Inspection on 25/09/08 for The Limes Rest Homes

This inspection was carried out on 25th September 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Limes Rest Homes 14/07/06

The Limes Rest Homes 28/12/05

The Limes Rest Homes 22/08/05

The Limes Rest Homes 20/01/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOMES FOR OLDER PEOPLE The Limes Rest Homes 75-79 Cartland Road Stirchley Birmingham West Midlands B30 2SD Lead Inspector Tina Smith Unannounced Inspection 09:15 25th and 26 September 2008 th X10015.doc Version 1.40 Page 1 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 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000062017.V372174.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000062017.V372174.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Rest Homes Address 75-79 Cartland Road Stirchley Birmingham West Midlands B30 2SD 0121 443 1789 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) anita@firstcareservices.co.uk First Care Services Ltd Miss Jennie Roberts Care Home 28 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (28) of places DS0000062017.V372174.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category 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. Old Age not falling within ant other category - Code LD (maximum number of places 28). Dementia over 50 years of age - Code DE (maximum number of places 28) The maximum number of service users who can be accommodated is 28. 14th July 2006 2. Date of last inspection Brief Description of the Service: The Limes, a care home since 1985, has been owned by First Care Services Limited since 2004. It consists of three houses joined together on a residential street, and is close to local shops, parks and bus routes. There is a front ramp for wheelchairs, car parking and an enclosed garden at the back. The Limes provides specialist personal care and accommodation for up to 28 people over the age of 50 who have dementia and other conditions. There are two floors with access by a passenger lift and a stair lift. On the ground floor there are four lounges, including one for quiet space. There is a kitchen and a separate dining room where some activities also take place. Three offices are arranged so that people can be seen and helped quickly, if necessary. A hairdressing room leads to the laundry, and there is a training room for staff at the back of the home. There are twenty single and four twin-bedded rooms on both floors. Some bedrooms have en-suite facilities, one has a shower, and there are assisted bathing and showering rooms on both floors. Each room has a call system so that staff can be contacted, and rooms are alarmed so that staff can assist people who become confused and prevent falls. There are gates in several places and office doorways for the same reason. Fees range from £350 - £450 per week, according to care needs. The home employs a physiotherapist for which there is no charge. Charges for extra services are in their brochure. The fee information applied at the time of the inspection; up to date information should be requested from the service. DS0000062017.V372174.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. Our inspections focus on the outcomes for people who live in the home and their views of the services provided. This process considers the care home’s capacity to meet regulatory requirements, national minimum standards of practice, and on aspects of service provision that need further development. Before the fieldwork visit took place a range of information was gathered from the last inspection, things the home has told us about, what others told us, and a questionnaire the home sent to us, called the Annual Quality Assurance Assessment or AQAA. We also sent surveys to people who use the service, relatives and staff. This gave us some information about the home, staff and people who live there, improvements they have made and intend to make. A visit was made to the home by two inspectors over 9 hours, extending into a second day for one inspector in order to collect records and to talk to the owner. The home did not know we were coming. There were 26 people living at the home. No one was having respite care, and most people have lived in the home over 12 months. We followed the experiences of people living there, looking at their care records and rooms, when possible had conversations with them, talked to a relative and discussed people’s care with staff. This process is known as case tracking. One inspector watched how people reacted to their environment, each other and staff for two hours. A Short Observational Framework for Inspection scoring tool was used called a SOFI, to learn about their outcomes in the home. We looked around the building to make sure that it was warm, clean, comfortable and secure. A meal was tasted; we watched how medication is administered and how people are fed. Records about running the home and managing staff were seen. We would like to thank the people and visitors we met, the owner and staff for their hospitality and cooperation. There were no immediate requirements after this visit, but information was collected for us to consider further action on requirements from the previous inspection which had not been fully met. This means that there was nothing urgent that needed to be done to make sure people stayed safe. DS0000062017.V372174.R01.S.doc Version 5.2 Page 6 What the service does well: Trained staff assess individual needs and confirm whether they can be met. Clear information on the service and fees is provided and there are ways to experience the home before making a decision to stay. People are happy. Relatives told us care is good, they are kept informed, and their views about the running of the home are sought and acted upon by staff. Consumer survey results are in the home’s brochure. Relatives told us: “Finding The Limes was a relief; it was the best I had seen in a long trawl of visits to homes…” “The owner and manager are dedicated, highly professional and loving and caring towards the residents – a good lead set for the rest of the staff.” Staff know people well, their needs and individual likes, dislikes and personal routines. This is used to help people settle in, to monitor and identify changes. People have daily opportunities to make choice so that they retain control of their lives, their faith and their abilities. Staff are encouraged to eat with people, as this helps them to eat more food. Those needing help are sensitively fed at their own pace. We saw positive effects on people when staff interacted with them, and during the daily activities provided as a group and with individuals. There is a comfortable and safe environment and equipment that meets people’s needs. Rooms have people’s own furniture and possessions. Relatives told us that staff and management work well as a team and take dementia care seriously. Staff and volunteers are checked to ensure they are safe to work in the home. Staff have training beyond mandatory requirements to understand people’s conditions and about best practice. There is an experienced manager, and an actively involved owner. They check quality, learn from and act on people’s concerns, complaints and keep CSCI informed. DS0000062017.V372174.