Inspection on 23/11/09 for The Grange Nursing Home

This inspection was carried out on 23rd November 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Grange Nursing Home 20/04/10

The Grange Nursing Home 12/01/10

The Grange Nursing Home 27/11/07

The Grange Nursing Home 04/12/06

The Grange Nursing Home 22/11/05

The Grange Nursing Home 17/05/05

The Grange Nursing Home 25/01/05

The Grange Nursing Home 20/07/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 04/09/2010.

Key inspection report Care homes for older people Name: Address: The Grange Nursing Home 72 Upper Northam Road Hedge End Southampton Hampshire SO30 4EB     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: Kathryn Emmons     Date: 2 3 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 34 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 34 Information about the care home Name of care home: Address: The Grange Nursing Home 72 Upper Northam Road Hedge End Southampton Hampshire SO30 4EB 01489790177 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): carolynr@tgnh.co.uk Mr Roy Clive Northover,Mrs Heather Northover,Mrs Angela Louise Northover Name of registered manager (if applicable) Mrs Carolyn Sarah Ryves Type of registration: Number of places registered: care home 63 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users to be accommodated is 63. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Physical disability (PD) Dementia (DE) Date of last inspection 0 0 0 Over 65 0 63 0 Care Homes for Older People Page 4 of 34 Brief description of the care home The Grange is a care home providing personal care and nursing care for up to 63 people over the age of 65 years and who may also have a physical disability or have a terminal illness. The Grange is owned by three partners and is a family business. It is located in Hedge End a large village close to the edge of the city of Southampton and there is easy access to motorway links. The home is close to shops and other community amenities. The establishment was purpose built and opened in 1991. It is a three storey building that has a large open communal lounge dining room on the ground floor and another two lounge diner areas on the first floor and lower ground floor. There are 2 passenger lifts that provide access to the first floor. There is a large well maintained garden with a patio area that is accessible to people living in the home. The home has a website and people interested in living there or staying for a short respite stay are provided with a brochure containing information about the service that it provides and are encouraged to visit. Care Homes for Older People Page 5 of 34 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: Two inspectors visited the service on Monday 23rd November 2009 from 10.00am until 8:00pm. The AQAA (Annual Quality Assurance Assessment) was received on time. We were able to use the information this contained to help us prepare for the inspection visit. We spoke with residents and staff as we looked around the home. We sent out comment cards to staff, residents and health care professionals. We received eight from staff, eleven from residents and two from health care professionals. This helps us gain information about the service and we have reproduced some of these comments in the main part of the report. Following our visit the manager advised that they had produced an action plan identifying how they were going to meet some of the shortfalls identified during the visit. Care Homes for Older People Page 6 of 34 Care Homes for Older People Page 7 of 34 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 Care Homes for Older People Page 8 of 34 following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 34 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 34 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. Residents have access to information so they can make an informed choice to stay at the service. Contracts provide residents with a formalised agreement for the services they can expect to receive. Comprehensive pre admission assessments will enable the manager to be clearer if the service can meet the prospective residents needs. Evidence: Information is available for prospective residents and their supporters. There are two documents called the service user guide and the statement of purpose. These provide information regarding the service and what support residents can expect to receive if they chose to live in the home. The information is supplied in a brochure format and is clear to read. Alongside the service users guide is the last inspection report and information regarding improvements the service have made. Complaint information is also included in the folder we saw on display in the lounge area. Two of the care practitioners have been trained in how to show people around the Care Homes for Older People Page 11 of 34 Evidence: service and answer any questions they may have. A trained nurse is available to answer any medical or nursing questions. There are no set times for visiting the service and the manager said it was important people could visit when they wanted so they could get a real feel of the service. Contracts are in place and these inform residents of the services they are going to be provided with including bedroom details and the cost of staying at the service. We looked at admission details for four residents. We could see that information had been obtained from other health care professionals who had been involved in supporting the resident before they lived at the home. We also found in two of the files that the information that had been obtained did not always match up with the plan of care. The service do not provide intermediate care but they do provide a respite service. Respite stays are for people who will be staying at the service for a short time while they may need extra support, or their normal support is not available. We had received information from one source which stated that not enough information had been obtained about a resident before they came to live at the service and this had affected the care they received. The manager and senior nurse told us that sometimes it was difficult