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Inspection on 23/09/09 for The Meadows

Also see our care home review for The Meadows for more information

This inspection was carried out on 23rd September 2009.

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

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

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

What the care home does well

The home offers a new purpose built well maintained environment, which offers people their own bedroom, which they are encouraged to personalise. To help people decide if the home offers the level of service they are looking for, prospective service users are invited to visit, stay for a meal if they wish, and spend time meeting other people living and working in the home. Also due to the home not being full (twenty five vacancies), people are benefiting from being able to choose which room they would like. When a member of staff left a person’s bedroom after helping them, the person receiving the care turned to us and said “see they are very kind”. This reflected our observations during this inspection, where we observed some staff interacting positively with the people they were supporting, enhancing the person’s well-being. A relative in response to being asked, ‘what does the service do well’, replied ‘everything, we have been very pleased with the care and help provided’.

What has improved since the last inspection?

The Meadows DS0000072735.V377642.R01.S.doc Version 5.2 When we visited in June 2009, we found the nursing support for nearly all the night shifts, and some of the days, was being provided by external agency staff. The turnover of agency staff was also high, with staff refusing to come back and work at the home. The home is now using nurses supplied by their own ‘in-house’ nursing agency, to fill the nursing vacancies. Although the staff are employed by the agency, and not the home, the aim is in time for them to be offered a permanent contract, if found suitable. In doing this, it has stopped their reliance of using external nursing agency staff, and enables care to be provided by staff who can get to know the people living at the home. The home has continued to develop the range of activities on offer, and purchase more specialist games, and craft items which we saw people enjoying taking part in. The management tell us that since July 2009, they have started ensuring that all staff receive regular two monthly feedback on their performance, and discuss their training needs. The management voluntarily stopped admitting new people (who privately pay for their care) for a while, whilst they looked to addressing shortfalls we had identified following the March 2009 inspection, and recruited a more permanent team of nursing staff. At the time of our visit, the home had employed a consultancy service. They told us that they had been at the home for the last two weeks, to support the manager, and undertake their own review of the service, as part of their quality assurance work.

What the care home could do better:

The home must have a management structure in place which ensures that the home is being run in a competent, professional way, by people who have the skills and knowledge to ensure the safety and well-being of the people in their care. Performance issues with staff need to be managed in a discreet and professional manner. Observations during the last three inspections, (including this one), and feedback from safeguarding referrals, shows that although staff are receiving training, there is no follow-up on how they are putting theory into practice, to ensure they fully understand what they have been told. When we asked a member of staff how much training they have had in dementia, they told us “two hours”, further discussions identified that two of the staff on shift, had never worked in care before. Staff need to be given support, guidance and more in depth training in dementia and communication needs. In doing this it will help staff develop their understanding of their emotional, as well as care needs, and find ways to support people who are unable to communicate their wishes. People living in the home entrust the staff to have systems in place, to ensure that staff never run out of their individual medications, and they are given their medication close to the time the doctor has prescribed. However, theThe MeadowsDS0000072735.V377642.R01.S.doc Version 5.2 management of medications has been weak at the home, leading to us carrying out two further follow up inspections focusing on medication, since March 2009. Where the home has addressed a shortfall, we are finding at a later follow up inspection, it has not been sustained. This must be addressed, to ensure the comfort, welfare and safety of the people living at the home. Since the home opened, they have constantly been changing their care plan format, to try and fulfil the promises made in their Statement of Purpose ‘An holistic, person centred approach will be utilised which focuses on care needs, behaviours, fear and emotional reactions’. This report concludes that although some work has been undertaken, this has not been achieved. The management informed us that after four changes, they are still looking for a suitable care plan format to use. During feedback at the end of this inspection, we raised our concerns that the changes seemed to be a “knee jerk” reaction to shortfalls identified in the individual care being provided, both by us, social and health care professionals. The management must focus on the quality of information, so staff are given clear guidance on the level of support the person will need, to give well-being to their life, based on their preferences and wishes. Where people receiving care are able to voice their opinions, and inform staff, we received positive feedback. The information held in care plans, must ensure all people receive good quality care, not just those that can speak up for themselves. Further work needs to be undertaken, to ensure staff receive training and support, to develop activities through the day, around individual people’s needs and capabilities. Although staff are receiving safeguarding training, recent safeguarding referrals, shows that some staff are not feeling confident enough to report the issues straight away to the appropriate people. This could affect a person’s wellbeing and safety.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Meadows Brybank Road Hatchett Village Haverhill Suffolk CB9 7YL Lead Inspector Jill Clarke Key Unannounced Inspection 09:45a 23 September 2009 rd DS0000072735.V377642.R01.S.do c Version 5.3 Page 1 This report is a review of the 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. 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. The Meadows DS0000072735.V377642.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Meadows DS0000072735.V377642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Meadows Address Brybank Road Hatchett Village Haverhill Suffolk CB9 7YL 01440 712498 01440 762524 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) Minster Haverhill Limited Manager post vacant Care Home 53 Category(ies) of Dementia (53), Old age, not falling within any registration, with number other category (53), Physical disability (53) of places The Meadows DS0000072735.V377642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home with nursing - Code N 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 - Code OP Dementia - Code DE Physical Disability - Code PD The maximum number of service users who can be accommodated is 53 17th March 2009 2. Date of last inspection Brief Description of the Service: The Meadows was registered with the Commission for Social Care Inspection 1st October 2008. The home is owned and managed by Minster Haverhill Ltd, a subsidiary of Minster Care Management Group, a national company with a large number of care homes. The Meadows is a new care home for frail older adult, older people with a dementia and/or a physical disability. The home is situated in a village which is near to Haverhill in Suffolk. The home is a newly built property and the accommodation for people to live in is on the ground and first floor. The second floor of the home is used for staff rooms. The Service User Guide which we were given at the time of the inspection states that the ‘current fees from £400 per week’, it does not give a maximum fee but does state that fees are ‘individually costed around the personal nursing and care needs of the individual person’. Subject to conditions, people are able to bring their pets in with them. The Meadows DS0000072735.V377642.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 0 Star. This means the people who use this service experience poor quality outcomes. We (The Commission) visited the home unannounced, to carry out a Key Inspection, which was undertaken by two inspectors, Jill Clarke and Julie Small. The manager was present throughout the inspection. This report has been written using accumulated evidence gathered prior to, and during the inspection. Since we last carried out our Key Inspection on the 17th March 2009, we have been back twice to undertake two further inspections (5th June and 7th September 2009). These focused inspections known as ‘Random inspections’, enable us to monitor what action the management had taken to address our concerns following the March and June inspections. During this inspection we focused on assessing against the Key Lines of Regulatory Assessment (KLORA). We also used ‘making judgements about the quality of services for people with dementia in care homes’, to underpin our KLORA judgements. Prior to the inspection we sent staff surveys for the manager to give out, we also left some surveys for relatives/visitors in the dementia care unit to complete if they wish. Surveys were also sent out to health (General Practitioners) and social care professionals (Social Workers and Care managers). In doing this it enables people associated with, or working for the agency a chance to feedback their views on what they think of the service provided, and how it is run. At the time of writing this report we have received the following surveys back; one relative, one health