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Public information about the home could be more accessible, and have more detail on dementia care to help people deciding on the home’s suitability. Care plans and risk assessments are reviewed monthly but also need updating when people’s needs change so that staff have clear instructions to work to. Pressure sore risk assessments need accuracy, and staff need detailed information to monitor health conditions and medication side effects. DS0000062017.V372174.R01.S.doc Version 5.2 Page 8 Access to health services should be provided when assessed, and as requested by health professionals. Care plan evaluation needs to be thorough and include whether the plan and guidance was followed, and the effect on the person and their condition. Infection needs to be effectively managed and prevented from spreading to others with NHS support – any problems need to be reported to the appropriate authorities. Personal safety and behaviour plans could prevent as well as respond to concerns expressed, incidents and accidents. Sexuality plans need to be individual and consider more issues. Guidelines for staff are needed to administer ‘as required’ medication to the doctor’s instruction to avoid drug reactions and to recognise excessive effects. The medication system needs to be auditable, and staff competence needs to improve to prevent errors so that the health and wellbeing of people is protected. Available guidance and codes of practice should be used to review and develop policies and procedures to protect people’s legal rights, equality and diversity. Hearing loops would assist people with hearing aids. Management audits should consider any patterns and whether any changes to systems, the environment or practice are possible to prevent harm. Regular appraisal of staff performance should take place so that people’s needs are met and staff development is planned for. Management systems need development to ensure people’s health and wellbeing is effectively monitored and managed. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000062017.V372174.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000062017.V372174.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1-5: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides information people need and various ways to visit so that they can decide if this specialist dementia care service will be suitable. There is a pre-admission assessment by trained staff, and the home confirm whether needs can be met. EVIDENCE: There is a good pre-admission process which makes sure people have the information they need to make an informed decision about moving there. People and their families told us the quality of care is good, and: “Finding The Limes was a relief: it was the best I had seen in a long trawl of visits to homes…” “Carers and the owner are always prepared to engage and are forthcoming with relevant information which is required.” DS0000062017.V372174.R01.S.doc Version 5.2 Page 11 There is a brochure with photographs, a service user guide and statement of purpose. This is updated each year and explains the services, fees and the qualifications of staff. There are ways to visit the home that assist people to meet the people and staff, view the facilities or experience a respite stay or a trial. We spoke to one family whose doctor decided a visit by the person would confuse them, so their family visited. Arrangements for visiting and information on the complaints procedure and fire safety precautions are clear. This information could be accessible to more people if available in different formats and languages. There is a general philosophy of care based on choice and people’s rights, and dementia care is mentioned, but the nature and approach of the specialist dementia service is not described. It would assist people and families assessing suitability of the home, for instance to know about colour-coded doors, any specialist activities, safety and security; explaining why and how restrictions on people’s lives are determined and reduced. We saw advocacy posters; this would be more accessible in the service user guide that is in people’s bedrooms, and for the guide to explain how advocacy can assist people. There were 26 people in the home, and two people expected shortly. We saw contracts signed by people or their representatives in each case-tracked care record, where end of life preferences are also specified. People who fund care themselves are helped by the home to get council assessments when their funds are low. Recent initial care plans have a form seeking representatives’ comments and signed agreement, if the person consents to this being shared. This is good practice. Trained staff gather information about the person and their condition from all sources to assess needs, risks, likes and dislikes. People and their families help the home to understand the person, who and what is important to them and personal routines. This is used, along with observation and review, to help people settle in, to adjust care, and access to health treatment for their changing needs. This supports people and families alike. Relatives told us that staff work well as a team. We spoke to staff and found they know the people they assist well. DS0000062017.V372174.