to get sufficient information for people who were coming to stay for a short time as normally information came from relatives, or the resident and was not always as reliable as information that may come other care workers. We could see from the AQAA that there had been a high number of respite stays in the past year. The manager said this was linked into the increase in bed numbers which rose from 43 to 63 in March of this year. The manager said that respite stays did not always run smoothly mainly due to there not always being accurate information about residents needs, and accepted that consideration needed to be given to the numbers of respite stays and the impact this may have on other long stay residents and the current issues with staffing levels. Care Homes for Older People Page 12 of 34 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. Inconsistencies in care plans may mean that residents are at risk of not receiving their assessed care needs including pressure area care and wound care. Lack of clarity regarding accessing dentists and mental heath team members may mean that residents are not receiving all of the health care services they are entitled to. Medication systems place residents at risk of not receiving their medication safely. Some written information did not demonstrate that dignity was respected. More information for end of life needs may enable the resident to be confident their wishes are known. Evidence: We looked at care plan files for five people. We found care plans in place which had been written by a trained nurse. There were inconsistencies with the care plans. Some plans contained a lot of information while others only contained basic information. It was not clear if the resident had been involved in the production of the care plan. We saw information in the form of assessment tools for care needs such as pressure care, risk assessments for falls and using bed rails. There were care charts which staff fill in when they have delivered care. These charts are meant to record fluid and dietary Care Homes for Older People Page 13 of 34 Evidence: intake and also provide information regarding turning people who are cared for in bed. The charts were not always complete so it was not always clear to see what diet and fluids people had taken and how often they had been repositioned in bed. There is a separate wound care file and this contains photographs of wounds with details of dressings and size of wounds.Some of the photographs were too blurred to assess the progress of the wound and one set of wound care information we requested could not be located. Care plans gave detail on how often someone should be repositioned in bed but some care charts showed a shorter time between repositioning the resident. This means that there are inconsistencies in providing pressure relief care which may have a detrimental effect on promoting good pressure area care practice. We were told pressure relieving mattresses are in place and we saw several on beds. We found one mattress not to be working correctly and were advised by a staff member that the maintenance person would try and fix the mattress and if this was not possible a referral would be made to the supplier of the mattress. Due to the frailty of some residents it is important that systems are in place to ensure that equipment is in good working order and that practices for preventing pressure sores are in line with current research based care practice. The manager advised that a new camera has been purchased for taking wound photographs and that trained nurses review care plans regularly. The link between care charts and care plans needs to be looked into so that staff can be clear on the expectations around pressure area care. The AQAA informs us that there are good links with the local doctor surgeries and that a chiropodist visits the service every few weeks. The AQAA advised that there are links with the Community Psychiatric Nurse (CPN) service and we saw in one set of notes involvement with the CPN . We could not be clear how many of the residents received this service as the information we requested during the visit was not given to us. We saw evidence of links with the local hospice so that staff could liaise with nurses who specialised in end of life care. We found a set of dentures on the nurse station and staff were unclear who these belonged to. We had received information prior to our visit that one resident had been left without their dentures. We were told by the manager that it was difficult to get dentists for the residents and that if dentures broke it took up to six weeks for a resident to be seen. We looked at medication administration (MAR) records for several residents. The records were confusing as each drug was given a letter from A onwards and when the drug was given the corresponding letter was placed in the given box. If a drug was not given a letter was used such as A for Asleep. This made it confusing to be clear if the medication had been given or not. The manager and senior nurse showed us a new medication administration sheet they were going to use. We spoke with a trained Care Homes for Older People Page 14 of 34 Evidence: nurse who said that they signed for medication before they gave it and would then cross out their signature if the medication was not taken by the resident. We found that tablets had been left with a resident at the dining room table. We looked at the controlled drug book and saw that on one occasion medication had not been given but the MAR sheet had been signed to show it had been given. We received information from two sources stating that one resident had not received their medication on time and another resident had been offered medication in tablet form rather than in a liquid form. We looked at records and found that medication had not been given at the correct time and a different form of medication had been offered. Medication stocks were seen and it was unclear what quantity of medication should be at the service. There were 281 tablets in stock for a service user who did not need them regularly or frequently and these could not be accounted for through an audit trail. Some of the medication