Inspection on 02/06/09 for The Beeches

This inspection was carried out on 2nd June 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 24 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Beeches 17/11/09

The Beeches 15/09/09

The Beeches 10/07/09

The Beeches 26/11/08

The Beeches 29/05/07

The Beeches 06/06/06

The Beeches 01/10/05

The Beeches 24/05/05

The Beeches 04/11/04

The Beeches 18/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Beeches West Harling Road East Harling Norwich Norfolk NR16 2NP     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Lella Hudson     Date: 0 2 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 40 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 40 Information about the care home Name of care home: Address: The Beeches West Harling Road East Harling Norwich Norfolk NR16 2NP 01953717584 01953717886 beeches03@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : The Beeches (East Harling) Ltd care home 44 Number of places (if applicable): Under 65 Over 65 0 dementia Additional conditions: 44 The maximum number of service users who can be accommodated is 44 The registered person may provide the following categories of service only: Care Home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Date of last inspection Brief description of the care home The Beeches is a care home providing personal care and accommodation for 44 older people who have dementia. The home is owned by The Beeches (East Harling) Limited and is located in the village of East Harling and close to local amenities such as shops and pubs. The home consists of a two-storey, converted house that is set in its own grounds. There are four shared rooms, the remainder being single rooms. All rooms have ensuite toilets, washbasins and showers or baths. The majority of rooms are on the ground floor. There are enclosed courtyards and a private garden to the rear and side Care Homes for Older People Page 4 of 40 2 6 1 1 2 0 0 8 Brief description of the care home of the Home. The fees are currently between £425 - £500 per week. Please contact the Home for more up to date information about fees. 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: This report contains information gathered about the Home since the last Key Inspection (29th May 2007). This includes information gathered during a Random Inspection that was carried out in November 2008 and also any complaints or Safeguarding referrals that have been made. We have also included information provided to us in the surveys that were returned to us by residents/relatives (14), staff (7) and health professionals (1). The report contains information gathered during an unannounced visit to the Home which was carried out on 2nd June 2009 between 9.10am and 7.10pm. During the visit we were shown around the Home, we spoke to the Manager, staff, residents and Care Homes for Older People Page 6 of 40 visitors, we looked at a selection of records and we observed staff working with residents. What the care home does well: What has improved since the last inspection? What they could do better: Healthcare professionals had raised concerns with the Commission about some aspects of care provided at the Home. During our visit we looked at these issues and found that improvements are needed with regard to some aspects of care provided at the Home. Pre admission assessments are not thorough enough for the Manager to make an accurate decision about whether the Home is able to meet the prospective residents needs. Residents are being admitted to the Home whose needs are not able to be adequately met there. Some of the residents personal and healthcare needs are not being met at the Home. We found examples of advice from District Nurses not being followed and also of times when referrals to the GP or District Nurse were not made in a timely way. We have concerns about the care provided with regard to residents who have additional needs such as pressure sores and to those who have difficult, or aggressive, behaviours. The training and support that staff receive is not adequate to ensure that the residents needs are met appropriately. There are some issues within the management team which means that staff are sometimes given conflicting advice about how care should be provided. The care plans are not sufficient to act as a reference and to provide staff with clear guidance about individual residents needs. There is a need for the Home to increase the number of hoists that they have as currently residents are having to wait as there are only two hoists available. Some improvements are needed to the accommodation. There is only one communal Care Homes for Older People Page 8 of 40 bathroom in use at the moment. Although many of the bedrooms have en suite showers there are still a lot of residents who want, or need, to use the assisted bath. Some of the toilet areas are in need of upgrading and redecoration although the Manager did say that there are plans for this to take place shortly. We saw examples of residents not being offered choices and of being assisted by staff who did not speak to the residents to explain what they were doing. Residents spend a lot of time with no interaction with anyone. Some activities do take place but there is a need for this to be increased so that residents have the choice of taking part in meaningful activities. There is a need for additional staff to be on duty as currently the staffing is not adequate to meet the needs of the residents. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 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 10 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some residents have been issued with contracts detailing the services provided at the Home. The Home admits residents without carrying out effective assessments. The Home admits residents whose needs it is not able to meet. Evidence: The AQAA states that the Home has a Statement of Purpose and a Service User Guide. It also states that the Home has an updated website which provides prospective residents with information about the Home. We did not look at the information provided about the Home during our visit. The majority of the surveys from residents/relatives state that they have received a contract (statement of terms and conditions) with some stating that they have not. Two additional comments were made about the clear contract that they had received and that they had been shown around the Home prior to moving there. Care Homes for Older People Page 11 of 40 Evidence: In April a complaint was made by the District Nurses about the lack of care provided to a resident who had been admitted to the Home. We were provided with a copy of the written response from the Manager about the situation and we discussed this with the Manager during our visit. The resident was dependent on insulin but the Manager said that she had not known this. She had known that the resident was diabetic but had not asked how this was managed as the written information indicated that it was through taking tablets. Therefore, the Home was not able to always provide a suitably trained member of staff who was able to administer insulin and the District Nurses had to be involved. The Manager said that she will ensure that the right questions will be asked in the future about residents who are diabetic. However, the same resident was readmitted to the Home at a later date and there were still not enough staff at the Home who were trained to administer insulin. However, we looked at a pre admission assessment during our visit for a resident who had moved to the Home three weeks previously. It was recorded that they were diabetic but there was no information about how this is managed. There was no information within the care plan either. When we spoke to a senior member of staff about the residents care for their diabetes she was not sure how often blood tests should be carried out and thought that the resident was diet controlled. We found examples of residents who have been assessed as having difficult, or challenging behaviours having been admitted to the Home. The staff do not have the skills to meet the needs of residents with challenging behaviours. 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. The health and personal care needs of the residents are not met. The care plans are not adequate to ensure that the residents needs are met in a consistent way. The privacy and dignity of the residents is compromised. Evidence: A complaint was made by the District Nurses about the Homes ability to care for a resident who was dependent on insulin to manage their diabetes. Following this we spoke to the District Nurses about the care provided at the Home. They had concerns about the care provided, particularly with regard to pressure care. They said that the staff do not always contact them appropriately and that advice is not always followed. They did also say that there has been some improvements recently following disscussions with the Manager. We looked at a sample of care records and could see from these that the District Nurse, or GP, had not been contacted at an early stage for some residents. For example, on the day of the visit we met a resident who had extensive bruising to their Care Homes for Older People Page 13 of 40 Evidence: face. Staff and the Manager said that this had been caused by another resident. The daily notes record the incident but with little detail. An accident report had been completed. However, the GP had not been asked to see the resident to assess the extent of her injuries. The pre admission assessment for one of the residents states that they have inflamed legs but there is no care plan for this. The daily notes record on one date that the resident has very painful red legs and two days later it states red spots on thighs and lower legs, she said it is painful. However there is no mention of what action was taken about this and no mention of referral for medical treatment. A residents pre admission assessment states that they are diabetic but there is no further information about how this is managed. In the care notes there is a record of their blood suger levels for one day. When we spoke to the senior staff about this they did not know whether the resident should have regular blood tests or not. In general, the care plans contain too much information that is now out of date, particularly for those residents who have lived at the Home for some time. This is confusing and means that staff have to look through a lot of records to find the relevant information. For example, the care records for one of the residents the pre admission assessment is still present and states that the resident uses a walking frame. Staff would need to refer to several other records to find out that the resident now spends the majority of their time in bed. The moving and handling assessment for this resident has been updated on an annual basis but is not complete, nor is the Waterlow assessment for pressure care. There is a Falls Risk