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7-10: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported by respectful staff to maintain their abilities and dignity. Systems to update and evaluate care plans, risk assessments and to manage medication need improving so that people’s health and wellbeing is safely monitored and managed. EVIDENCE: People able to tell us, said that they are happy in the home. Relatives said: “She is safe and well looked after “As far as I am aware – they appear to be caring, friendly, almost loving at times and I am very grateful for that.” “All the residents appear to be well cared for in their appearance and requirements.” DS0000062017.V372174.R01.S.doc Version 5.2 Page 13 We saw through the SOFI that almost all (98 ) staff interactions with people are positive and re-assuring. Staff know the people and relatives well, their care plans, reasons for their medication and equipment. We saw good communication plans that encourage the expression of views and feelings. Religion, culture and sexuality are assessed, although this could improve. The home uses this information to provide care the way it is wanted, to maintain people’s self-esteem, monitor and identify changes. We know this from daily records, charts and reviews held with people and their families. Three personal care and health records were looked at in detail and several further records were sampled. Each person has an individual plan about what they are able to do independently and the assistance required for staff to help them maintain their health, wellbeing, independence and dignity. There are opportunities for people to manage their own medication and finances safely, but most people in the home need assistance in these areas by staff or by working in partnership with families, representatives and professionals. People choose the gender of carers, and make daily decisions about food, medication, personal hygiene and clothing. They sometimes refuse and this is respected. Key areas of risk such as falls, nutrition and skin integrity are assessed and reviewed monthly or after illness or incidents, and specialist help is sought if necessary. Personal care, physical and mental health needs are generally met, but systems and audit need to improve to maintain people’s health and safety. For instance, the assessment of pressure sore risk needs accuracy. One person’s record identified a low risk since 2007, even though they were treated by District Nurses for pressure sores twice during the same period. Aids for prevention, though, were used. Health professionals are often in the home and people attend appointments, although in one record we could not find when they saw the dentist they were assessed to need. In other records we found good oral hygiene plans. NHS support of the home has recently. An NHS Nurse Practitioner works with the home weekly to avoid unnecessary hospital admissions. The home employs a physiotherapist to help people keep mobile. Most people seen are active; there is only one person using a wheelchair indoors. Personal care is discreet, and people’s dignity is maintained by adjusting their clothing, knocking on doors, and using preferred names. We saw good continence plans of people with limited communication who need support to find and use the toilet to prevent accidents. Staff record and pass information to each other daily about changes in people’s conditions, mood and behaviour. Monitoring measures such as personal care, food and weight charts are kept up to date. We found that staff are sometimes more up to date than the person’s risk assessments and care plan, DS0000062017.V372174.R01.S.doc Version 5.2 Page 14 that staff do not have enough guidance and oversight in certain areas, and that care plan evaluation is incomplete. For example, one person whose condition is hard to treat lost their mobility after a hospital stay. Care changed, but their plan is not up to date so that staff have clear instructions and use the right equipment safely. Staff appropriately queried new medication with the GP, but when essential medication was re-prescribed we cannot be sure it was always administered as prescribed to help them improve their mobility and mental health. There are gaps in the medication administration record and an extra tablet was found; it is not possible to reliably establish whether all their medication was given or refused. We saw a good plan to encourage healing from an MRSA infection and prevent infection risk to others, but staff are not sure whether it is still in use and it has not been updated since February 08. There were no records ensuring the person was tested by the NHS or that problems about this were reported to the appropriate authorities. There has been no outbreak of infection at the home. Staff could improve their knowledge of conditions and treatments of people in the home, with professional advice. Signs of deterioration requiring health specialists are not always recognised, such as loss of swallowing ability. One family told the home that their relative had an allergy to an unknown antibiotic. Allergic symptoms and medication side-effects are not detailed to enable staff to recognise signs and respond and monitor appropriately. The AQAA told us that management plan to improve ‘as required’ medication guidance for staff. Plans were started during the inspection after risks of under and over dose were identified to them regarding a second inhaler for a person with asthma and low oxygen levels. No appointment has been made with a GP as requested in July 08, there are no guidelines for staff and this is given more frequently than the prescription, without a medical decision to do so. There are unexplained gaps, where both inhalers and other medication may not have been given on some days. An evaluation of this person’s condition and care plan is therefore incomplete, and risks to the person’s health were not recognised or queried by the staff responsible for medication or management. Medication recording is still not accurate or fully auditable. This means that errors can occur and not be detected by management or any other professional. We found gaps in many medication records, including people on variable dose medication, e.g. once a week. These were also concerns at the last inspection. There have been improvements but some also persist and new problems have emerged with the medication system. We found the medication procedures and management drug audits do not fully protect people, and that staff do not always follow the procedures. Staff are not clear about medication storage checks, and this can affect the stability of DS0000062017.V372174.R01.S.doc Version 5.2 Page 15 