can be given in a varied dose depending on how much medication the resident needs. There were no care plans for nurses to follow to help them make decisions regarding how much medication to give. This means that residents are at risk of not receiving their medication safely or correctly. We were told by a senior staff member that all medicines are disposed of in clinical waste or destroyed if a controlled drug substance. We found a clothes store cupboard which contained topical medications belonging to six different people. When we read the names out to a member of staff we were told that some of the people lived at the service while others had left the service. The manager and senior member of staff said they had not been aware these medications had not been disposed of correctly. We observed interactions between staff and residents. These were appropriate and residents were spoken to in their chosen form and in a kind way. Residents we spoke with said they were treated well and comment cards we received made positive comment regarding how the staff spoke to residents. We had received information from two sources regarding concerns about how people had been spoken to by two members of staff. We raised these concerns with the manager for them to look into. As we read residents daily notes we found on occasion some comments which were not appropriate or valuing to the resident. We again brought these to the managers attention. We saw a screen in a shared room and staff were seen to knock on residents rooms before entering. We observed one resident being assisted discreetly to be made more comfortable while sitting in their wheelchair and another resident was being assisted to take their meal. A resident we spoke with said that they always received their care with their bedroom door shut. The local Primary Care Trust has commissioned ten beds in the home to provide end Care Homes for Older People Page 15 of 34 Evidence: of life care. Links are in place with the local hospice and five staff have attended additional training in palliative care, with a further five booked onto the course for the future. A recognised assessment tool is used to ensure pain relief and needs are continually reviewed and met as the person approached the end of their life. Records we saw for one resident were complete and feedback from the nurses involved was that they felt the care they had carried out was very good and they had received very positive feedback from relatives and the hospice link nurse. We looked at one file for a person who had been admitted for end of life care and it was not clear what their funeral wishes or spiritual needs were. This means that it may not be clear to staff what the residents wishes are as they approach the end of their life and they may not be well enough to voice these . Care Homes for Older People Page 16 of 34 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are able to participate in varied activities. There is good community involvement and spiritual and cultural needs are provided for. Residents can receive visitors when they chose and they are given choice over daily life decisions. Dietary needs are mainly provided for but due to inconsistencies with recording this is not always demonstrated. Evidence: Residents who completed comment cards indicated that they enjoyed the activities provided at the service. As we walked around the home we saw many photographs showing activities residents had been involved in. The manager advised us that there is a WI (Womens Institute) branch at the home and this is the only one of its kind in the country. The residents also make toiletries called the Grange Range and sell these locally to raise money for charity. One of the trained nurses is responsible for leading the activities team and providing activities that are suitable for the different needs and abilities of the residents. When we arrived at the service a Music for health session was taking place. This was lead by outside entertainers and was well attended by the residents who were joining in by playing musical instruments. We saw visitors come into the home and a resident we spoke with said they were able to receive visitors when they wanted to. There is an activities programme on display and this included Care Homes for Older People Page 17 of 34 Evidence: details regarding a minister visiting to carry out Communion services. Comment cards indicated that residents feel they are given choice and during the visit we saw staff give residents choices such as choosing to participate in activities, what drink they would like and where they would like to sit in the lounge. A staff member told us that it is entirely resident choice when they get up in the morning and when they went to bed. We had received information from one source stating that there were not always specialist feeding equipment for residents to take their drinks safely and that sometimes the wrong kind of food had been provided such as soft food when pureed food had been required. We observed lunch and tea being served . There was a choice available and a resident during the visit confirmed there were normally two or three choices for lunch and two for tea. Other residents we spoke with at tea time said they enjoyed the food and that they had been given a choice for tea time. We saw a resident using a two handed beaker and there were also cups with lids on so residents could be independent when taking their drinks. We saw a staff member providing a soft diet to one resident. The manager said that dietary needs could be catered for and the care plans made it clear what type of diet a resident needed. As mentioned earlier some of the food charts were not always complete so it was not always clear what type of consistency of food a resident had been given or how much drink they had been been offered or taken. The manager accepted this and said that action would be taken to improve recording. Care Homes for Older People Page 18 of 34 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. Revising the complaint procedure means that residents can be clear on how their concerns will be investigated. Residents can not be confident that their rights as