. We were shown a blank template showing some care aspects that might attract additional charges and asked to see written details of the associated assessments recorded for the currently accommodated residents but were told that none were accessible at the time of our inspection. At conclusion of the inspection Mrs Cockwell told us that the only person who would be able to provide the information was on holiday until the following week. In summary, it is of concern that the care service was unable to supply to us reliable and clear written details of the assessments leading to the application of additional Care Homes for Older People Page 11 of 40 Evidence: fees, and was unable to provide a robust and reliable description of the additional fees that may be charged e.g. Silver Service, Reminiscence Plus Care. This report therefore contains a requirement for transparency and clarity of these aspects. We examined the records of two recently admitted residents and found them to include details of pre admission assessment carried out by registered manager Mrs Cockwell while visiting the prospective resident sat their previous addresses. To improve the usefulness of the information we recommend that when numeric scores are recorded following for example assessment of dementia, the document be expanded to state the significance of the score to ensure that service users who may request to read their own records can understand the various aspects. Care Homes for Older People Page 12 of 40 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is insufficient evidence that residents receive the care they need. Associated records and care practices require improvement to ensure staff have sufficient guidance to enable them to properly care for and protect residents from the harm and ill health that unplanned and potentially inappropriate care and incorrect medicine administration might cause. Evidence: During the course of the inspection we became increasingly concerned about the standard of care and associated record keeping, so we examined the records of 15 residents, being a higher number than we would have looked at if our impression of the standards had been better. We combined the information we obtained from the documents we read, with the things we saw taking place in the home during our inspection, and what we were told by staff and visitors. Care Homes for Older People Page 13 of 40 Evidence: This provided evidence that on many occasions the frequently complex and changing needs of residents have not been properly managed and there have been a number of occasions when weaknesses in care practice, medicine handling and record keeping have meant that residents may not have received the care they needed and have instead been placed at risk of distress and harm. For each of the 15 people whose records we examined we identified failings by the home to properly care for them. The following is a summary of our findings. A Progress Note written during January 2010 stated that staff found a resident in the bedroom of another resident, where she had urinated on a portable electric heater while it was switched on, thereby having unwittingly endangered herself. This incident was not known to the registered manager until we drew it to her attention, it had not been reported to us as is required in accordance with Regulations, and there had been no subsequent review of the potential risks posed by using the portable electric heaters which were supplied to residents by the home. A Moving and Handling Assessment had been completed for this resident and for a number of others by the registered manager who had written Yes to the forms enquiry of the resident being fully independent, but also wrote Yes to the enquiry Is Resident Totally Dependent?, thereby rendering the documents unreliable and largely meaningless. The resident was recorded to have on a recent occasion Been sick, but there was no necessary detail, e.g. undigested food, digested blood, and no later reference to the circumstance. The care plan for this person stated that on occasion she was resistive to care but the plan provided staff with no guidance on how they should manage such an event. The admission assessment states that the resident was fully continent but Progress Notes show that within two weeks of admission to the home she had become incontinent of bowels and bladder. Records provide no evidence of the home having considered referral to a Continence Adviser, or of any investigation of this sudden deterioration. Progress Notes show that the resident now routinely uses continence pads, but the care plan does not provide staff with this essential information. The care plan of a resident, written by a Wellness Advisor, states that she Is unable to express psychology limitation. We enquired of the registered manager and a Wellness Advisor the meaning of this statement but neither was able to explain it. Progress Notes stated that during December 2009 a visiting health professional advised the home to obtain a specific treatment for the resident, but none of the records, including the care plan, indicate that this was done. During February 2010 Care Homes for Older People Page 14 of 40 Evidence: the resident developed an infection but the condition and the prescribed treatment are not referred to in the daily records or the care plan. There is no record of the Mental Capacity assessment of this resident but the care plan states she must be not be permitted to leave the home alone. The care plan of a resident whose wife has died states that he and his wife are still together, thereby providing staff with inaccurate information which might lead to the resident being caused distress. The care plan informs staff that the resident requires the use of continence products and needs staff to change them at regular times, but fails to state what these