medication. There are irregularities in the recording of controlled drugs causing audit problems too, and this poses risk for wider public safety. Management have attempted to improve systems and staff performance, but actions have not been timely or robust, and have not sustained results for people’s safety. Staff have accredited training, but their competence is not checked. CSCI are considering further action to ensure this improves so that health and wellbeing is managed and monitored. We also saw good practice. We watched medication administered carefully, checked and explained so that people can give informed consent and the right medication is prepared and recorded after being administered. But we also saw a possible cross-infection risk, by staff handling medication and not washing their hands in between people. There are assessments and plans about safeguards and restrictions on people’s lives. This is necessary to any service assisting people who have periods of confusion or who lose the capacity to recognise danger, as there are new laws about people’s rights. Staff need learning opportunities. At the time of the inspection, no one in the home needed bedrails. Some records did include staff guidelines about managing behaviour and risks from agitation, wandering and aggression. We advise these are reviewed to identify triggers and measures so that plans can prevent as well as respond in proportion to risks people can pose to themselves and others. DS0000062017.V372174.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12-15: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People exercise some control over their lives and they can take part in a range of activities. Relationships with families and friends are maintained. There are nutritious meals that meet people’s dietary needs. EVIDENCE: Life stories are compiled with the help of people, their relatives and friends. These are used, along with photographs and mementoes, by staff to get to know people and help them retain their memories. Staff know and record people’s likes, dislikes, moods and personal routines such as whether they sleep with the light on. Routines are flexible, although people may need familiar routines to settle in and for orientation. People’s interests are recorded, along with important relationships, religious and cultural needs. There is a choice of religious service in the home. The Limes assists people to maintain relationships with family and friends; consent about this is sought on admission. There is an open visiting policy, and people are encouraged to maintain links with community groups. We were told of examples, such as when relatives take other people in the home with them to church, or on a DS0000062017.V372174.R01.S.doc Version 5.2 Page 17 fishing trip. There is a private telephone available, and people take this to their rooms. Relatives are often in the home and told us: “Staff have been excellent in keeping in touch when mum has needed medical help.” “They certainly support any suggestions I make, e.g. getting her ready so that I can take her to church.” “Like every other care home probably – I would like to see meaningful daily activities organised which are…tailored to the residents interests. I know some activities do take place but not enough…” “…mum… likes classical music…to be active and is used to taking walks. There are a lot of nice local parks around here, but the only walk she is having is when I visit weekly.” “Mum is a gentle lady who is not used to aggressive behaviour and a lot of noise…and sometimes gets upset by the behaviour around her. The carers…encourage her to quieter areas when necessary…” We saw individual and group activities, such as staff helping someone to choose a book, movement to music and dancing, and people knitting. There is an activity programme, not on display due to redecoration work, and we saw activities twice a day. There are games, a daily newspaper, arts and craft and outdoor equipment. There is a volunteer who often spends time with people in the home, although this is unstructured and could be developed further. The physiotherapist comes once a month, and there are exercise games people like. We would encourage a wider range of materials people can access themselves. An activities organiser is being recruited to provide a more personal service using community facilities. In the past year a local school choir provided sign language to music, there are old movies on a large screen, a Neil Diamond look-alike event, visit to a nature centre, etc. Care plans about sexuality involve offering daily choices about people’s appearance, such as clothing, shaving, hairdressing, make up and jewellery to express ‘femininity’ or ‘masculinity’ and maintain people’s self esteem. Expression of sexual orientation relevant to the person’s lifestyle is not identified. This is generalised to all case-tracked records and is not individualised. The home’s policy gives clear guidance to staff about privacy and consenting relationships. The policy, care planning and staff attitudes need development and the home has experience to draw upon. We had notifications from the home inappropriately labelling people’s sexual expression and disinhibition as DS0000062017.V372174.R01.S.doc Version 5.2 Page 18 ‘challenging behaviour’. We are aware the home has assisted people sensitively regarding confidentiality, loss of capacity to consent to a relationship, sexual abuse and abuse experienced earlier in life. The day’s menu on an orientation board was not accurate as we saw a different meal being served. People may find it easier to make their mealtime choices from a menu with pictures. The council has awarded the home a 4H award in food hygiene, rating them as very good. They are now working on Better Food Safer Business standards. A consumer survey showed that people are happy with the menu. The cook is given information on people’s favourite foods, dietary needs and foods to avoid. There is a four-week rotational menu. Special diets prepared include mashed food, pureed and diabetic meals. We sampled nutritious food and people told us they liked it. Some people have enriched food if they need more calories, as well as nutritional supplements. Every meal has a daily choice and on the spot alternatives although for tea, soup is on the menu every day. One person with diabetes is having healthy alternatives to reduce a weight gain. Another person we case-tracked is assessed to be at risk of malnutrition and has gained weight. There are fish and chip suppers and pub lunch outings and birthday parties. Staff are encouraged to eat with people using the service, as it was found that this helps people to eat more food. We saw people fed at their own pace, with praise and encouragement to hold a spoon to try to feed themselves. This means there is good choice, best practice, and good nutritional outcomes for people at the home. The SOFI told us there are very good outcomes for three people we observed. People were in positive or passive states 96 of the time, and they were occupied by conversations, tasks or objects for most of the observation. Staff were complimented on their skills by two inspectors. DS0000062017.V372174.