Assessment which states the resident is at a high risk of falling. The care plans do not reflect this and there is no risk assessment for the use of bedrails. There is a care plan for agression shown by the resident but no clear plan as to what form this takes and how this may be avoided. From the care records it can be seen that the resident has pressure sores and that the District Nurse visits. There is no care plan to guide staff as to how they should provide care to these areas although there is an entry in the daily notes to say that the District Nurse has advised that the resident should be turned every two hours. We also looked at the District Nurses care plan for this resident and it is clear that the staff had not been following the advice given about how long the resident should be out of bed for and they had been sitting for too long, causing their skin to break down. We spoke to staff about when the resident should get out of bed as there was no record of them getting up for at least a seven day period. Staff said that it depended Care Homes for Older People Page 14 of 40 Evidence: on which Senior staff were on duty as to whether the resident got up or not. The Manager confirmed this. The resident has a chart in their bedroom recording regular turns and the food and drink that they have had. One of the entries states that the resident was asleep and so did not have any lunch, there was no record of them being offered food later to replace the lunch that was missed. The daily notes for one of the residents records possible problems with a stoma over four days but there is no record of a medical opinion being sought. There is also no record of the problem having been addressed at all. One of the residents was observed to spend nearly all day sitting in a chair near to the lounge. They spent a lot of time hitting themselves on the legs. We spent at least an hour sitting close by the resident and none of the staff tried to talk to the resident and distract them from this behaviour. One of the residents has behaviours that can be challenging to other residents, staff and to other visitors. The care records state on several occasions that the resident is aggressive without clear descriptions of the behaviour. There is no care plan in place for staff to follow. Discussions with staff show that some staff have a better understanding of how to distract and communicate with the resident than others. Some staff were observed being kind and patient with the resident whilst others walked past when the resident was clearly causing another resident some concern. Discussions with staff show that they do not all have the skills to support residents who have aggressive behaviours. However, according to the training matrix given to us 10 staff have attended training entitled Agression. Staff told us that some staff are not at all confident in dealing with challenging situations and that they leave other staff to do so. Another residents daily notes record that the staff had noted a small red mark and blister which was reported to the senior staff and thought to be a scald. It records the first aid that was given. There were further records of a medication spray and cream being applied but with no details of what these were called. On the fifth day there is a record of the open wound being cleaned and a dressing in place. No referrals were made to the GP or the District Nurse until the 8th day after the incident when the District Nurse was asked to see the resident whilst they were visiting the Home to see another resident. Care Homes for Older People Page 15 of 40 Evidence: We received one survey from a health professional and the responses to whether the staff seek advice appropriately, whether the residents health care needs are met and whether the staff respect the residents privacy and dignity is usually. It states that the staff sometimes have the right skills and experience to meet the needs of the residents and that the staff are caring. The views in the staff surveys were mixed about whether staff get up to date information about the needs of the residents. Four stated usually and three stated always. Additional comments were made such as: Care plans have got out of date information in Information is often not passed on The current staffing levels are not adequate to meet the needs of the residents. There are three residents who rarely come out of their bedrooms on the first floor and at least two residents who spend a lot of time in bed which puts additional pressure on staffs time. The staff told us that there are at least 9 residents who need two staff to assist them with mobility as they use the hoist. At least two residents have behaviours which can be challenging. The staff surveys are mixed in their responses about whether there are enough staff on duty with three stating usually, two stating sometimes and two stating never. Additional comments were made such as: at busy times - getting up and at meal times, residents are not given enough time to do so in a relaxed atmosphere staff work well on the floor we treat residents with respect not enough staff The Manager confirmed the staffs view that the current provision of two hoists in the Home is not enough and that more are needed. A comment was made in one of the staff surveys about the lack of enough hoists in the Home which means that staff are moving residents manually. The completed AQAA states that the staff receive training about privacy and dignity. Comments were made within two of the staff