products are. A Progress Note written during November 2009 states Pressures sores recorded and treated. There was no other reference to this circumstance and the registered manager was unable to locate any further information regarding this aspect of need. A Progress Note written during October states that this resident had shown Aggressive behaviour towards other residents but gave no other detail e.g. verbal or physical aggression, how the incident had been managed etc. and the care plan made no related reference. Records of an accident that took place during January 2010 refer to the use of a Crash mat, but there is no evidence of assessment for the use of this item, nor of the resident or representative having consented to the use of this equipment which could be considered a restriction on the residents freedom of movement. Within the records of social and recreational activities there is a description of a resident complaining of pain, but no indication this was reported to Wellness or care staff, and no other record of this circumstance. Similarly, another resident is recorded in a Progress Note written during February 2010 to have been complaining of severe pain, which the record states was reported to a Wellness Advisor, but there is no subsequent record of this circumstance, and no care plan reference to it. A resident is recorded to have been found with a large bruise on an upper thigh, but there is no evidence of investigation into the cause of this injury. An accidental fall is recorded to have taken place during February 2010 but did not lead to review of the falls risk assessment of February 2009. A record written during July 2008 states that the resident would like a representative of his religion to visit him, but there is no evidence that the home has contacted the relevant person or that a visit has ever taken place, and the registered manager did not know if this had happened. The home is in possession of a letter written during January 2010 by a medical consultant, directing a nightly skin treatment, but neither the care plan nor any other record Care Homes for Older People Page 15 of 40 Evidence: provides care staff with this information. Progress Notes indicate the occasional application of cream to particular areas of skin of a resident but there is no recorded guidance to staff regarding this i.e. the care plan makes no reference to the use of any cream. During January 2010 a Progress Note states the resident had Pain in right side of ribs, and 3 days later a Progress Note states Bruise on the back of her leg. Not sure how she got it. No further information has been recorded for either circumstance. For this resident, and for a number of others, records showed that frequently when the person reported feeling unwell care staff measured and recorded the blood pressure of the person. However, records contained no indication of what was considered to be an acceptable blood pressure for the particular resident, and omitted to describe action staff should take if the measurement they took indicated the person was at risk of serious ill health. For example, for this person the blood pressure was first recorded to be 222/106 and later, after resting, was 116/71. Progress Notes recently recorded for a resident made a number of references to the pain and deteriorating health of the person but the care plan did not reflect these conditions and made no reference to the variety of creams needed and used by the resident. A recently written Progress Note described the presence of unexplained bruising of which the registered manager had no knowledge until we brought it to her attention and for which we have subsequently made a safeguarding referral. A Progress Note written during February 2010 stated that a resident had experienced itching from a skin mole and it had bled when scratched. With the exception of cleaning the wound and applying a sticking plaster no further action had been taken although good practice advises that medical opinion should be sought for any changing skin moles. During December 2009 notes written by a Wellness Advisor stated that a resident had been prescribed medicine to control seizures, but this change in condition and treatment had not been included on the care plan. The care plan of a resident stated that the person experienced frequent anxiety and severe pain and staff should be mindful of this when moving the person, but Progress Notes provided no indication that staff were monitoring these conditions. The care plan stated that the legs of the resident were to be elevated, but gave no reason for this. Care Homes for Older People Page 16 of 40 Evidence: During October 2009 a resident fell sustaining a head injury and was attended by paramedics but records show the falls risk assessment written some months previously was not subsequently reviewed in the light of the accident. Records of a resident refer to the use of an alarmed pad at night to alert staff if the person gets out of bed, but there is no evidence of assessment for the use of this item, nor of the resident or representative having consented to the use of this equipment which could be considered a restriction on the residents freedom of movement. The Progress Notes written for this person fail to provide evidence that staff monitor the pain and changing mental health of this person, although the plan of care directs them to continually do this. Records of a resident contained a form with the direction Do Not Resuscitate which had been signed by a relative but there was no evidence that the mental capacity of the resident had been assessed. The care plan of this resident made no reference to the direction in a February 2010 Progress Note to monitor a particular health aspect, at the direction of a doctor. Daily records are generally of very poor standard, being task orientated and providing