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16-18: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and concerns are taken seriously and acted upon. The home uses the council adult protection process to prevent and safeguard people from abuse. EVIDENCE: The complaints procedure is in the home’s brochure, in every bedroom. A residents meeting notes that “some of the residents understand the complaints procedure…most know they can talk to staff if they have any concerns”. The home could experiment with a more accessible complaint format for people with little communication to use. People told us they are happy. There is only one person in the home without family or friends, and they have a Power of Attorney who is consulted as necessary or their social worker. Relatives are aware of the complaint procedure, know who to raise a concern with and are confident that staff would listen and act. One relative said, “have always cooperated 100 to any concerns I may have raised on mum’s behalf.” There were two complaints since the last inspection. We reviewed the home’s log, which is well kept and confirmed the home responded to everyone’s satisfaction within timescales. DS0000062017.V372174.R01.S.doc Version 5.2 Page 20 Several company policies and procedures protect people’s legal rights, such as encouraging people to vote and manage their own post, and how staff can help people give informed consent. A local advocacy service is promoted. Staff told us they are not clear about when a statutory advocate needs to be involved, and did not know how to gain access to this service. Only one in three casetracked records had an assessment about people holding their own room keys, noting “use master key when required”, but we did not see a consent form. Care is not forced and we saw that appropriate people are consulted when best interest decisions are needed. We advise that policies and procedures are reviewed using new laws and codes of practice to check they are up to date, particularly regarding restrictions on people’s lives and physical intervention. Abuse is taken very seriously at The Limes and is not tolerated. Staff have mandatory training to recognise abuse and use local multi-agency protocols and the home’s policy. They act quickly to safeguard and protect people in their care. There were 3 adult protection concerns since the last inspection. Two staff were dismissed and one was referred to a government list to protect vulnerable people. Staff records sampled showed that staff and volunteers are carefully selected and checked so that people are in safe hands. There are some people with dementia who develop aggression and may not be in control of their actions and can pose a risk to others. Staff had specially commissioned training about this, to give staff more skills. The home develops behaviour plans, sometimes with mental health services or doctors. We advise that these could improve to identify any possible triggers so that staff can intervene at early points to prevent aggressive incidents as well as respond to them. Individual care plans and risk assessments are reviewed after falls and incidents. We found that personal safety plans of people at risk of harm from others inside and outside of the home need development. The home acted appropriately to safeguard a person’s interests from a family member, but this was not in their care records or personal safety plan. The home also notified us of a few minor injuries from people falling after being pushed or grabbed by others. We saw a care plan of someone reporting they were pushed but it only addressed re-assuring them; they are assessed to be at risk of falls. DS0000062017.V372174.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19-26: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally clean, comfortable and safely maintained. People are able to bring their own possessions, and equipment is provided for their needs. The layout is planned to offer security, but this can also restrict choice. EVIDENCE: The Limes is in a residential street with access to public transport, local amenities and parks. It is only distinguishable as a care home by a front ramp for wheelchair access. There is a new conservatory, a safe enclosed garden and there is equipment for outdoor games. Staff told us people really enjoy this as a group. We saw that the home and grounds are secure. There are window restrictors to prevent people falling. The front door is locked to prevent intruders and for safety of people who would be at risk of wandering onto the busy road. There DS0000062017.V372174.R01.S.doc Version 5.2 Page 22 is good lighting in all but the quiet lounge, where we were told a bulb had blown and would be replaced. The layout of the ground floor and three staff offices enables people to be seen in the various rooms many choose to move between, although staff are rarely in offices for long. Seating is arranged in small clusters to promote conversation and so that there is safe access between rooms. We saw some bottlenecks in doorways as people tried to get to or from the dining room for meals. The environment meets most people’s specialist needs, but internal restrictions on movement have not been fully assessed. There are magnetic or latched gates and a security coded door that many people are unable to negotiate. This prevents access to areas that pose risk to people’s safety, but there is free access to toilets. People can go to their bedrooms with staff assistance, but some may find it hard to make their wishes known. New laws apply to restrictions on people’s lives, and to blanket policies in services. We saw one