surveys stating that residents are treated with respect. The residents/relatives surveys are mixed with regards to whether the residents receive the care and support they need - eight state this always happens and five state usually. The responses are equally divided as to whether staff are always available. Additional comments were made about the care provided: as far as we are concerned, its the tops more than happy with all aspects of the home my mother is happy herer care and support is very good quality of life could not be bettered staff work hard but havent enough time not enough staff at night time We observed some staff talking kindly and patiently to residents, explaining what they Care Homes for Older People Page 16 of 40 Evidence: were doing and answering residents questions. However, we also observed staff walking past residents who were calling out without speaking to them. We observed staff handing residents drinks and putting biscuits into their hands without offering them a choice or even explaining to them what they were doing. We saw one of the residents persistently invading the personal space of other residents and causing them concern. Staff did not intervene or try to divert the residents attention away from other residents. Responses within the staff surveys indicate that the Manager and the two senior staff do not work well as a cohesive team. This was confirmed during discussions with staff during our visit. We were given examples of how this causes confusion amongst staff about the care needed by individual residents. The lack of clear care plans also adds to the confusion. We observed a senior member of staff giving handover in the lounge to the staff arriving for the next shift. The handover contains information about all of the residents and should be held somewhere confidential. There were visitors and other residents present in the lounge. We looked at the system in place for the management of medication. One of the senior staff is responsible for ordering medication and all senior staff are responsible for checking in medication and administering it. The Manager carries out regular audits of the medication system. The medication is stored securely and records are kept of medication which arrives at the Home. We looked at the medication records relating to one of the residents. The recent changes in medication could be cross referenced with the daily notes. However, the resident was prescribed PRN (as required) medication for difficult behaviours and the daily notes did not record all of the times that the resident was administered this medication. There is no PRN guidance available for this medication although we did see PRN guidance for other residents medication. The resident we were casetracking had been given PRN on several occasions and when we looked at the daily notes there was no supporting evidence as to why the resident had been administered the medication. There was no evidence of difficult behaviours occuring or any aggression. In fact, on four consecutive days the resident had been given the PRN medication in the morning despite the daily notes stating that the resident had slept well. When we asked a senior member of staff about this they said that they had decided to see if it made a difference to the behaviour of the resident. Care Homes for Older People Page 17 of 40 Evidence: We checked the controlled drug register against the medication held in the cupboard. Initially the records did not appear to be accurate but following further investigation it appears that the records have been inaccurately completed rather than that medication is missing. However, this had not been identified as an issue prior to our visit. Care Homes for Older People Page 18 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Relatives are made to feel welcome when visiting the Home. Activities are provided but are dependent on staffing levels. Residents nutritional needs are assessed but there is a lack of choice and the dining experience is not a positive one. Evidence: We spoke to one of the relatives who was visiting and they said that they are very happy with the care that their relative is receiving. They said that they choose to visit at a mealtime as they enjoy assisting their relative and not because there are not enough staff to do so. They said that they are always made to feel welcome by the staff. We observed staff making relatives feel welcome and answering questions that they had. Comments were made within the residents/relatives surveys such as: the whole family are made welcome The Manager said that they are trying to improve the information that they have about the residents previous life and the things that they used to enjoy doing. We saw that this work has been started within the care plans and that staff are liaising with Care Homes for Older People Page 19 of 40 Evidence: relatives about this. A residents and Relatives association has recently been started at the Home. The AQAA states that an activities organiser was employed in March 2008 and that she has undertaken training in reminiscince therapy. It states that other staff have also completed this training. The Home has a small lounge which is starting to be decorated and furnished as a reminiscence room. There are games and craft materials available in the lounges and we observed staff encouraging residents to be involved in using these. We spoke to the activities organiser and to other staff about the provision of activities. The activities organiser