only minimal information regarding mental and physical health. Medicine Handling Medicine handling is carried out by staff trained in this work, in this care home they are called Medicine Technicians. We were told that none of the currently accommodated residents manage their own medicines. For medicine handling the home uses a monitored dosage system, whereby most of the medications are stored in blister packs, to simplify the process of administration. We examined a sample of Medication Administration Records (MARs)and found evidence that residents do not always receive prescribed medicines at the correct times and in correct amounts. On 17 July 2009 we carried out a random inspection to consider the standard of medicine handling following notification by the home that they had given the medicine prescribed to a resident of this home to a resident of the separately registered Sunrise Assisted Living Neighbourhood, established on the ground and first floors of the building. The report of that inspection included a number of requirements to minimise the risk of future errors taking place. The Progress Notes written by the home during January 2010 state that staff had discovered that for 2 weeks they had been administering to a resident twice the Care Homes for Older People Page 17 of 40 Evidence: prescribed dose of a particular medicine and throughout the same 2 weeks had also unintentionally omitted another medicine because they had failed to renew their stock level.The records of the home state that 2 days after the error was identified the registered manager Eileen Cockwell was notified but the service did not notify CQC although this is required in accordance with Regulation 37 of the Care Standards Act. The resident has been placed at risk of harm by for 2 weeks receiving a greater amount of a prescribed medicine, and during that period not receiving another prescribed medicine because the service had run out of this medicine. Following the inspection we raised a safeguarding alert. The MAR in use at the dates of our inspection indicated that although a resident was prescribed a medicine to be administered every morning none had recently been signed for to confirm administration. A member of staff told us this was because it had been stopped on the instruction of the prescribing doctor but the policy of the home was to permit only Wellness Advisors to alter the MARs, and because they had not made the amendment the direction for administration was unchanged, and no written guidance was anywhere on the MAR to advise staff not to give the medicine. We explained that this practice is dangerous, because if a staff member were to adhere to established practise and administer medicines in accordance with the MAR, the instruction to cease the medicine would have been unwittingly disregarded. We noted that on a number of occasions and for a variety of residents, medicines prescribed for regular administration had not been given, but staff had not recorded the reasons for omitting them. During our tours of the home we observed that in a number of bedrooms there were creams obtained on prescription, although they were not included on the current MAR and the home was unable to provide documentary evidence that they continued to be prescribed for the particular residents. The care records of a resident stated that the person was to receive prescribed medicines covertly, concealed in drinks. This instruction had been signed by the prescribing doctor. We raised the subject of covert medicines with the registered manager who referred us to a Wellness Advisor. The Wellness Advisor at first told us that the home did not conceal any medicines in drinks or foodstuffs and that the use of covert medicines referred to changed presentation because the person had swallowing difficulties so the medicine had been changed from tablet to liquid form. When we showed the Advisor the form completed by the doctor she agreed that for this resident the medicines were concealed in drinks. We asked her if any other residents received medicines covertly and she told us Not Many, but was unable to tell Care Homes for Older People Page 18 of 40 Evidence: us who received covert medicines, and explained she was unfamiliar with the residents because she had only been working in the home for 5 months. In summary, we found extensive evidence of poor and unreliable care practice and medicine administration, resulting in our referral to Social Services of a number of alerts regarding the safeguarding from risks of harm of vulnerable people. Despite these significant concerns, we noted that in the presence of staff residents appeared relaxed, confident and at ease. Staff interactions with residents were of a friendly and polite manner and the atmosphere throughout the home was calm and unhurried. Residents and visitors spoken with during the inspection said that residents are treated with respect and their privacy and dignity is protected at all times. Care Homes for Older People Page 19 of 40 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. More should be done to encourage and support residents to engage in social and recreational activities to maximise their experience of daily life in the home. A choice of menu is provided and meals are nutritional and appetising. Evidence: There is a weekly programme of recreational and social activities including handicrafts, one to one and small group activities in addition to seasonal events and celebrations. The layout of the home and the internal decoration is specifically designed to provide a stimulating and safe environment to people with dementia. The corridors and communal areas contain many items to encourage the interest of residents e.g. musical instruments, writing desks, workbench with tools, a wedding dress with accessories, a cot with baby clothing and toys. There is a