assessment about someone requiring an escort but it was not clear whether this was inside as well as off the premises. We did not see any assessments about the need for restrictions on movement within the home and grounds. We also did not see any information on access to the garden in the home’s brochure, or posters reminding people they could use the garden and which door to use, as one is kept locked. There are people of varied abilities and mental capacities in the home, some more able to make informed choice and take risks. The provision of hearing loops in communal areas would benefit people with hearing aids. There are large screen movies shown, but we saw an orientation board and photograph display that was too cluttered and faint to assist people with impaired sight and dementia. The home is preparing a display with staff photographs so that the staff on shift can be identified by people and visitors. There is a kitchen and a separate dining room, and activities take place in both rooms. The kitchen has an area away from the main cooking facilities for this. There are good food hygiene records. The home has a 4H award from the council, demonstrating very good food hygiene. They are now working on Better Food Safer Business standards. There is enough equipment for people’s needs, in good working order and serviced by the handyperson, NHS or approved contractors. There is limited storage space with the current use of the building. We found wheelchairs and a weighing chair stored outside a wheelchair user’s bedroom in such a way that access was partially blocked. This could result in a preventable injury. It was immediately changed, but more care needs to be taken daily. DS0000062017.V372174.R01.S.doc Version 5.2 Page 23 The heating and water system are serviced and tested as bacteria free. Hot water temperatures are maintained within the safe range. Health and safety measures are audited regularly and there are 3 fire drills a year. The home is maintained within a planned refurbishment strategy. It is comfortable and is currently being decorated. Each lounge used to have a different colour scheme, but now it is all beige and each room is less distinguishable. We were told people and relatives had been consulted. Flooring is being replaced at night, to prevent disruption to the people living there, which is good practice. Each bedroom is unique. People bring their own furniture and possessions, and some relatives put photographs on doors so people can find their own room. There are curtains in shared rooms and locks on each door for privacy, and each room has a lockable drawer. Rooms have call systems to seek help. There are alarm switches outside people’s rooms so that people who wander or who are at risk of falls can be assisted during the night in addition to room checks. We did not see consent forms or recorded best interest decisions about this. There are sufficient toilets, assisted bathing and shower rooms on both floors. We saw good infection control measures. Half of the staff are trained in infection control, and more is planned. We found the home to be generally clean and hygienic, but there was a strong offensive odour in the bedroom of a person case-tracked. The carpet was only recently replaced, and we were told that this issue affects others in the home. The person’s carpet is cleaned two or three times a week while a decision is made with the family about another type of flooring. A night-time toileting programme, as well as daily carpet cleaning may more effectively control the odour, dignity and provide a bedroom more congenial for sleep. The visitor’s register is kept in the office as people in the home often misplace it. We had to ask for it to sign in when staff were busy. This book is one of several fire safety precautions, and the home may need to review how they keep track of visitors in the building. No one can leave without staff assistance. The fire alert posters required by law were removed for decoration and they will need replacing. In case-tracked records we saw individual fire evacuation plans, which is good practice. DS0000062017.V372174.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27-29: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a well-trained team of staff who have a good understanding of their individual needs. There is a robust system of recruiting staff and volunteers so that people using the service are in safe hands. EVIDENCE: Staff surveys were not returned to us, so we examined five staff files and interviewed three staff and sampled rotas. The Limes have a robust recruitment and selection process and people can have confidence they are in safe hands. There is an ethnically, age and gender diverse workforce. Some staff have been at the home for many years. Staffing is consistent – agency staff are not used to cover staff sickness and leave. Staff are clear on their roles and told us they are happy with cover arrangements. We note there are interchangeable job roles; care staff also cover laundry and kitchen duties during staff leave. Care staff prepare tea each day and most staff are trained in safe food handling. Staffing levels and skill mix are planned on the basis of the needs of people in the home, and we saw sufficient staff to feed people and provide activities twice a day. Staff told us they enjoy this. An Activities Coordinator will supplement this and provide personal attention to people and on outings. Care DS0000062017.V372174.R01.S.doc Version 5.2 Page 25 staff are trained in first aid. Medication is given before the night shift, as this is staffed by care workers. There is an on-call system with management for emergencies or advice. Other shifts have a senior who can administer medication. Managers are supernumerary, or extra on the care rota. Current staffing: AM - 3 carers / 1 senior care PM - 3 carers / 1 senior care Night - 2 carers (waking night staff) Records tell us that staff, young apprentices, students and volunteers are checked to ensure they are safe to work with vulnerable people, most before they start work. One person is working under supervision until all checks are received. There is no current policy about renewing checks, which would be good practice as some checks are dated 2004. There is one long standing volunteer and the home wants to recruit more so they can offer individual outings. We checked the volunteer policy saying volunteers would be