works four days per week 9am to 3pm. She works as a carer in the mornings and so only works as the activities organiser for about 2 hours in the afternoon four days per week. During the holiday periods there is no activities organiser at all due to her shift pattern. She is enthusiastic about her role and has lots of ideas for enabling residents to take part in more meaningful activiites. She is also keen to increase their involvement in the community. Staff said that they do not have much time to spend with residents on an individual basis. They said that they do try to provide activities during the afternoons when they may have more time to do so. We spoke to staff about how residents are enabled to make choices. They said that they feel that the residents have a choice about basic issues such as when they get up and when they go to bed. They said that they have a choice about what they have to eat and where they have their meals. We observed some staff explaining to residents what they were doing and what was going to happen next eg. that it was time to go to the dining room for their lunch. However, we also observed staff giving out drinks to residents without offering them a choice about what they were given. We observed staff putting biscuits into the hands of residents without any conversation with them at all and without offering the resident a choice. The AQAA states that the cook has completed NVQ Level 2 in cooking and is undertaking Level 3. It also states that all kitchen staff have completed food hygiene courses. We did not speak to any of the kitchen staff during our visit. There are no staff on duty in the kitchen to prepare and clear up after the tea time meal. The cook prepares the food, where possible, prior to finishing her shift. The care staff are responsible for the tea time meal which means that there are less staff available to work with the residents at that time. Care Homes for Older People Page 20 of 40 Evidence: The Manager has put an additional member of staff on duty to assist at breakfast time. This member of staff assists residents to have breakfast before then taking on domestic duties. The Manager herself was assisting residents with breakfast when we arrived at the Home. The residents/relatives surveys are mixed with regard to whether they like the meals with the majority stating usually and the others stating always. Additional comments were made such as: food is excellent quality We spent a short time in the dining room during the lunch time meal. The tables are large wooden tables for up to six residents. We observed that some of the residents were chatting together but we also observed that one of the residents was taking food from another residents plate. We also noted that one of the residents who has, on occasion, been aggressive towards other residents was sitting at the end of the table, next to the wall. From this position it was difficult for the resident to leave the table and they were very close to several of the other residents. It was a warm day at the time of our visit and we observed staff regularly giving drinks to the residents throughout the day. However, residents were not offered a choice at these times. At tea time the trolley with sandwiches, quiche and cake on was brought into the lounge. Residents were not given the option to go to the dining room for their tea. The residents were not given a choice about what they were given. Savoury and sweet food was all put onto the same plate and given to the resident. The residents were provided with a spoon to eat this mix of food. When we discussed this with the Manager she said that this was due to cultural differences of the staff present. However, the senior member of staff was on duty and did not monitor what the staff were doing. 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. The complaints procedure is on display and the Manager takes complaints seriously. The residents are not adequately protected from being at risk of abuse. Evidence: The complaints procedure is on display around the Home and the responses within the residents/relatives surveys all state that they know how to complaint. The staff surveys all state that they know what to do if someone wants to make a complaint. The Manager has provided a report regarding the complaint made about the care provided to a resident with diabetes. The Commission were notified of this complaint by the Safeguarding team and the Manager of the Home. The Commission have also been notified of concerns raised by the District Nurses and previously mentioned in this report. Discussions with the staff show that they have all received Safeguarding training at some time but not all staff have received updated training. The Manager provides this training and it is recommended that staff should receive external training which includes information about the local procedures in place for reporting concerns and the role of the local Safeguarding team. The Manager had not referred the situation where one resident had been hit by Care Homes for Older People Page 22 of 40 Evidence: another to the Safeguarding team and was asked to do so whilst we were at the Home. The Commission had not been notified of this either. We discussed Safeguarding with staff and they all said that they would raise concerns with the Manager and were aware of the Whistleblowing policy. However, within the staff surveys and in discussions with staff it is clear from their comments that there are problems within the management team and that this may result in staff being reluctant to raise any concerns. There is also a concern about a lack of confidentiality within the management team. 