citizens will be upheld and that support is in place to assist them in having their rights upheld. Lack of identifying safeguarding adult issues places residents at risk of not being protected from harm and potential abuse. Evidence: We saw the complaint procedure on display and it was also included in the service users guide. The manager advised us that in the past few months the complaint procedure has been changed to ensure that complaints are responded to promptly. Previously all concerns had been raised with one of the providers and due to them not always being available some of the timescales passed for responding to complaints. There is a complaint file in place and this contained the action that had been taken to look into any complaints that had been made. We received information from two sources that people felt it was difficult to raise concerns with the management team. When we spoke with residents during the visit they said they felt they could raise any concerns with the manager and comment cards indicated that most people knew how to raise concerns. A comment card we received from a health care professional also stated that managements responded well to concerns. The AQAA informs us that the manager intends to provide resident forums and resident meetings as a way of discussing any issue residents may have about how the home operates. Care Homes for Older People Page 19 of 34 Evidence: We found in records and were informed as part of safeguarding adult information that an incident had occurred which did not uphold a residents rights and did not take into consideration their rights with regard to Deprivation of Liberty Safeguards (DOLS) and the Mental Capacity Act. We were informed that two staff did question the incident and how this affected the rights of the resident but this was not addressed by the manager for a couple of weeks. The manager told us that some staff had received training in the Mental Capacity Act and that one of the trained nurses provided guidance to staff on these matters, however it was clear that on this occasion the guidelines had not been followed. We have shared information, and received information from social services as part of several safeguarding adult strategy meetings. We were advised by the manager that they were not aware of any safeguarding adult issues. Through discussion with the manager we gained information which indicated that a safeguarding adult issue should have been referred from the home to social services. This had not been carried out which means that a service user may still have been at potential risk. The manager confirmed that she would be taking action but it was still not clear if a safeguarding adult referral was going to be made. We were told by the manager that she had enrolled on a course, starting in the near future, to learn more about safeguarding adults, the Mental Capacity Act and Deprivation of Liberty. Staff receive training from the manager in safeguarding adults and there is a policy is in place for staff to follow. Care Homes for Older People Page 20 of 34 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. Residents live in clean, spacious and tidy surroundings. Bathrooms are functional when equipment is removed and residents would benefit from them being more personalised and homely. Infection control systems including domestic and laundry arrangements are satisfactory and minimise infection risk to residents and staff. Checking hot water temperatures on a more frequent basis will minimise risk of scalding to residents. Evidence: Since March the number of beds at the service has increased for forty three to sixty three. Additional bedrooms and lounges have been built on the lower ground floor of the service. Comment cards received back all indicate that the home is kept clean and tidy. During our visit seven domestic staff were on duty and four staff were working in the laundry. The home was clean and tidy and smelt fresh in all the areas we visited. Two of the bathrooms we saw had equipment stored in them, such as hoists and other moving and handling equipment. We were told that equipment was removed from the bathrooms when in use. We saw that the bathrooms were not homely which may not provide residents with a relaxing and comfortable environment to take a bath in. The manager said that they were still in the process of speaking with residents to agree on additional decorations such as pictures. The manager advised that thermostatic valves are fitted to all hot water outlets and the maintenance person checks the temperature Care Homes for Older People Page 21 of 34 Evidence: weekly. However, staff should be able to test the bath water before a resident uses the bath, but there were not any thermometers in the bathrooms so staff used their elbows as a guide. This means that the service rely only on the weekly checks of the valves and cannot provide assurances regarding the temperature of the water at the point of the resident using the bath. We received information from one source that a couple of residents had been seen wearing unclean clothing. Residents clothing was clean and well pressed and laundry staff explained how they ensured that all clothing was washed ,ironed and returned to the residents the same day they were sent to the laundry. All clothing was marked to ensure it was returned to the right resident. Individual staff liaise with relatives if more clothing is required. We found all residents to be wearing clean clothing and at lunch we found staff offering residents the option of wearing an apron to protect their clothing. We saw moving and handling equipment at various places around the home and there were hand rails along corridors. Some of the chairs in the lounge lifted up to assist residents with raising from the chair. We saw certificates for the servicing of the hoists as in some instances the date written on the service panel on the hoist was longer than six months ago which is the recommended frequency for servicing the hoists. Staff told us they had received training in infection control and we saw staff wearing gloves and aprons when carrying out certain care tasks. We saw disposable laundry sacks and clear