treated as if they were employees, but there are no supervision or training records and the home did not have a plan on how the volunteer is used. New staff have a Skills For Care induction to safe working at the home that includes a person-centred approach. New staff told supported by mentors and by management, and all staff impressed us with their understanding of personalised care, dementia, abuse and whistle-blowing. Two staff were complimented by inspectors on their skilled practice. The Limes provide excellent training opportunities to their staff. Relatives said: “I know they are well trained and exude confidence and knowledge about the residents’ need…” “[the home]…takes dementia training of staff very seriously.” There is accredited medication training at two levels, dependent upon staff roles. Mandatory and refresher training is planned on a training matrix and supervision records show that management ensure staff take this up, but there are few training certificates in staff files. Newer staff records have induction checklists and mandatory training includes abuse and safe systems of work and infection control. Qualifications meet national minimum standards for NVQ 2 or above. Staff are able to obtain higher qualifications, and some senior carers and the Deputy are training in NVQ 4. Care staff have advanced level dementia care training. Extra training is commissioned when needed that responds to the needs of the home and people living there, e.g. pressure sore prevention and challenging behaviour. The home are working towards the Gold Standard for end of life care. Some staff were trained by the council on the Mental Capacity Act, and will be DS0000062017.V372174.R01.S.doc Version 5.2 Page 26 training in Deprivation of Liberty Safeguards. People can have confidence that staff have the skills and experience that matches their needs. New and longer-standing staff told us they loved their jobs because they like the people living at the Limes, their work and the staff team. There are good handovers for daily communication about people’s needs. Relatives said the staff are caring and we saw skilled staff using touch and hugs to reassure and respond to peoples moods and to gently draw them away from risks, e.g. dragging dining room chairs down the hall. There are staff meetings, where learning is shared. We only saw one appraisal for 2008 in 5 staff records examined, and management confirmed that medication performance is not observed and competence is not checked. One staff member’s overall performance has not been appraised since 2004. Discussion with management identified there is uncertainty about supervision and appraisal. Supervision frequency exceeds national minimum standards but records are not fully dated. Learning is also shared in supervision, but supervision and staff records did not evidence that action is always taken to address poor performance as a result of management audits or a cause for concern log we saw. This needs robust attention to ensure staff performance continually improves, and that people’s needs are protected regarding medication practice. DS0000062017.V372174.R01.S.doc Version 5.2 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31-33, 35-38: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed to provide a person-centred service, which people benefit from and their financial interests are safeguarded. Management systems and procedures need to develop and staff competence, so that people’s health and wellbeing are proactively protected. EVIDENCE: The home has a qualified and experienced manager registered by CSCI, who has just completed the Registered Manager’s Award. The Manager, on leave during the inspection, is supported by a deputy and the owner. There are 6 monthly meetings to review the running of the home, and monthly spot checks by the owner to speak to people and visitors and review health and safety. DS0000062017.V372174.R01.S.doc Version 5.2 Page 28 Relatives and staff told us that staff and management work well as a team, and find the manager and owner approachable and supportive. “The owner and manager are dedicated, highly professional and loving and caring towards the residents – a good lead set for the rest of the staff.” We saw quality monitoring reports and records of residents and family meetings and complaints. There has been a focus on improving laundry arrangements in response to missing clothing. We did not see management checks that recording and care plan quality meets company expectations. The home is usually good about notifying CSCI about incidents, but there was some confusion after new guidance was issued. We have not always been notified about pressure sores. The owner confirmed that periodic audits of incidents and accidents take place for individuals so that patterns can be identified and prevented, eg about falls. Audits were not available to us during our visit about any patterns and steps taken or systems changed for prevention overall. We discussed improving bottlenecks and seating at mealtimes with the owner, and a concern in a care review that was not acted upon for a person at risk of falls, being pushed. There is excellent recruitment practice in choosing the right staff to work in the home and proactive planning for a future workforce. Recruitment of the Activities Coordinator has been delayed by robust vetting checks. Management prioritise induction and probationary periods, only confirming staff in post when satisfied. We sampled staff meeting minutes and found that training is checked and the equipment needs of people in the home, and action on regulator reports. Consumer and stakeholder surveys are undertaken and we saw the results in the home’s brochure. People are pleased with the menu and cleanliness of the home, and suggested attending football matches and bingo outside the home. Satisfaction with personal care “ranged from excellent to very satisfying.” We sampled the home’s records, reports by other regulators and contractor certificates. Safe working practices are audited. Essential maintenance and servicing are up to date and plans are in place for continuous improvement to health, safety and infection control. There is a fire safety action plan. Policies and procedures are reviewed annually by the owner. The AQAA told us there are no procedures regarding the Mental Health Act. As there were two emergencies this year, we recommend development in