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Home provides adequate accommodation for the residents. The bathroom and toilet areas need improving in order to meet the residents needs. Evidence: The Home is a large detached house set in well maintained, attractive gardens. There are also smaller, enclosed patio areas for residents to use. The original part of the Home is the only part that has two storeys. There are four rooms on the first floor. The Home does not have a passenger lift but does have a chair lift. The Manager said that the company who fitted the chair lift will not come to service it any more as they consider it to be obselete. However, they do come to mend it if it needs maintenance work. The Manager said that it is currently in good working order although it is of concern that the chair lift does not have a safety certificate. All of the bedrooms are ensuite and some bedrooms have ensuite baths or showers. Some of the rooms that we saw have been very nicely personalised and others are more functional with little personalisation. The Manager said that this depends on whether the relatives wish to personalise the bedrooms or not. The AQAA states that several bedrooms have been decorated and new flooring fitted to Care Homes for Older People Page 24 of 40 Evidence: several rooms. The corridors have started to be decorated and new radiator covers are being fitted. An overhaul of the electrical system throughout the Home has been carried out and a new certificate issued. It also states that a new bath and hoist has been purchased. The Manager said that residents are offered a key to the lock on their door but that if they choose not to have one their rooms are locked during the day if they do not want to go back to their rooms. She said that this is to prevent other residents going into indiviudals bedrooms. The Home has a large lounge with a conservatory leading from this. The conservatory has lovely views of the garden. There is also a small seating area near to the dining room and the additional lounge which is being decorated as a reminiscence room. Several of the toilet areas are in urgent need of redecoration and the Manager said that these are due to be upgraded shortly. There is no call bell lead in one of the toilets. The Home currently only has one communal bathroom in use. Although many of the bedrooms have ensuite bathrooms there are several residents who are unable to use these and need to use the communal bathroom with the assisted bath. The one communal bathroom which is in use has a fan which is extremely noisy and there was a large bowl of toiletries on the side with no names on. There are some signs around the Home to assist the residents to find their way around but there is a need for additional signage. The bedrooms have a large number on and a small photograph of the resident but this is placed quite high up on the wall which makes it difficult for some residents to see. Following an incident when a confused resident left the Home unescorted during the night in November 2008 all of the windows on the ground floor now have restrictors fitted. The patio areas are enclosed but the main garden is not completely secure as there is a large gate and fencing down one side of the garden which is a lot lower than the wall which surrounds the rest of the garden. All external doors have keypad locks on. There is a raised drain cover in the corridor by the dining room which poses a possible trip hazard. Care Homes for Older People Page 25 of 40 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffing levels are not adequate to meet the needs of the residents. Staff receive induction and training but there is a need to review the quality of the training. The Home has not always carried out appropriate recruitment procedures but appears to be doing so now. Evidence: The residents/relatives surveys are mixed with regard to whether there are staff available with equal numbers stating always and usually and one stating sometimes. All state that the staff listen and act. Additional comments were made such as: manager and staff are caring and supportive staff listen effectively staff work hard but havent enough time all staff are helpful not enough staff at night cant always get a drink when want one The staff surveys all state that recruitment checks were carried out prior to them starting work. When we carried out a Random inspection in November 2008 we found that not all staff had had approrpiate checks and a requirement was made at that time. During this visit we found that the sample of recruitment files that we saw contained the necessary checks. The staff surveys are mixed with regard to whether there is enough staff with 3 stating Care Homes for Older People Page 27 of 40 Evidence: usually, two stating sometimes and two stating never. The responses were also mixed with regard to whether communication works well in the team. They all state that they receive training. Additional comments were made such as: information is often not passed on we have to keep asking for training new staff not always getting induction staff not replaced on the floor when training taking place staff treat residents with respect there is a relaxed atmosphere staff need more praise and encouragement from managers not enough staff at busy times, getting up and meals, residents are not given enough