comfortable and well equipped sensory room containing specialist lighting and music. However, we examined the records of approximately half of the currently accommodated residents and found that almost without exception activities were Care Homes for Older People Page 20 of 40 Evidence: limited to trips out in the homes own minibus and social visits to the home by friends and family of the residents. There was very little evidence of residents being involved in social and recreational activities in the home. We acknowledge that the mental and physical condition of most residents of this home is likely to result in special challenges for the staff in finding activities suited to the varying levels of understanding and concentration of residents but this is a specialist service and we feel there should be more evidence that staff engage with residents on a one to one basis to help them to pass the time in pleasant and interesting ways. The home relies mostly on unpaid volunteers to organize and lead activities and the impression we received was that the paid staff of the home focus on meeting the physical needs of residents and have little involvement with them beyond these aspects. We noted that Progress Notes written by care staff frequently record the precise amount of time, i.e. the number of minutes, spent on each occasion of assisting residents with activities of daily living e.g. dressing, washing, helping at mealtimes. We had previously been informed by the provider organisation that the presence of a laundry room accessible to residents was to enable staff to engage with residents and together to manage each residents personal laundry i.e. for a resident and care worker together to load and unload washing and drying machines, iron and repair the clothing of that particular resident, as a meaningful recreational activity. During this inspection we spoke with staff who told us that now care staff rarely involve residents in this activity. Visitors are welcome at any time and those spoken to during the inspection said they are always made to feel welcome and placed at ease by the staff. Meals are well presented, provide good nutrition and are liked by residents. Most residents take meals in the large dining room and others receive them in their bedrooms. Meals are cooked in a commercial standard kitchen on the ground floor of the premises which provides food for the two registered care homes operating from the premises. There is always a choice of meals and snacks and drinks are readily available from the kitchen area adjoining the dining room in the Reminiscence Neighbourhood. Care Homes for Older People Page 21 of 40 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is evidence that the home does not manage complaints properly and that neglectful and incompetent care is placing residents at risk of harm and abuse. Evidence: The complaints register kept by the home contains no complaints received since the last key inspection and the registered manager and a senior manager of the provider organization told us that no complaint against the service had ever been received by home. However, among the care records of a resident we found a letter of complaint from the relatives of a resident, alleging significant shortcomings in many aspects of service including care practice, and staff attitude and competency. The home was unable to supply us with evidence that this complaint had been investigated and a response provided to the complainant. Since the last key inspection there have been a number of errors in medicine administration so during July 2009 we carried out a random inspection to assess the standards of medicine handling. That inspection found weaknesses in the use of covert medication and identified that care staff employed by this home appeared to have no control over medicine handling because the provider organization has accorded the overall responsibilities for this work to Wellness Advisors employed by the Sunrise Care Homes for Older People Page 22 of 40 Evidence: Assisted Living Neighbourhood, operated from the ground and first floors of the building in which the Reminiscence Unit is established. At this inspection we have found that poor practices in medicine handling continue to place residents at risk of harm. During February 2010, prior to the dates of this inspection, the local Social Services office were notified of concerns regarding the standard of care provided to a particular resident and have commenced investigation of aspects of the care home, in accordance with established protocols for safeguarding vulnerable people. As a result of the findings of our inspection, we have raised safeguarding alerts regarding the standards of care provided to 3 residents. These matters are currently being investigated by the local Social Services office. Care Homes for Older People Page 23 of 40 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well designed, spacious and light, furnished and decorated to a high standard, and providing a comfortable environment but more should be done to ensure risks of cross infection are minimised. Evidence: Access to all areas is gained through the reception area on the ground floor of the premises. Private accommodation is selected from a variety of suites for single or shared occupancy. Every bedroom or suite or rooms has en suite hygiene facilities and a kitchenette unit without cooker for the preparation of drinks and snacks. Residents have the option of furnishing their own room, most of the currently accommodated residents have chosen to do and have brought into the home many personal effects to individualise their rooms and maximise their comfort. Each bedroom includes at least three double electric sockets, television and telephone point. There is a personal alarm call system with handsets or cords in each room and en suite facility. Each