professional, and one social care manager. The home was asked to complete an Annual Quality Assurance Assessment (AQAA), which they sent to us on the 31st March 2009. This provides us with information on how the home is meeting/exceeding the National Minimum Standards (NMS) and any work they are looking to undertake in the future. Further information on the NMS can be found on our website www.cqc.org.uk During the inspection we spent time talking to six people whose bedrooms are located on the ground floor, who generally require nursing care and support with physical disabilities. We also spoke with two people living upstairs, on the first floor dementia care unit. This enabled us to hear their views on the care they receive, and also allows us to spend time observing the daily routines of the home, and how staff interact with the people they look after. The Meadows DS0000072735.V377642.R01.S.doc Version 5.2 Page 6 Because people with dementia are not always able to tell us about their experiences, we have used a formal way to observe people in this inspection to help us understand. We call this a Short Observational Framework for Inspection (SOFI). This involved us observing five people who live at the home, whilst they were in the lounge for one and half hours. We recorded their experiences at regular five minute intervals, which included their state of wellbeing, and how they interacted with other staff members, other people who live at the home, and the environment. Our observations have been recorded, where applicable in the relevant sections of this report. We also spent time receiving general feedback from people managing, living and working at the home, which included the Manager, three Nurses, six Care assistants, a Cook and an Activities Coordinator. Records we looked at included, care plans, training and staff personnel files, complaints folder, and staff rotas. We were given a copy of the home’s Statement of Purpose, Service Users Guide, Training ‘matrix’, and staffing rotas for September 2009, to take away with us to read. We gave a summary of our findings to the manager at the end of the inspection. What the service does well: The home offers a new purpose built well maintained environment, which offers people their own bedroom, which they are encouraged to personalise. To help people decide if the home offers the level of service they are looking for, prospective service users are invited to visit, stay for a meal if they wish, and spend time meeting other people living and working in the home. Also due to the home not being full (twenty five vacancies), people are benefiting from being able to choose which room they would like. When a member of staff left a person’s bedroom after helping them, the person receiving the care turned to us and said “see they are very kind”. This reflected our observations during this inspection, where we observed some staff interacting positively with the people they were supporting, enhancing the person’s well-being. A relative in response to being asked, ‘what does the service do well’, replied ‘everything, we have been very pleased with the care and help provided’. What has improved since the last inspection? The Meadows DS0000072735.V377642.R01.S.doc Version 5.2 Page 7 When we visited in June 2009, we found the nursing support for nearly all the night shifts, and some of the days, was being provided by external agency staff. The turnover of agency staff was also high, with staff refusing to come back and work at the home. The home is now using nurses supplied by their own ‘in-house’ nursing agency, to fill the nursing vacancies. Although the staff are employed by the agency, and not the home, the aim is in time for them to be offered a permanent contract, if found suitable. In doing this, it has stopped their reliance of using external nursing agency staff, and enables care to be provided by staff who can get to know the people living at the home. The home has continued to develop the range of activities on offer, and purchase more specialist games, and craft items which we saw people enjoying taking part in. The management tell us that since July 2009, they have started ensuring that all staff receive regular two monthly feedback on their performance, and discuss their training needs. The management voluntarily stopped admitting new people (who privately pay for their care) for a while, whilst they looked to addressing shortfalls we had identified following the March 2009 inspection, and recruited a more permanent team of nursing staff. At the time of our visit, the home had employed a consultancy service. They told us that they had been at the home for the last two weeks, to support the manager, and undertake their own review of the service, as part of their quality assurance work. What they could do better: The home must have a management structure in place which ensures that the home is being run in a competent, professional way, by people who have the skills and knowledge to ensure the safety and well-being of the people in their care. Performance issues with staff need to be managed in a discreet and professional manner. Observations during the last three inspections, (including this one), and feedback from safeguarding referrals, shows that although staff are receiving training, there is no follow-up on how they are putting theory into practice, to ensure they fully understand what they have been told. When we asked a member of staff how much training they have had in dementia, they told us “two hours”, further discussions identified that two of the staff on shift, had never worked in care before. Staff need to be given support, guidance and more in depth training in dementia and communication needs. In doing this it will help staff develop their understanding of their emotional, as well as care needs, and find ways to support people who are unable to communicate their wishes. People living in the home entrust the staff to have systems in place, to ensure that staff never run out of their individual medications, and they are given their medication close to the time the doctor has prescribed. However, the The Meadows DS0000072735.V377642.R01.S.doc Version 5.2 Page 8 management of medications has been weak at the home, leading to us carrying out two further follow up inspections focusing on medication, since March 2009. Where the home has addressed a shortfall, we are finding at a later follow up inspection, it has not been sustained. This must be addressed, to ensure the comfort, welfare and safety of the people living at the home. Since the home opened, they have constantly been changing their care plan format, to try and fulfil the promises made in their Statement of Purpose ‘An holistic, person centred approach will be utilised which focuses on care needs, behaviours, fear and emotional reactions’. This report concludes that although some work has been undertaken, this has not been achieved. The management informed us that after four changes, they are still looking for a suitable care plan format to use. During feedback at the end of this inspection, we raised our concerns that the changes seemed to be a “knee jerk” reaction to shortfalls identified in the individual care being provided, both by us, social and health care professionals. The management must focus on the quality of information, so staff are given clear guidance on the level of support the person will need, to give well-being to their life, based on their preferences and wishes. Where people receiving care are able to voice their opinions, and inform staff, we received positive feedback. The information held in care plans, must ensure all people receive good quality care, not just those that can speak up for themselves. Further work needs to be undertaken, to ensure staff receive training and support, to develop activities through the day, around individual people’s needs and capabilities. Although staff are receiving safeguarding training, recent safeguarding referrals, shows that some staff are not feeling confident enough to report the issues straight away to the appropriate people. This could affect a person’s wellbeing and safety. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 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 The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4, and 5. The home does not offer Intermediate care, therefore this standard was not assessed. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot rely on the written information alone to support them in identifying if the home will be able to meet their individual needs. People with dementia cannot be assured that the home will be able to meet their needs. EVIDENCE: We were given a copy of the home’s most current (September 2009) Statement of Purpose and Service User Guide to take away with us. The booklets are given to ‘all service users’, prior to them moving into the home, to ensure they have ‘all the information they may need’. The Statement of Purpose informs the reader that the home ‘provides nursing care for 53 ladies and gentlemen who may have both physical and mental The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 11 frailties including dementia’. It also states that they offer a care service ‘for young and older adults’. There is no information to support a prospective service user in identifying the age range of the people living at the home, or the type of ‘physical and mental frailties’ to support them in identifying, if the staff will have the specialist skills, and knowledge to support them. The information given on the Registered Manager is incorrect, as currently the post is vacant (see Management and Administration section of this report). There is also reference to their regulatory body being both the Commission for Social Care Inspection, as well as the Care Quality Commission (which took over the role on the 1st April 2009), which could be confusing to the reader. To support people’s range of communication needs, the home states they would be ‘happy’ to explain or read the Service User’s Guide individually to people. It can also be supplied ‘in large print and on audio tape if this will help’, and we noted that computer graphics have been used to illustrate what is being said. The