time to do so in relaxed atmosphere The majority of the training is provided by the Manager who said that she has attended training to enable her to provide this and that she uses training materials provided by recognised training organisations. A lot of the training is through the use of DVDs and questionaires or through distance learning. It is recommended that staff receive training from external providers about some subjects, such as Safeguarding, and that the use of DVDs and questionnaires is restricted to use for updating training rather than the original training. All staff receive training, including domestic and catering staff. There have been several examples throughout this report that show that the current staffing levels are not adequate to meet the needs of the residents. Discussions with staff and the responses within the staff surveys also confirm this. In the AQAA it states that there are usually between 6-8 staff on duty during the day and 3 at night. Through discussions with the Manager and staff, observations during our visit and looking at rotas we can see that there are not as many staff on duty during the day as the AQAA states. The usual staffing level is for there to be five staff on duty, including a senior, between 8am and 2pm. There is the same between 2pm and 9pm and 3 staff on duty overnight. In addition to this there is a member of staff on duty from either 6am to 10am or from 7am to 11am and also between 5pm and 9pm. One of the domestic staff also assists residents with breakfast. In addition to the care staff there are domestic, laundry and catering staff. However, there are no catering staff on duty during the afternoons and so the care staff are responsible for the provision of, and clearing up after, the tea time meal. As previously stated in this report we observed some staff who were very kind to the residents and spent time explaining what was happening around them. We also observed some staff who did not spend any time talking to residents and who did not offer them any choices. Care Homes for Older People Page 28 of 40 Evidence: Care Homes for Older People Page 29 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 Home is not managed in a consistent way which puts the needs of the residents first. The health and safety of the residents and staff is not always protected. Evidence: The Proprietor does not manage the Home but the Manager said that she does visit the Home on a regular, weekly basis. The Proprietor was away at the time of our visit. The Proprietors son, a Director of the company which owns the Home, is the administrator at the Home and was present during our visit. The Manager is suitably qualified and experienced to manage the Home. She has recently undertaken additional training in Dementia Care and also with regard to the Mental Capacity Act and the Deprivation of Liberty. The Managers hours are not counted as part of the rota. She mainly works Monday to Friday but also does work alternate Sundays and is available if needed at other times. Care Homes for Older People Page 30 of 40 Evidence: The residents/relatives surveys include additional comments about the management of the Home, such as: the management and staff are caring and supportive managers and staff are approachable and friendly. Some comments within the staff surveys state: lack of confidentiality from managers need more praise and encouragement from managers support always given The Home has two Care Managers, one full time and one part time. There are also senior care staff. The Care Managers have responsibilities for different areas of care and assist the Manager with management tasks and staff supervisions. The Care Managers and Senior care staff manage the shifts when on duty and are responsible for the administration of medication. Discussions with staff and the Manager as well as comments made within the staff surveys show that there are some serious problems within the management team. The Manager said that the Proprietor is aware of this. These problems are causing difficulties for the staff team as the management provided is not consistent and they are told conflicting information. It also means that the residents are not receiving consistent care in some circumstances. Staff supervision does take place and staff said that they can talk to one of the management team but it appears that the responses are not always consistent and this causes confusion for staff about the care needed by residents. There are system in place to monitor the quality of the service provided. For example, the Manager carries out regular audits, such as medication and care planning. Monthly visits are carried out by an external consultant. The views of the relatives and residents are sought through use of questionnaires and relatives/residents meetings. However, the issues identified in this report have not been picked up through the Homes internal quality assurance processes. There are systems in place for monitoring the health and safety of residents and staff. We saw a selection of maintenance records for the equipment. However, there are other areas where the health and safety of residents and staff are being compromised. For example, staff state in surveys that they are moving residents manually as there are not enough hoists. One of the residents was able to leave the Home in the middle of the night unsupervised. The chair lift does not have a current safety certificate. The care records are not consistent or clear enough to ensure that