bedroom door is fitted with a key operated lock with master key override facility. Care Homes for Older People Page 24 of 40 Evidence: There are a variety of communal rooms and areas, including the dining area, a variety of lounge areas and an open air terrace fitted with safety glass. Decoration is in colours that are sympathetic for people with dementia. Each door has a name plate and a Memory Box containing pictures and small items meaningful to the particular resident occupying that bedroom, as an identifying feature to assist the resident in locating their bedroom. With the exception of the sensory room all communal areas are essentially open plan, although divided up into different sections, including a kitchen and dining area, lounges and activity areas. In addition there are alcoves off the corridors which have features of interest, e.g. costumes and memorabilia from bygone times. To minimise risks of accident, all windows above ground floor level have limiters to restrict window openings to approx 6 inches and radiators are fitted with covers. All areas of the building have level floors or are accessed via two large passenger lifts or, for use by staff and in emergency, a number of stairways. There are toilets that are suitable for wheelchair users. Corridors are wide and all doors in resident areas are at least 800 mms wide, allowing ease of access to wheelchair users. There is a laundry room for use by residents assisted by staff, all laundering is carried out separately i.e. the items used by one resident are laundered separately from those used by other residents. Staff informed us that the previous practice of care staff assisting residents to launder their own items has almost completely ceased, and staff now carry out laundry tasks without resident involvement. We spoke with a staff member employed to work in the kitchen, who was supporting care staff who were engaged in other work. This person had been working in the kitchen earlier in the day and without changing clothing or wearing protective clothing was now working in the laundry. We recommend the home to develop and implement a written policy and procedure to address this aspect of mixed working, to include measures designed to minimise risks of cross infection. During our tour of the home we saw disposable gloves for the use of staff were readily available in areas accessible to residents and recommend the home to record risk assessment regarding the potential for accidental ingestion and choking presented by Care Homes for Older People Page 25 of 40 Evidence: these items. Staff informed us that there is no sluice room in the home. We feel this is likely to cause difficulties regarding the safe management of potentially infected items and recommend the home to consider provision of a suitably equipped room. We noted that unpleasant odours were apparent in some room and recommend that the floor coverings of affected toilet areas be thoroughly cleaned or replaced. Care Homes for Older People Page 26 of 40 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home employs enough staff to meet the needs of residents and to ensure their safety and comfort and maintenance of the good condition of the premises. Records demonstrate that staff receive training for their work but more must be done to ensure that all are sufficiently familiar with their responsibilities to ensure the provision of appropriate care to residents. Evidence: Staffing levels are provided in accordance with the assessed needs of residents. At all times the home is in the charge of a senior staff member. All staff spoken with during the inspection were enthusiastic about their work and felt that they provided a good standard of care to residents. The records of four employed staff members were examined and found to contain all essential information including written references and evidence of identity. To further improve the standard of recruitment processes and record keeping we recommend that greater detail be recorded on records of interview to reliably reflect the content of the interview, for example the exploration of work history, gaps in employment or any other areas lacking clarity on the application form. Criminal Records Bureau (CRB) disclosures are obtained for all staff, including unpaid Care Homes for Older People Page 27 of 40 Evidence: volunteers, in advance of commencing work with residents. All new staff undergo a period of induction designed to ensure their familiarity with the home and a clear understanding of their responsibilities. All staff undertake and as necessary update training in core subjects including fire safety, moving and handling, and food hygiene. The registered manager told us that at least 50 of care staff employed by the home have obtained a National Vocational Qualification in care. As described for the Health and Personal Care section of this report, a Wellness Advisor employed for 5 months told us she was unfamiliar with the medicine administration arrangements for residents of the home although between them she and another Wellness Advisor hold responsibility for managing all matters associated with medicine administration. We consider this to be a significant and potentially dangerous weakness and this report contains an associated requirement. Care Homes for Older People Page 28 of 40 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience 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 the home is inadequate to the current circumstances. The registered providers have failed to reliably monitor the operation of the home and prior to the inspection had not identified the many weaknesses identified in this report. The poor management of the home means that people who use the service cannot be assured it is run in their best interests and that they are properly protected from harm. Evidence: Mrs