thirty-four page booklet gives lots of general information. We found that the index was not very user friendly, as the headings are not linked to the page numbers. The booklet does not include any ‘localised’ information, to support a new person moving in, to know what goes on in the home, and the local community. For example access to local shops, transport links and meal times. The Statement of Purpose informs people that they ‘may attend religious services either within or outside the home as they so desire. However, the Service User Guide provides no ‘localised’ information on what local places of worship/meetings to support people in identifying how their religious, faith or spiritual needs can be met. There is also no information given to say if there are any religious/spiritual services happening at the home. We looked at two people’s pre-admission assessments undertaken for new residents admitted since our last Key inspection. The assessments had not been signed or dated in the space provided on the form, to confirm when it was undertaken. When completing the assessment form fully, it will provide staff information on the person’s medical, social, mental, physical and mobility needs. However, we found that not all the sections had been completed on the first assessment form, which included physical well-being and mental state. We found that the information given in the home’s AQAA reflected our findings, as it informs us under what they could do better ‘evidence and written document regarding the pre-placement assessment and discussions could be more extensively documented and recorded’. The Service Users Guide states under ‘trial period’ that ‘we will carefully assess new admissions to the home to ensure that they are compatible with the people who live’ there. There was no further information given on the admission policy, however the Statement of Purpose told us that the ‘manager will complete a comprehensive assessment of the prospective service user at The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 12 their place of residency’. Looking at people’s pre-admission assessments, and feedback from the management, identified that they currently do not use any separate assessment ‘tool’, for people with dementia. This led to discussions that if they used one, it would support them in identifying the resident’s level of ability when they first moved into the home, and their compatibility with the other residents. Time spent talking with people living at the home, with staff, reading care records, survey feedback and our own observations, shows that where some people’s needs, are being met, where others, especially with more complex mental health needs are not. This is further evidenced throughout this report in the relevant sections (see Health and Personal Care, Daily Life and Social Activities, Complaints and Protection, Staffing, Management and Organisation) where we identify that staff are not being given the guidance, skills and knowledge to support people with communication and dementia needs. The feedback we received through a relative survey, told us they feel the care home ‘always’ meets the person’s needs, and that they have “been very pleased with the care and help provided” to their next-of-kin. Both the Health and Social care feedback, told us that they feel staff ‘sometimes’ have the right skills and experience to support people’s social and health care needs. With one person telling us that the “staff they have appear to be caring and trying their best – but worry if staff have the abilities to look after more complex cases”. The Service Users Guide informs people when they first move in it will be for a ‘trial period’, to give them time to be able to see how they like the home, staff ‘and other people’ who live there. The guide also informs people that prospective resident’s can get a feel of the home, and the level of service offered, by visiting and staying for a meal, overnight or joining in with a social event. Two people we spoke with told us that they had visited the home before they moved in, to check that it was the right place for them and that they had chosen their bedrooms. Another person told us that they had chosen to move into the home when they had visited a relative who had also lived there. The AQAA informs us of further positive work they are looking to undertake, to aid the admission process, is ‘to set up a welcoming committee which will be aimed at welcoming new service users’. The Statement of Purpose, Service Users Guide and AQAA gives no information on the home providing ‘intermediate care’, aimed at those people, requiring support with rehabilitation, such as following a stay in hospital, prior to going home. Therefore we did not assess this ‘key’ standard during this inspection. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can expect that a care plan will be in place, which sets out how their physical care needs are to be met. However they cannot be assured that their care plan will give enough information on their wishes and preferences, and in supporting their mental health needs. People cannot be assured that they are protected by the home’s medication procedures. EVIDENCE: At the 17th March 2009 inspection, the manager informed us that they ‘were in the process of updating and improving the format of the care plans’ for people living at the home. They told us that they planned to complete the new care plans that week. The completed AQAA received following the inspection, also mentioned that the home is ‘developing a person centred approach with all care plan documentation and the delivery of the planned care’. In order to do this, the management told us that the information held in the care plan, will The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 14 focus ‘on looking at the individual strengths of each service user and how the staff supporting them can best promote their independence. This then impacts on the emotional wellbeing and dignity of each service user’. In June this year, following two safeguarding referrals (see Complaints and Protection section of this report), shortfalls were identified in monitoring two peoples nursing and personal care needs. This resulted in Suffolk Adult Care services, undertaking a review of all the residents they had funded care for. These visits identified further weaknesses in the home’s recording of information, which we have also observed during our inspections. They also identified that the home was continuing to change their care plan templates, and were on their fourth version. During this inspection we were informed that the home is still looking for the ideal care plan format to use, and they are looking at one’s currently being used by other organisations. During this inspection we looked at four residents (two from both floors), and where possible, spent time talking with them, and observing how they interact with staff. We also spent time gaining feedback from care and nursing staff who look after the people. By doing this it helps us judge if the information given in the care plan matches the person’s expectation, and the current level of care they are receiving. It also helps us identify if the home is doing what they say they are in their Statement of Purpose, by providing ‘a holistic, person centred approach’, which ‘focuses on care needs, behaviours, fears and emotional reactions’. To enable staff to support people with their different behaviours, linked with their mental health needs such as dementia, care plans need to focus on what provides ‘well-being’ (what makes them feel good) for that person. The care plans we saw, lacked guidance for staff on dealing with different behaviours individual residents might show, as they struggle with their dementia and being able to make sense of their life. This reflected our findings during our ‘random inspection’ earlier this month. When we read a resident’s care plan it referred to them as being ‘verbally aggressive’, and ‘will shout and swear at staff and residents for attention’. We observed this happening, but also saw that the situation could have been easily prevented by staff giving them a cup of tea when they asked; rather than spend 29 minutes promising them the drink when the “tea trolley” came round. We also noted in the same person’s care plan, that according to the person writing it, that the person was ‘incontinent of urine as an attention seeking behaviour’. We raised concerns as to whether the resident had the mental ability to do this, and the skills and knowledge of the person giving staff this guidance. When we asked a healthcare professional we surveyed, if they felt the ‘care service’s assessment arrangements ensure that accurate information is The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 15 gathered and that the right service is planned for people’, they replied ‘sometimes’. Feedback from a member of staff and social care professionals also identified that care plans are sometimes being written by people ‘who didn’t really know the person’. Another care plan looked at during this visit, further identified the lack of guidance given to staff in supporting residents with dementia. Information given in the care plan informed staff that the person ‘can be aggressive’. There was no information on what approaches staff have found to work well ‘smiley today’ and ‘had a good day’, and not so well ‘been in a funny mood been scratching carers’. By doing this it would support staff in building up a picture of what they can do to give quality to the person’s day. There was no ‘reflective practise’, to help staff look at the situation leading up to the person being labelled as ‘aggressive’, to see if it was their own lack of understanding what the person was trying to communicate to them – had led to the situation occurring. Records show that staff are ‘risk assessing’ and monitoring the condition of people’s skin, and nutritional needs. The assessment sheets had been dated and signed by a staff member, on a monthly basis to show that they have been reviewed. Where fluid and food charts were being used to monitor a person’s intake, we found that these were not always being fully completed in people’s care records. We asked a