labelling to ensure laundry was washed at the correct temperature. Sluices are located on each floor and were clean and tidy. Care Homes for Older People Page 22 of 34 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. Inconsistencies with staffing levels may mean that residents receive varying quality of care and support. Lack of robust recruitment procedures place residents at risk of not being cared for by the right people. Service users are supported by a staff team who have access to training. Evidence: We had received information from four sources which stated that there did not seem enough staff on duty at times and that it took a long time for call bells to be answered and responded to. The call bell system does not have a timer fitted so it was not possible to assess the average call response time. The manager advised that the system was being updated so that response times could be monitored. We pressed a call bell on our visit and it was responded to in under a minute from a staff member on a different floor as the floor we were on did not have any staff in place. At the time of the increase in bed numbers we were informed of the new staffing levels. We looked at duty rotas for the previous month and saw that on several occasions the staffing level numbers had not been met. The manager stated that she was aware that on occasion there were shortfalls in staffing levels. This was mainly at weekends and on some nights due to staff sickness and not having staff that worked weekends as many staff had contracts for weekday working only. We were told by the manager that a recruitment drive was in place and two new staff were due to start work in the next couple of weeks. Currently fifty people are living at the service and the manager said Care Homes for Older People Page 23 of 34 Evidence: the staffing levels were sufficient for this number of residents but would consider staffing levels when admitting new residents. Comment cards we received back show that two residents said staff were, always available, seven said, usually, one said, sometimes and one said, never. Other comments included, looked after well, staff are very kind to me, they are very good, come very quickly to me, especially at night, and I cant think of anything else they can do to make it better. The AQAA informs us that over 80 of the care staff have a National Vocational Qualification in care (NVQ). This means that they have received training and skills at a more enhanced level than what is covered in induction. The manager informs us that she is a NVQ assessor and that the home was a designated NVQ assessment centre. We were also told that all new staff will now have to undertake an NVQ following their induction and this will be part of their employment arrangements. We saw induction programmes were in place and the manager said that all new staff spent six months on their induction programme. The AQAA informs us that the service do not use agency staff at all and this was confirmed by the manager during our visit. The manager said that by the time agency staff had been shown around the service and told the fire safety arrangements half of the morning had gone. All staff are recruited through the home and the manager made the decisions regarding who is employed at the service. We looked at four recruitment files for staff that had started work at the service since we last visited. Two of the files contained the correct information including 2 written references, criminal records bureau check (CRB), an application form and proof of identification. In one file we saw that references had not been obtained from the last employer even though this was a job which had involved the member of staff carrying out personal care. Another file had two references however the staff member had bought the references with them to the interview and only one of these was checked, and then only by a telephone call. Lack of robust recruitment procedures may mean that residents cannot be confident that the right people are caring for them. The manager accepted the findings and said she would ensure all future recruitment was carried out correctly. The manager advised us that she was a qualified Train the Trainer and carried out a lot of the mandatory training. Another member of staff was responsible for carrying out manual handling and one staff we spoke with said they had received this training a couple of months previously. We looked at records which showed staff had received training including first aid, health and safety, infection control and fire training.The Care Homes for Older People Page 24 of 34 Evidence: manager also told us that a lot of the care staff had completed a four month dementia course and an equalities and diversity training session, five staff had been booked on a palliative care course and two staff were due to attend a pressure sore prevention training session. Care Homes for Older People Page 25 of 34 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. Lack of satisfactory management of systems, practices and safeguarding adult issues by the manager places residents at risk of not receiving good outcomes and not having risk of harm or abuse minimised. The current quality assurance system does not ensure that the quality of the service is clearly known, or improvements identified and monitored to provide better outcomes for residents. Inconsistencies with health and safety arrangements do not protect residents from environmental risks. Evidence: The registered manager has been in post for several years and holds a registered nurse qualification and the Registered Manager Award. The manager is supported by a senior clinical nurse and team of qualified nurses. There are administration staff also working in the service to assist with some aspects of paperwork and residents finances. Staff we spoke with said they had a good working relationship with the manager. Two residents and a relative we spoke with said they thought the home was homely and comfortable and thought the manager was approachable. However, there was evidence that complainants were not satisfied that the management team Care Homes for Older People Page 26 of 34 Evidence: was