Eileen Cockwell has been the registered manager of this service during the 3 years of its operation. This report identifies many serious weaknesses in the management of the home, including aspects regarding the safety and well being of residents and following the Care Homes for Older People Page 29 of 40 Evidence: inspection we alerted Social Services to a number of safeguarding concerns which will be investigated. The home has processes for quality assurance, satisfaction surveys are periodically issued but the effectiveness of these appears poor, in the light of the findings of this inspection. Care plans are minimal and omit much essential information. Records invariably do not coordinate with other records so there are gaps, the records are hard to follow and Wellness Advisor records often do not relate to care plans. There is evidence that on occasion residents have not received the care they need. We were repeatedly told no complaint has ever been received against the home, but we found a letter of complaint to which the home could provide no evidence of investigation, written response and outcome. Bruises recently recorded in progress notes have not been notified to the registered manager, to us or raised as safeguarding concerns. The manager was unaware of a recent incident of a resident urinating onto an electrically operated convector heater while it was in use i.e. was switched on. Examination gloves for use by staff are freely accessible to residents and the registered manager was unaware of the risks of choking leading to death, posed by these items. There was evidence of recent occasions when residents have not received the medicines they have been prescribed and the Wellness Advisor on duty during the inspection either did not understand what Covert Medicines are, or purposefully sought to mislead us. Few residents have been assessed for mental capacity and the home was unable to supply evidence of residents or their representatives having given consent to the use of devices which may be considered to constitute a form of restraint e.g alarm mats, electronic key pad door locking system designed to prevent residents from leaving the home. Accident recording is minimal and accident auditing has not been carried out to identify trends or aspects of high risk. Assessment is not routinely carried out following accidents, nor is the care plan updated. We identified weaknesses in recruitment and employment practice e.g. only one written reference was obtained prior to a care worker commencing duty in the home, Care Homes for Older People Page 30 of 40 Evidence: a recently employed care worker was promoted to a senior level although employment records provide no written evidence to support the rapid promotion, records show that the process of formal staff supervision records is based exclusively on a ticklist of the staff members own opinion. We saw that laundry was being carried out by a kitchen worker without use of protective clothing, and thereby posing risks of cross infection. Funding and fee arrangements are unclear and the home was unable to supply information detailing the way the additional charges are determined. Records of residents personal expenditure management are kept on the computer and the registered manager told us that the only person able to access the information was at the time of the inspection on holiday and not due to return to work until the following week. Accordingly, we were unable to assess compliance with the standards associated with the management of service users monies and arrangements for determining fees. In accordance with Regulation 26 of the Care Standards Act it is a requirement for the provider organisation to arrange for an unannounced visit of the home to take place at least every month, and for a written record of the findings of each visit to be supplied to the registered manger, and made available to the Commission. The registered manager told us that since August 2009 she has not received reports of any such visits. The provider organisation has not properly discharged essential duties of effectively monitoring the home and has failed to identify the significant failings in many aspects which were apparent during this inspection. Care Homes for Older People Page 31 of 40 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 9 13 Protocols for medication 04/09/2009 prescribed as required must be sufficiently detailed to allow staff to give medicines consistently in accordance with the prescribers intentions. This will ensure that people recieve their medication safely and appropriately. 2 9 13 The records for people who have to have their medicine administered covertly must be regularly reviewed and detail all the medicines that they take. This will ensure that the records accurately reflect the current practice. 04/09/2009 Care Homes for Older People Page 32 of 40 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 2 5 The registered provider 25/03/2010 must include in the Service Users Guide details of the amounts of fees to be paid and in accordance with Schedule 4 must keep a record of the care homes charges to service users including any extra amounts payable for additional services not covered by those charges. To support these arrangements and ensure clarity of information to service users there should be available reliable evidence of the basis on which the fees have been calculated. 2 7 15 The registered person shall prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. 