person being cared for in bed if they were comfortable, they replied “yes”, saying they were well looked after. There is information on how staff are to support people with their physical needs. However, they did not always indicate a person’s personal preferences and the individualised care that they may require and prefer. It was noted that the care plans did not identify how people’s diverse needs are to be met in areas such as their sexuality, behaviour and in cultures other than English. There was no communication aids being used, or offered to help a person inform staff of their needs, which left them isolated. Discussions with staff identified that they feel at times they were not always provided with up to date information when people’s needs has changed. Concerns over safeguarding issues brought to our attention in May this year, identified that although staff were recording changes in a person’s health, this was not always being acted on straight away. During our ‘random visit’ on the 5th June 2009, we recorded a eight day delay in a person being seen by a Doctor, and receiving treatment. During our next ‘Random inspection’ (7th September 2009), we ‘tracked’ a person who had been prescribed antibiotics, and found that the health advice had been sought, and treatment started within appropriate time scales. Feedback from a health care professional, expressed their views in their survey that they have had ‘late visit requests for problems that have been present for days’. They also replied ‘sometimes’, The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 16 when asked ‘does the care service seek advice and act on it to meet peoples’ social and health care needs and improve their well-being’. Four people we spoke with who lived in rooms located on the ground floor, told us that their health care needs were being met, and that they were provided with the opportunity to see a doctor if they felt unwell. A person told us that they were not happy with the spectacles that they had recently been provided with, and that the staff had assisted them to make an appointment with an optician to discuss their spectacles. People were complimentary about the approach of the staff that worked at the home. They also told us that the staff always treated them with respect, and that they always knocked on their bedroom door before entering, which was confirmed in the observations that we made during the inspection. We observed excellent interaction from a nurse and a carer who was on duty during the inspection, they interacted with people in a caring and gentle manner and it was noted that people responded positively to them. When we observed a person after lunch informing a member of staff that their hair had not been combed, the staff member promptly helped the person to brush their hair. When they left, the person said “see they are very kind”. We did observe some shortfalls where further attention is required to ensure people’s dignity, where one person’s clothing was stained and there was talcum powder sitting on their neck and chest area. A person told us that their food was cut up for them at mealtimes and that there had been no further options provided. For example a specialist fork with a cutting edge, to allow them to cut up their food independently. We observed two pairs of staff transferring people using a hoist, giving reassurance to reduce any possible anxiety the people may have during this activity. However, whilst one set of staff concentrated on moving the person safely in the lounge area, they had forgotten to ensure the person’s modesty, as we could see their underwear. In June this year, we carried out an unannounced random inspection to see if the requirements made following the March key inspection had been complied with. We identified that they had, however further shortfalls were identified in the storage and administration of medication. This resulting in four further requirements being made. This included people being given their medications at the time they ‘are scheduled to be administered’, as we found Nurses were taking too long to give people their morning medication. Therefore this resulted in some medications being given too close together. We returned to the home again unannounced on the 7th September 2009, to judge if the requirements made following the June visit had been complied with. We found all but one (securing the controlled drug cabinet to the wall correctly) had been met. However, we also identified that where we had found in June that they had met the requirement of ensuring they ordered medication promptly, so they did not run out, we found that the problem had reoccurred. This raised The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 17 concerns over the homes ability to manage systems, to ensure people received their prescribed medication as prescribed for their health and welfare. Following our visit on the 7th September 2009, requirements were made, which the home had to comply with by the 25th September 2009 (see Statutory requirements section of this report). As this inspection is before that date, we did not check to see if they had complied (although the Manager did inform us that the cabinet holding the controlled medications was now correctly bolted to the wall) as this would be undertaken as another separate ‘random’ inspection being carried out next month. However, discussions with care staff during this inspection identified that some nursing staff completed the medication round promptly and others completed the morning medication round at lunch time, and then started the lunch time round. This raised concerns that the there has been further ‘slippage’ on a previous ‘complied with’ requirement. We also found that due to staff sickness, a person who required their medication to be giving at set periods during the day, did not receive their 8am medication until 11am. Upstairs, we observed the medication being given out during the morning. The nurse gave the medicine pot holding all the tablets to the person, and helped them hold it to their lips. This resulted in the person swallowing all the tablets in one go, and start coughing, and the nurse asking if they had “gone down the wrong way”. We asked the agency nurse what their normal area of expertise was, and they replied “critical care”. Part of the lunch time medication round for people living downstairs was also observed. The nurse followed safe practise, by ensuring when they left the trolley storing the drugs they locked it, so no one else had access to its contents. The tablets and liquids was provided to people in clean pots and the nurse signed the MAR (medication administration records) charts when people had taken their medication. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can expect activities to be arranged by the home, but cannot be assured that everyone will have equal access to stimulating activities, and periods of occupation during the day. People can expect their visitors to be made to feel welcomed. EVIDENCE: People’s daily records that we looked at downstairs showed the activities that they had chosen to participate in and where they had declined the offer of activities. Whilst walking around the ground floor lounge, we looked at the activities programme for the week of the inspection, displayed on a notice board. Activities were provided on a daily basis and included; meet and greet, sing-along, men’s group, bingo, craft group (card making), art group (painting), coffee morning, reminiscence, hairdresser, manicure, music, table games and DVD’s. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 19 During the morning we observed a group of four people undertaking art work and card making in the downstairs lounge. The activity was being organised by the activities coordinator, who helped each person in turn with their art work. Interaction was observed to be good and there was lots of chatting about memories and laughter. A person was sitting in an armchair in the lounge and they were not included in the activity, or asked if they wished to join in. A member of staff asked if another person could join the group at the dining table, and we watched them joining in by colouring in the pictures. Discussions with a member of staff identified that the person was not usually encouraged to join in the activities. Saying when they had previously asked if they could do some painting, they had been told “imagine the mess”. Staff we spoke with, also told us that activities were provided to an ‘able’ group of people and those who were challenging or less able were excluded. This reflected comments we heard, whilst observing upstairs, with staff trying to identify who would be suitable to go down and join in with the activities. In the upstairs dementia care unit, as part of our ‘SOFI’ observation, we observed staff undertaking a range of activities with the residents in the lounge which included ball games. It was positive to see the difference in the wellbeing of the resident who we had previously observed at the random inspection undertaken 2 weeks earlier. During that visit, staff were being ‘controlling’ by telling the person they would need to wait for their cup of tea, which resulted in them becoming anxious and shouting out. However this time, we observed them enjoying the interaction with staff, who gently encouraged them to join in with the ball games going on. As they played, and in noticing that we were not joining in, with a smile - aimed the ball at us, and having liked our reaction, used the same tactic on any member of staff in close proximity, who happened to turn their back on them. The laughter and positive interaction had a good effect on those, who did not join, as we could see them open their eyes to observe what was going on. Another person also started to sing. Another resident we were observing clearly did not want to join in with the activities, and could see them become annoyed when having already said “no”, within a short time, was approached by another member of staff asking the same question. This resulted in the person taking the ring from the member of staff’s hand, and putting it down by their side, to confirm again that they did not want to join in. A third person, who had been shouting on and off, was given one of the new games which had been purchased, which they promptly labelled as “childish”. The member of staff picked up on this and offered a newspaper instead. We noted another person showing signs of ill-being, as they held their head in their hands. However, when staff approached and interacted, this resulted in more positive body language, and well-being. The problem we could see was in staff being able to maintain the interaction, whilst fitting in other care tasks – and being called away. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 20 During our observations, and discussions with the manager, we identified that they are looking after residents who are at different stages of dementia. They viewed many of the people as not requiring nursing, and are classed their needs as being residential care. However, this was not reflected in the daily routines of the unit, with people not being positively supported to occupy their time to feel valued. Such as helping lay the tables, prepare food “I would love to do some cooking”, fold laundry, linked to ‘life’ skills prior to developing dementia. Downstairs after lunch, a person was observed to watch a DVD, when the afternoon activities were due to take place, the DVD was turned off, without discussion with, or consideration to the person who was watching it. Although nine people joined in with the afternoon activity making masks, both the person who had been watching the DVD, and the other resident who we had observed colouring pictures earlier, were excluded from the activities. A person we spoke with told us that there are plenty of activities to keep them occupied and they showed us art work which they had displayed in their bedroom. Three other people also told us that there was always something on offer to keep them occupied. A person who stayed in bed said that they watched television and were not engaged in organised activities. Another person told us that they regularly attended a day service called ‘wood ‘n stuff’. People told us that their visitors are always made to feel welcome, which was also confirmed by relatives we had met at a previous inspection. On the notice board in the lounge, we saw a poster inviting relatives to a meeting to be held on the 29th September 2009. Care records also showed where people had visits from their family and friends. When we arrived at the home, people we visited (ground floor) were having breakfast (which they said they enjoyed) either in the lounge, or in their bedroom, which included cereal and toast. One person told us that they always got up in the morning at 7:30 and they were provided their breakfast at 9:30 to 10:00, which they said was a long time to wait. They told us that they were sometimes given a drink when they got up, but sometimes they waited until 9:00. People were provided with a jug of squash and a cup to help themselves to cold drinks throughout the day and they were also offered a choice of hot drinks at 11:20. The lunch time menu showed that people can chose from three nutritious and varied meal options, including vegetarian. We observed a staff member taking people’s lunch choices for the day after the inspection. Lunch was served at approximately 12:45. Three people we spoke with said they chose to eat their meals in their bedroom. We noted that two of the people had not eaten their meal, which was fish, mashed and croquette potatoes and broccoli. They told us that they had breakfast at 10:00 am and The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 21 were not hungry. One person told us that their meal was not nice, they said that the fish was very dry. Three people told us that the food at the home was good and another person said the food was poor. Two people told us that the meat that was provided at the home was tough and a person said that they did not know what the meat was on Sunday but it was very tough. A person said that they preferred plain food which they had requested, but they were not listened to. During the inspection we observed the cook arrange to meet with the person to discuss their dietary preferences. At the last key inspection people had told us that the food was not hot enough. However at this inspection it seemed to have been addressed, as people told us that the food had improved and that it was always hot. We spent time observing the lunch time routines on the first floor, which was busy, noisy, and task orientated. It did not provide a relaxing, social environment to eat. At 12:10. six people, one of whom was shouting out, sat at the table, whilst staff set the table for lunch. The dining room arrangement was made up of one large table with people sitting around, and another smaller table, where 3 people were sitting, and a member of staff. At 12:45 people were starting to eat their meal, with one person being given finger food, to support their individual nutrition needs. Although one carer sat at the smaller table, assisting a person with their lunch, the member of staff helping at the larger table, was also assisting a person to eat their meal, but they remained standing, due to lack of space. Two other members of staff were involved in serving the meals from the hot trolley, whilst four other members of staff also came in and walked around during lunch checking on people. The person who had previously been trying to help another resident stand, we could see like to be near that person. However, where they had originally been sitting at the table next to them, when they got up for a short while, staff had brought another resident into lunch had sat them in that seat. We observed from then on, they did not want to sit and eat, instead tried to stand near the person they had this attachment to, or walked around the dining room. We could hear a Nurse’s keys rattling as they walked around. Two members of staff at one stage stood either side of a resident, whilst they talked over them. Observing the body language of the people sitting opposite the person shouting out, showed us that they were anxious. Discussion with staff identified that another visiting professional had commented on busy meal time, observing that there was “too many people were walking around”. When we asked a member of staff why they had not made use of the both dining rooms, as this could reduce the background noise, which research shows can increase anxiety for people with dementia. We were told that the staffing levels did not accommodate using both dining rooms. Further The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 22 discussion identified that the table arrangement had been recently changed, but could not confirmed why, or who had done it. When we gave feedback to the management, they confirmed that they had been making changes, and felt that our presence had caused the staff to be anxious, which the residents had picked up on. However, we had asked a resident earlier if it was always that noisy, they replied “yes”, giving us examples when it is “sometimes worse”. Downstairs at 16:45, we observed people being served their evening meal which was soup or sandwiches. A staff member was observed to give sandwiches to one person who threw them across the floor, they continued to try to get the person to accept their food, with no success. A member of the nursing team arrived and they spoke to the person in a comforting manner, asked them what they wanted and they accepted their meal. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a formal complaints system in place, however people cannot be assured that their verbal concerns will be recorded, listen to, or acted upon. People can expect staff to receive training in safeguarding their welfare. However, they cannot be assured that staff will report, and act on any concerns promptly, to safeguard the interest of the people they care for. EVIDENCE: We looked at the home’s complaints book, which identified that formal complaints are being responded to in a timely manner. One of the complaints had been investigated by the home’s management and it was noted that the investigation had identified that two staff members had not reported a person’s injury promptly. Both the statement of Purpose and Service Users Guide, informs people on how to make a complaint, which will be investigated and the person complaining ‘will be advised of the results within 28 days’. Discussions with four people living at the home, confirmed that they all knew how to make a complaint. However their experiences’ on how it was acted on varied, with two people telling us that when they raised issues to staff they were dealt with promptly. The third person did not feel their concerns were listened to, and acted upon saying that the manager “doesn’t like to be told”. The fourth The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 24 person told us that they had raised concerns about the staffing levels during the night, which was not recorded in the complaints book. They went on to say that the manager had told them, that there were no issues with staffing (see Staffing section of this report). A social care professional told us that they have “found the service sometimes lacking in dealing with concerns raised by professionals quickly and effectively”. A person living at the home felt that there had been improvements in the home, as they now have ‘key worker’, who they can discuss issues with, and felt confidant that the member of staff would ensure that they were resolved. Staff told us that they knew what actions to take if a person wished to make a complaint about the service they receive. Four of the staff said that the management in the home did not respond to their concerns promptly, and they often felt that they were not listened to. With one member of staff saying if they needed to report any concerns or issues, they would ask a colleague to accompany them to speak with the manager. Staff told us that they have been provided with safeguarding training and are aware that they should report issues promptly. We asked them how they would do this, and they told us that they were to approach the manager or if the manager was not available they were to report issues to the Operations Manager. They could not recall when or how