this area in consultation with local NHS services. The restraint procedure is not fully up to date in light of new laws about mental capacity, important for a dementia care service. There is other policy development noted elsewhere in this report. DS0000062017.V372174.R01.S.doc Version 5.2 Page 29 The financial interests of people are safeguarded by the system introduced since the last inspection. We found that appropriate expenditure is made and accounted for through records and receipts, checked by two accountable staff. Spending and funds is agreed with people and their representatives, and invoices are regularly sent. In general the home is well run and has a person-centred approach that benefits people in their care. Management seek to continuously learn and improve. There are management systems in place that need development so that people using the service have consistent quality in all aspects of the service. In many respects human resource management is excellent, however we discussed robust action needed with the owner regarding staff supervision, appraisal and determining staff are competent. Progress was made following the last inspection, but was not sustained regarding health and personal care. During the past year there was a reduction in management capacity due to illness and management training. Management were aware of some problems and had plans in motion to make improvements. Immediate action was taken by the owner to address risks we found, so people are safe. Management have a good record of working with us. We have confidence matters will be addressed quickly and effectively, but we are also considering further action to ensure this is sustained for the safety of people living in the home. DS0000062017.V372174.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 3 3 3 3 3 2 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 2 3 DS0000062017.V372174.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 12(1)(a) and (b) Requirement The Registered Person must ensure that access to NHS services is maintained in accordance with assessed needs and risks, and as requested by health professionals. The registered person must ensure that all medication is auditable. Drug audits must be undertaken on a regular basis to confirm safety of the medication system and staff competence. (Not met by 30/09/06) The quantities of all medicines received and any balances carried over from previous cycles must be recorded and added on the Medicine Administration Record (MAR) chart to enable audits to take place. (Not met by 30/09/06) All prescriptions must be seen prior to dispensing and checked and a system installed to check the dispensed medication received into the home. (Not met by 30/09/06) All MAR charts must be accurately written reflecting the DS0000062017.V372174.R01.S.doc Timescale for action 15/12/08 2. OP9 13(2) 15/12/08 3. OP9 13(2) 15/12/08 4. OP9 13(2) 15/12/08 5. OP9 13(2) 15/12/08 Version 5.2 Page 32 6. OP9 13(2) 7. OP9 13(2) 8. 9. OP9 OP36 13(2) 18(1)(a) dose and directions the doctor has prescribed and advised, be signed directly after the transaction and accurately record what has occurred. (Not met by 30/09/06) The installation of locked cabinets to store any excess medication and those awaiting return to the pharmacy is required (Not met by 30/09/06 ) There must be only one controlled drug register, with numbered pages, to ensure controlled drugs are auditable for public safety. All medicines must be stored in compliance with their product licenses to ensure their stability. The Registered Person must ensure that staff are competent to manage, administer and witness medication. 15/12/08 26/11/08 26/11/08 31/01/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP1 OP7 OP8 OP9 Good Practice Recommendations The statement of purpose and service user guide needs detail about the dementia care service; they can be made more accessible to a wider audience. Risk assessments and care plans should be accurate in respect of pressure sores, infection, and mobility so that staff guidelines match people’s current needs. Staff need detailed information to monitor health conditions and medication side effects. Occasional use or ‘as required’ medicines should have supporting guidelines for staff to administer as the doctor intended, endorsed by a clinician to avoid drug reactions and to recognise excessive effects. If this medication is required regularly, the doctor should be consulted. DS0000062017.V372174.R01.S.doc Version 5.2 Page 33 5. 6. 7. OP9 OP9 OP17 8. 9. 10. 11. OP18 OP22 OP26 OP33 12. OP33 13. 14. 15. OP36 OP38 OP38 Medication policies and procedures should be up to date and reflect good practice to guide staff and protect people. Staff should be familiar with them. An improved system is advised for accurate audits of homely remedies, ensuring compatibility with individual’s drug regimes. The Mental Capacity Act 2005 and the Mental Health Act 2007, and their codes of practice should be used to review policies and procedures so that people’s legal rights are protected and statutory advocates are used when needed. Personal safety and behaviour plans should prevent as well as respond to concerns, incidents and accidents. Hearing loops in communal areas would assist people with hearing aids. Bedrooms should be kept clean, hygienic and free from offensive odours. It is advised that the home develop existing and new policies and procedures regarding: a) emergency mental health assessment with local agencies b) sexuality to be inclusive of sexual orientation, inability to consent, and abuse c) equality and diversity d) management audits Audits of care plan quality, recording, incidents and accidents should take place to identify patterns, and any possible changes in systems, practice and the environment to prevent harm. Regular appraisal of staff performance should take place so that management ensure staff practice meets people’s needs, policies and procedures are followed. The home needs to ensure CSCI are notified of required matters, including pressure sores. It is recommended that Health Protection Agency advice is sought and/or problems reported to the appropriate authorities regarding infection control and communicable disease. DS0000062017.V372174.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000062017.V372174.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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