30/04/2010 Care Homes for Older People Page 33 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This plan must include all relevant information and instruction to ensure that staff have available to them the information they need to provide consistent and appropriate care. 3 8 3 The registered person shall 30/04/2010 so far as is practicable enable service users to make decision with respect to the care they are to receive and their health and welfare. This means that arrangements for end of life care, including considerations regarding resuscitation, shall be properly supported by a written policy and procedure which reflects and includes the associated legal aspects. The registered person shall 18/03/2010 make suitable arrangements for the recording, handling, safekeeping, self administration and disposal of medicines received into the care home. This means that there must be robust evidence that each resident receives the medicines they have been prescribed, at the 4 9 13 Care Homes for Older People Page 34 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action correct frequency and dosage. 5 12 16 The registered person shall 30/04/2010 ensure that there is appropriate provision for the social interests and activities of service users, to minimise the distress and anxiety that boredom may lead to. . 6 16 22 The registered person shall 08/03/2010 ensure that any complaint made under the complaints procedure is fully investigated and shall within a period no longer than 28 days inform the person who made the complaint of any action that is to be taken. This is to ensure that all complaints are dealt with promptly and effectively. 7 18 13 The registered person shall make arrangements, by training staff or other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. . 08/03/2010 Care Homes for Older People Page 35 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 8 26 13 The registered person shall 25/03/2010 make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. This means that protective clothing must be provided and used in accordance with a policy and procedure to protect staff and service users from risks of infection. 9 30 18 The registered person shall 30/04/2010 ensure that persons working at the care home receive training appropriate to the work they are to perform. This means that to protect residents from harm all staff must be able to demonstrate their competency for the work they are employed to carry out and the registered person should periodically review and assess levels of competency. 10 31 37 The registered person shall 25/03/2010 give notice to the Commission without delay of the occurrence of any allegation of misconduct by any person who works at the care home, and of any event in the care home which adversely affects the Care Homes for Older People Page 36 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action wellbeing or safety of any service user. . 11 33 24 The registered person shall establish and maintain a system for monitoring the quality of care provided at the care home. . 12 36 37 Where the registered 08/04/2010 provider is an organization or partnership arrangements must be made for the care home to be visited unannounced at least once a month and a written report prepared of the conduct of the care home. A copy of the report shall be supplied to the registered manager and the Commission. . 13 38 13 The registered person shall 25/03/2010 make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. . 14 38 12 The Registered Person must 18/03/2010 make proper provision for the health and welfare of the residents. Where risks of accidental electrocution 08/04/2010 Care Homes for Older People Page 37 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action have been identified appropriate action must be taken to minimise the risks. This means that following a potentially harmful incident with the use of portable electric heaters the risks of using these and similar items should be promptly reviewed. 15 38 13 Records of investigation, 30/04/2010 assessment and outcome should be promptly recorded with regard to all accidents involving residents of the home, to ensure that risks of recurrence are minimised. . 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 3 When numeric scores are recorded following for example assessment of dementia, the document should be expanded to state the significance of the score to ensure that service users who may request to read their own records can understand the various aspects. The home should develop and implement a policy and procedure for End of Life care, to ensure that the rights of people are protected and their wishes are respected. More should be done to encourage and promote residents opportunities to exercise choice and control over their lives, in accordance with their individual capacities. 2 11 3 12 Care Homes for Older People Page 38 of 40 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 4 26 We recommend the home to consider provision of a suitably equipped room for the safe management of potentially infected items. The home should develop and implement a written policy and procedure for the guidance of staff involved in food related and laundry tasks to include measures designed to minimise risks of cross infection. There should be a process of continuous self monitoring of the home, reflecting aims and outcomes for service users and ensuring the ongoing safety and suitability of the premises and working practices. There should be robust evidence that the home operates a meaningful process of periodic staff supervision to include consideration of all aspects of practice and career development needs. Periodic audit should be recorded of all accidents to identify any trends or aspects of risk and there should be evidence of appropriate action being taken to minimise identified risks. We recommend the home to record risk assessment regarding the potential for accidental ingestion and choking presented by examination gloves stored in areas accessible to vulnerable people. 5 26 6 33 7 36 8 38 9 38 Care Homes for Older People Page 39 of 40 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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