they had been told this, but thought that it may have been in training. We asked what actions they would take if both were not available and one said that they would be “stuffed”. We asked if they were aware of reporting issues to the police, CQC or the safeguarding team in Suffolk Social Care, they said that they were, but thought that they had to approach management first. A staff member told us that their colleagues were aware of how they should protect themselves when working with people, but were not so aware of how to safeguard vulnerable people. Since our last inspection there has been five safeguarding referrals made to protect the welfare of people living in the home. One instigated by a health care professional, one by an external care provider, one by a relative, and two (the most recent) by the home. However, although the home had made the last referrals, which at the time of the inspection was still being investigated, there had been delays in staff reporting the incidents. This reflected feedback given in a social are manager’s survey, who under what could the service do better in, is for the home’s “whistle blowing procedure” to be given a “higher profile” to support staff in feeling confident to raise concerns straight away. Four of the safeguarding referrals, has resulted in strategy meetings to be held, which has identified areas that the home needed/needs to improve in, to safeguard the interests of people they are looking after. Adult Care Services, following the shortfalls in the nursing and care practise, identified during the first two strategy meetings, have undertaken their own review of the people The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 25 they have placed at the home. This resulted in the home being asked to draw up an action plan, to address the shortfalls identified, which Adult Care services will continue to monitor. Where a safeguarding referral was made, following concerns made by a relative, when two residents left the home undetected. This raised concerns over the staff’s knowledge of missing person’s procedures, which the manager said they would address. The home has since changed the numbers used to exit the external doors. Where we have identified shortfalls in staff following safe medication procedures, we have undertaken two follow up visits. Once the ‘Random’ reports are ready to be published, people can contact us direct, to request a copy, as they are not currently available on our website. As part of safeguarding people’s welfare, we asked the manager if they have a policy on personal care being provided by a carer of the same gender, unless otherwise requested, and agreed to by the person receiving the care. The manager initially thought there was, but was then unsure, but assured us that it has been discussed with staff, and that they all know that a person can give preference about the gender of carer, undertaking personal care. Where people are unable to give their preference, personal care, such as washing a person, would be provided by a carer of the same gender. However, although we were given these reassurances, information we have recently received, raised concerns that staff are not always working to this verbal policy. The manager confirmed that they will be looking into the situation we discussed with them. The training matrix (spreadsheet showing the names of staff and what training they have done) we were given, showed that safeguarding training had been provided to four of the six nurses, five of the seven night staff, twenty four of the twenty five day care staff and the non-care staff that worked at the home, such as kitchen and domestic staff. The training records did not show what training the manager had completed. We also found no mention of staff receiving training on the Mental Capacity Act or Deprivation of liberty safeguards, to support them in safeguarding people’s interests and welfare. The two recruitment files we looked at showed Criminal Bureau Record (CRB) checks, had been undertaken, and prospective staff’s names are being checked to ensure their name does not appear on the list of person’s not allowed to work with vulnerable people. We observed two members of staff, assisting a person to transfer from an arm chair to their wheelchair. One of the staff explained how they supported the person, which included one member of staff to hold their hands, whilst the second member of staff placed the person’s legs in the foot rests, to prevent the person hitting or grabbing at staff during the transfer. This was not identified in their care plan. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 26 We spoke with the manager regarding this, as the actions were a restraint to prevent the person from hitting out at staff, when being transferred. They told us that the holding of the person’s hands was as a comfort. However, we had not observed staff holding the person’s hands, other than when they were being supported to transfer. There was no indication in the person’s records to show that a Deprivation of Liberty assessment had been undertaken. Whilst reading the person’s care plan, we also found reference to the person’s nails being kept short, to prevent them from pinching staff. Again there was no Deprivation of Liberty assessment to show how and why this had been decided. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 27 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can expect to be provided with a well maintained, clean, safe environment which meets their mobility needs. People can also expect to be supported to personalise their bedrooms, to make it feel more homely. EVIDENCE: A tour of the ground floor was undertaken and it was noted that it was clean, tidy, well maintained and that there were no offensive smells. The communal areas included a large lounge/dining area, which provided armchairs, a long dining table and sufficient numbers of chairs for people who lived on the ground floor, a television and a kitchenette area, which we observed staff to use to prepare toast and drinks during the morning and drinks during the day. The kitchenette area had a sliding door, which was closed and secured when The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 28 staff were not present. There are also two other smaller lounges, which were not used during the inspection. Staff told us that no one used the lounges. At the last key inspection we noted that people had been using one of the smaller lounges to watch television. We found the first floor mirrored our findings of the ground floor, but people do not have free access to the enclosed gardens located downstairs. The corridors give people plenty of space to walk around. The decor, signage and soft furnishings did not include items to stimulate people with dementia senses and promote independence and occupation. Discussion with staff and a member of the management team, showed that they had also identified this, and had plenty of ideas on how they are looking to address this. Access to the home and upstairs floor is by using a key pad. Following the situation where two people left the home undetected (see Complaints and Protection section of this report) the external door numbers are now different from the internal doors. In the downstairs office, a monitor shows information being received from external CCTV cameras. We visited a total of six people in their bedrooms and it was noted that they were personalised with items of memorabilia, including souvenirs and photographs. When we asked a person if they liked their bedroom, they replied “alright – not bad”. When we asked if they were warm enough, they replied “yes”. This then led to discussions about the people in their photographs, and childhood memories. The bedrooms were clean and tidy, however, one person showed us their bedroom and told us that they had gone out in the morning of the inspection and arrived home at lunchtime, to find that their bed had not been made and their used breakfast items were still in their bedroom. Due to identifying in our Random inspection two weeks earlier that the one bed we checked was found to have soiled linen, we also checked another bed during this visit, and found the cover to be soiled. As soon as we pointed this out to staff they confirmed that they would change it. Communal bathrooms and toilets in the home we looked at were clean. Each bedroom has en-suite facilities. The lights in the bathrooms and toilets automatically came on when they were entered. The large laundry is situated on the ground floor of the home and it was noted that there is sufficient washing and drying machines to launder the clothes of the people currently living in the home. No concerns have been raised with us, during inspections, or through survey feedback concerning people’s laundry. The laundry and bathrooms provided hand-wash facilities. Staff as part of their infection control procedures, also have access to liquid hand wash, disposable The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 29 paper towels, gloves and aprons to minimise the risk of cross infection. We asked staff if they always had access to enough gloves and aprons, and that they had undertaken ‘infection control’ training which they said they had. The training records we were given identified that none of the six nurses, three of the seven night staff and sixteen of the twenty five care staff had been provided with the infection control training. However, discussion with a Nurse identified that they had been on the training, therefore the training records may not be up to date (see Staffing section of this report). During the inspection we observed staff using good infection control procedures, which included washing their hands and wearing gloves and aprons when supporting people with food and personal care. When we looked in the ground floor ‘sluice’ room, the machine that cleans the equipment, such as urinals, and commode pots, had been out of action for two days and was awaiting repair. On top of the machine was a dirty commode pot, standing in washing bowls (used by people being washed in bed) which the Nurse agreed was soiled with faeces. When we asked about the system used to dispose of bodily waste, we were informed that