residents needs are being met in a consistent way. There are incidents in the care records that are not recorded in accident records and vice versa. Health professionals have not been consulted as necessary to ensure that residents health needs are met appropriately. Care Homes for Older People Page 31 of 40 Care Homes for Older People Page 32 of 40 Are there any outstanding requirements from the last inspection? Yes £ No R 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 Care Homes for Older People Page 33 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 3 14 It is required that effective pre admission assessments are undertaken To ensure that the Home can meet the needs of the residents 30/06/2009 2 4 14 It is required that the Home only admits residents whose needs can be met there To ensure that the residents needs are met in a consistent way 30/06/2009 3 7 15 It is required that the care 30/06/2009 plans contain detailed guidance about how to meet the residents needs To ensure that the residents needs are met in a consistent manner 4 8 23 It is required that equipment 31/08/2009 is provided to assist the residents with mobility Care Homes for Older People Page 34 of 40 To ensure that residents do not have to wait long periods of time when needing to mobilise 5 8 13 It is required that the residents are referred to health care professionals as required To ensure that residents receive appropriate healthcare 6 9 13 It is required that accurate records are kept of the administration of medicines Ti ensure that the medication system is safe and ensures that residents receive their medicines at appropriate times 7 9 13 It is required that medicines 30/06/2009 are administered in line with the prescribers instructions To ensure that the residents get their medicines at appropriate times 8 10 12 It is required that the privacy and dignity of the residents is respected To ensure that the residents are cared for respectfully 9 12 16 It is required that the residents are able to take part in meaningful activities To ensure that residents have a choice about taking part in meaningful occupation Care Homes for Older People Page 35 of 40 30/06/2009 30/06/2009 30/06/2009 30/09/2009 10 15 12 It is required that the dignity 30/06/2009 of residents is respected at mealtimes To ensure that the needs of the residents are met in a respectful and dignified manner 11 18 13 It is required that all staff have received updated Safeguarding training To ensure that residents are protected from abuse 30/09/2009 12 18 13 It is required that the Safeguarding procedure is updated to reflect the local procedures To ensure that staff have clear guidance in the event of a concern being raised. 30/06/2009 13 19 13 It is required that the raised 30/06/2009 cover in the corridor receives attention to make it safe To prevent residents and staff from trips and falls 14 21 23 It is required that call bells are available in all toilets and bathrooms To ensure that residents and staff are able to call for assistance if needed 30/06/2009 15 21 23 It is required that the toilet areas are decorated and upgraded as necessary 31/07/2009 Care Homes for Older People Page 36 of 40 To ensure that the residents have access to toilets that meet their needs and that are nicely decorated 16 21 23 It is required that the second bathroom is upgraded so that it can be used To ensure that the residents have access to an adequate number of bathrooms 17 21 12 It is required that residents have their own toiletries To ensure that the dignity of the residents is preserved and that residents have choice about which toiletries they use 18 21 23 It is required that the noise from the fan in the bathroom is reduced To ensure that the noise does not disturb residents whilst using the bathroom 19 27 18 It is required that staff are provided in adequate numbers and with the right skills and experience to meet the needs of the residents To ensure that the needs of the residents are met 20 30 18 It is required that staff receive appropriate training in both mandatory subjects and areas relevant to the residents needs 31/12/2009 31/07/2009 30/06/2009 30/06/2009 30/09/2009 Care Homes for Older People Page 37 of 40 To ensure that staff have appropriate training to enable them to carry out their roles effectively 21 32 12 It is required that the 30/06/2009 management of the Home is consistent and that the Managers work well together and with the staff team. To ensure that the residents needs are met in a consistent way and that the Home is well managed 22 33 24 It is required that an effective quality assurance system is in place To ensure that issues are identified and action taken to make improvements 23 38 13 It is required that the health 30/06/2009 and safety of the residents and staff is promoted To ensure that the residents are safe 24 38 23 It is required that the 30/06/2009 Manager ensures that there is a current safety certificate for the chair lift To provide protection to residents who use the chair lift 30/09/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 38 of 40 1 18 It is recommended that staff receive Safeguarding training from an external provided and that this includes information about the local Safeguarding arrangements. It is recommended that improved signage is used around the Home to assist resisdents to find their way around the Home. 2 19 Care Homes for Older People Page 39 of 40 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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