approachable. We discussed with the manager our concerns regarding inconsistencies with systems in the service such as medication systems, recruitment practices, staffing levels and the clear lack of understanding in respect of safeguarding adult issues and referrals. The manager was receptive to the discussions and said she fully intended to address the issues. It is a concern that the manager wasnt aware of these issues before being brought to her attention as part of our visit. Quality assurance programmes are in place and as part of this audits take place for various systems such as medication and care plans. We saw a copy of a recent medication audit. This had not identified the shortfall that we found but did evidence that other issues had been found and resolved. We were told that one of the providers is in the service on a regular basis and produces monthly reports for the other providers and the manager. We saw several of these reports, however they were quite basic and mainly focused on the physical environment and where shortfalls had been noted there was no evidence of these having been followed up on the following month. Quality assurance surveys are available at the reception desk and cover a few aspects of the service. Every few months these are replaced with new surveys covering different aspects so that throughout the year feedback has been received about all aspects of the service. The manager also said that feedback questionnaires were sent to people who had stayed for respite care and these were returned anonymously. We saw that all staff receive supervision sessions except the manager. These take place on a cascade system. We discussed the importance and relevance of the manager accessing supervision and support. The manager said they took the lead on health and safety arrangements for the service. We saw evidence that fire safety checks and training took place, equipment was serviced and risk assessments were in place for infection control measures. We discussed concerns regarding a lack of satisfactory hot water management systems and also that we found a bottle of cleaner fluid in a cupboard which residents would have access to. The manager said that all staff had received training in COSHH (Control Of Substances Hazardous to Health) so was unclear why cleaning fluid had not been locked away. Care Homes for Older People Page 27 of 34 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 28 of 34 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 Pre admission assessments must be carried out on all prospective residents by a suitably trained person. Residents will be confident that their assessed needs are known and that they can be met if they live at the service. 31/12/2009 2 7 17 A record must be maintained 14/12/2009 of all pressure sores and what treatment is being provided to the resident. Records will evidence that residents receive good pressure area care and that the treatments they are receiving are based on current care practice. 3 7 15 All residents must have care plans in place which contain sufficient information for care to be delivered safely and in accordance with 14/12/2009 Care Homes for Older People Page 29 of 34 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 residents choices and preferences. Providing clarity in how to carry out care means residents will receive their care correctly. 4 8 13 Residents must have arrangements in place for them to have access to all health care professionals they need advice and treatment from. Prompt referral to other health care professionals means residents will be able to receive services they are entitled to. 5 9 13 A clear audit trail of all medications received into the home must be maintained and kept up to date. An audit trail will enable staff to be clear of medication stocks and what medications have been received and what has been disposed. 6 9 13 Systems must be put in place to ensure medications are given as prescribed. 14/12/2009 14/12/2009 14/12/2009 Care Homes for Older People Page 30 of 34 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 Medications must be given as prescribed so that residents receive their medications safely. 7 14 17 Records for detailing food 14/12/2009 and drink given to residents must be recorded accurately and in sufficient detail. Records will provide information for an assessment to be made of the nutrition residents receive. 8 17 12 Residents must have their 14/12/2009 rights upheld and promoted. Making decisions in consultation with the resident enables their rights to be upheld and for them to be able to agree if their rights are limited. 9 18 13 All staff must be aware of 14/12/2009 the measures in place and have the necessary knowledge to identify safeguarding adult issues and be able to take action to minimise the risk to residents. By having a good working knowledge staff can take action promptly to keep residents safe. Care Homes for Older People Page 31 of 34 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 10 27 18 There must be sufficient numbers of qualified and competent staff on duty at all times to meet the health and welfare needs of residents. To ensure staffing levels are sufficient so that residents receive support promptly and have their assessed care needs met. 14/12/2009 11 29 19 All staff must be recruited correctly including the necessary information such as two written references with one being the previous employer and where the staff member has carried out work as a carer or nurse. To ensure the right people are supporting residents. 14/12/2009 12 31 12 The registered manager must manage the service and its systems and be able to demonstrate that the welfare and needs of residents are met and monitored. To ensure that shortfalls are resolved so that the service operates in the best way for residents. 14/12/2009 Care Homes for Older People Page 32 of 34 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 10 Information regarding residents should be written in a way which upholds their dignity and ifs not devaluing. Care Homes for Older People Page 33 of 34 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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