staff empty the commode pot” into the person’s en-suite toilet, and then “wash the pot in the sink”. We raised concerns about cross-infection, especially in the en-suites which stored people’s prescribed creams and medical equipment. When we asked why staff did not put the container, complete with bodily waste straight into the machine, the member of staff said they had been told not do that. When we discussed this with the manager, they thought the machine did get rid of bodily waste, and they would look into the situation, as they felt it could be more a communication problem. The armchairs and beds we looked at, due to being a new home, had been purchased for the ‘average’ person’. We noted from discussions with staff that two of the residents were over six foot tall. Taking this into account, we could not see any work being undertaken with a specialist, such as Occupational Therapist, to check that the current furniture supplied by the home, meets the individual needs of the people living there. It was positive to hear staff say that they had been told to ask for equipment as they need it. However, further discussions identified that suggestions made so far, have not been acted on (see Management and Administration section of this report). The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 30 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot be assured that staff will have the skills and knowledge, and be provided in sufficient numbers, throughout the day, to support their assessed needs. EVIDENCE: When we arrived to start this inspection, we were informed by the manager, that they currently have twenty eight residents, the majority (sixteen) of whom have a form of dementia. The staffing arrangements for the day we inspected were four carers on the first floor, reducing to three carers in the afternoon. On the ground floor the staffing levels were three carers in the morning and afternoon. In addition there was two nurses working, one responsible for each of the floors during the day (8:00 to 20:00). At night nurse takes responsibility for the whole home. During previous visits to the home, we identified a high amount of agency staff being used. However when we arrived to start this inspection, the manager informed us that although they had needed to use an agency nurse that morning to cover sickness, this had been the first time that they had used external agency staff since July 2009. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 31 Staff working on the ground floor told us in the mornings, when people needed to be supported to get up, they found it to be very busy. Further discussion identified that when they worked with the usual level of four care staff on each shift, they felt it was sufficient to meet people’s assessed needs. Although they felt they are meeting the assessed needs, our findings (see Health and Personal Care and Daily Life and Social Activities sections of this report) shows that although ‘tasks’ are being undertaken, people are not getting the support they require with their communication, emotional and social needs to ensure their well-being. They told us staff absences are not always covered, which leaves three carers on duty (such as the day of our visit), however they could still manage – but were much busier. Upstairs, we were informed that they “haven’t got enough carers”. A member of staff told us that there were times when they were short staffed, due to staff not turning up for their rota’d shifts, for example due to sickness. They provided us with an example of only one carer attending work a weekend before the inspection. However, they said that a carer had been called in to work, and another carer from the first floor had covered the shift. When we looked at the staffing rotas we were given for the weekend of the 12th and 13th September 2009, it confirmed what we had been told. In addition to the care and nursing staff, there is an activities coordinator, and ancillary staff providing housekeeping, training, catering, maintenance and administration support. People living at the home were complimentary about the approach of the staff team, who they told us always treated them with respect, and respected their privacy. However, one person told us when they rang their call bell, staff were slow to respond. They felt this was because they are seen as being more able and did not need as much support as others. Another person told us that the care staff very busy, as they saw them rushing about throughout the day. They also said their call bells were not always answered promptly. However, during the inspection when we observed the call bells being used on the ground floor, we found they were being answered promptly. Two people told us that there are times when there is one night staff on the ground floor and one on the first floor, which meant that they had to wait when they required assistance during the night. During the feedback at the end of the inspection the manager, told us that there is always one nurse and three or four carers between floors each night. Upstairs, our period of observation (SOFI) is showed that staff were providing activities and one to one time with the people sitting in the lounge. Staff were seen to be busy undertaking tasks (organising activities, serving drinks, writing up care plans). However, this still left some residents in their bedrooms, and others walking around who also required support, and one to one time. When The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 32 we arrived the Manager told us that a carer would be going around with the Agency Nurse, whilst giving out the medications. This we felt was a positive move, as the carer knows the residents; therefore, if a person is unable to confirm their name to the nurse, they would be able to do this on their behalf. However, when we went upstairs at 10:15, we noted that the nurse was giving out medication on their own. They told us I “did have someone with me – but overwhelmed in there”, pointing to the lounge where the member of staff was busy helping out, and serving drinks. During our feedback with the management at the end of the inspection, we gave our observations that we did not feel that the staffing levels were sufficient to meet all the people’s needs. Especially people requiring support with their communication, and behavioural needs. This not only took in our observations during this and the other two random inspections, but also from a Healthcare professional’s comment “too few staff” and shortfalls identified during safeguarding meetings. The AQAA completed in March 2009, and feedback during the key inspection undertaken that month, informed us that ‘over the next few months the home aims to closely study the actions and activities of staff in relation to the direct and indirect care needs of service users’. They went on to tell us how this will be undertaken ‘using time in motion studies carried out by staff, close observations and using evidence collated from the revised care plan documents’. In undertaking this it will ‘lead to a re-assessment of the staffing levels within the home, within all departments and areas’. However discussion with the manager identified they are not working out the staffing levels based on dependency needs of the people they look after, which is quite varied. The visiting consultant, who informed us that they had been supporting the management for two weeks, told us that they had undertaken their own “90 minute” observation of care on the dementia unit, which they felt was “very positive”. They also pointed out that the staffing level gave a “1:3 ratio” based on fifteen residents. However, this will not be the case during the afternoon, evening, or when they have not covered absences. A relative we spoke with prior to this inspection felt that the staffing levels in the evenings and especially at weekends, was not enough. They said the caring staff worked hard and were very busy, but often this led to people with dementia being left alone in the lounge. They felt this was not right, especially as they were unable to use a call bell to summon staff. They felt awkward when they heard the people shouting out for a nurse, and although they could help with their own relative, and take them to the toilet – they were aware that they should not help others in case they “injured them” or their self. Discussions with a member of staff confirmed that people tend to shout “nurse, nurse”, as they cannot remember staff’s names. We observed that staff did not wear name badges, which does not help, and were informed that they have asked for them. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 33 During our observation session in the morning, we observed a person with dementia helping another resident to get up from their chair, who was very unsteady. A member of staff quickly intervened, asking them not to help the other person up, but to call them instead. As soon as the staff member left the room, the same resident continued to keep trying to help the person up. A member of staff reminded the person that they had “forgotten”, to ask the carer, and not to move the person themselves. The member of staff was not taking into account, that the person was not retaining what had previously been said. At 14:45 we noted a resident walking around showing signs of ill-being, as they looked anxious and worried, which staff linked to the person’s recent bereavement. However, staff talked kindly to the person, walking with them back to their bedroom. There was no clear strategies, guidance on how to support the person. When we checked again at 16:35, the person was still walking around the unit looking anxious. Taking into account our observations, through this and previous visits, and lack of guidance in the care plans to enable staff to support people with dementia, we asked staff about the training and supervision they have received. From these discussions we identified that two out of the four carers had not worked in care prior to starting at the home. Dementia training consisted of “two hours” training when they first started. We asked three other care staff about their ‘induction’ training. Two told us that they had been provided with an induction when they started working at the home, and one could not recall doing an induction. The staff did not know if their induction incorporated the Skills for Care Common Induction Standards, which gives staff a foundation of skills and knowledge to work from. One carer said that their induction consisted of looking around the home and reading the home’s policies and procedures. The training matrix which was viewed showed two nurses, four night staff and fourteen day care staff had been provided with the ‘Minster Care Induction’. The manager provided us with a carer’s workbook, which they were working through during their induction. The workbook showed that the carer was provided with in house knowledge of their role, which included reading care plans and procedures and orientation of the home. The induction did not incorporate the Skills for Care Common Induction Standards, which staff are to be provided with within six months of working at the home. The same staff also told us that they had been provided with a good training programme, which included fire safety, health and safety, safeguarding, moving and handling, food hygiene, and COSHH (Control of Substances Hazardous to Health). They told us the moving and handling training had been provided by the home’s manager, they felt that it was of good quality and they The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 34 were provided with practice of how to use manual handling equipment, such as hoists. The training records (matrix) we were given, did not match with the training staff’s training records we looked at, which we fed back to the manager. The training matrix, showed that out of the six nursing staff listed: one had been provided with Boots MDS (monitored dosage system), four manual handling, four safeguarding, one health and safety, one COSHH, two pressure area care, two first aid, three food hygiene and none had been provided with safe handling of medication, infection control, fire awareness, fire drill, nutrition, documentation, challenging behaviour, dementia and bed rails training. We noted that some of the training undertaken by the manager, they had signed as being ‘Registered Manager’, which is incorrect (see Organisation and management section of this report). As the training matrix did not show which care staff had achieved a National Vocational Qualification (NVQ), the manager gave us this information. They told us six care staff had achieved their NVQ awards, and a further three are awaiting certification of their awards. This identified that the home has not yet met the target of 50 of care staff achieving a minimum of an NVQ award at level 2, as identified in the National Minimum Standards relating to older people. We were shown documentation from an NVQ training provider, which gave details of the staff who are looking to register, to commence this training. This shows that they are working towards ensuring that the care team are appropriately qualified to meet people’s needs. No night staff had achieved an award, however, out of the ten that are due to register for the award (day after our inspection) four work on nights. The training matrix showed that the seven night carers have undertaken health and safety, fire safety awareness and COSHH training. Six had been provided with moving and handling, first aid and challenging behaviour training, five safeguarding, food hygiene, pressure area care and dementia, three infection control and documentation and none had been provided with training on nutrition and use of bed rails. The home employs twenty five carers to cover day shifts, and the training matrix identified that all have undertaken training to move people safely. It also showed that twenty four carers have undertaken training in safeguarding, twenty one health and safety, dementia, first aid, COSHH and food hygiene, eighteen challenging behaviour, sixteen infection control and fire safety awareness, twelve pressure area care, seven documentation and none had been provided with nutrition, safe handling of medication (as medication is given out by nurses) and use of bed rails. A relative completing our survey, when asked if they felt the care workers have the right skills and experience to look after people properly, replied “usually”. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 35 The recruitment records for the two staff employed by the home since we last visited showed that checks had been undertaken to validate their identity, and to ensure that they are able to look after vulnerable people. Two written references had been obtained for both staff. However, for one person we noted had stated that they were a ‘friend’, had been asked to supply a reference by completing the questionnaire sent by the home, the questions were more relevant to an employer, than a friend. For example they had been asked to answer questions on the prospective applicant’s ‘quality of work’, ‘attitude to seniors’, and ‘timekeeping’. We also noted that on the other person’s application form, they had not given a full breakdown of their employment history. Without this information, as part of the home’s safeguarding responsibilities they would be unable to identify and explore any gaps in the person employment history, and any other posts they have held working with vulnerable people. When we asked for a Nurse’s recruitment paperwork, we were informed that the person came via the organisation’s ‘in-house’ nursing agency, therefore they did not hold a copy of their recruitment paperwork. Instead they were able to provide us with a ‘Nurse Profile’, which is supplied by the agency and gives a brief summary information to show that they are registered as a Nurse, have had a Criminal Bureau Record (CRB) check undertaken and references have been obtained. The manager said that most of their nursing staff come via the agency, and continue to work temporary at the home until a decision is made by both them and the home, as to whether they are to become a permanent member of staff. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 36 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot be assured that there is a competent management structure in place, to ensure that the home is well run, and staff are being provided with appropriate supervision and guidance to support them in their role. EVIDENCE: At our key inspection in March 2009, the new manager informed us that ‘they were in the process of making a registered manager application’ with the Commission to become registered. In undertaking this process it enables our registration team to look at the fitness of the person applying, to ensure that they have the personal qualities, skills and knowledge to manage the service. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 37 At this inspection the manager informed us that they had not yet started this process. The AQAA informs us that the manager has ‘achieved the NVQ level 4 in Care and Management alongside the Registered Managers Award and has 4 years experience of managing care services’. We were informed at our last inspection that ‘the manager was supported in their role by the Matron (previous deputy manager), who took a clinical lead in the home. We also identified at that key inspection, that the manager had ‘directed’ nursing staff when they could call a doctor out. This was linked to keeping good relations with the local doctors. As the manager does not hold a nursing qualification, we explained to them that the nursing staff should be left to use their ‘professional judgement regarding when a doctor should be called out based on individual events’. The manager had agreed with this; however at a safeguarding meeting (19 May 2009), the manager informed us that nurses had been instructed, that day or night, that they must contact the manager first, before they call out a doctor for a resident. We raised our concerns again, that nurses must be responsible for making clinical decisions. During our next random inspection (5th June 2009) we asked a nurse what action they would take if they needed to call out a doctor urgently, they told us that they have a policy to follow to contact the manager first. They then showed us a memo which had been written by the manager (1st May 2009), which was stuck in the handover file. It read ‘where it is a routine call or an emergency I would like to be consulted before this call is made’. We raised our concerns again with the manager about nurse’s accountability for clinical practice, and the following requirement was made; ‘Nurses must be able to undertake their clinical responsibilities, to ensure people’s individual nursing care needs are being monitored and met’. The Manager also removed the memo from the file during the inspection. When we next visited (7th September 2009), we asked a nurse if they were being able to contact the doctor when they felt it was needed, and make clinical judgement they replied “yes”. However at this inspection, information we were given by another nurse, identified that the manager has tried again, unsuccessfully, to override a nurse’s clinical judgement. When we attended a strategy meeting on the 1st June 2009, following a second safeguarding referral, we were informed that to address shortfalls identified in the monitoring of nursing care, that the home has recruited a “clinical lead nurse”. We were told that the person has “35 years experience”, and will be monitoring health care and clinical aspects, such as wound care. However, when we visited the home four days later to undertake a ‘random’ inspection, we identified that it was not a new recruitment, but the same clinical person who we mentioned in our March Key inspection report as taking the ‘clinical lead in the home’. Discussions with the person identified that they had The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 38 recently been given the time to undertake clinical work, where previously they had not been able to do. In our surveys, under the heading ‘what could the home do better’ a social care manager commented that during safeguarding investigations there has been ‘some evidence that the home are defensive of concerns raised’, and ‘that actions that have been stated to have taken place have in actual fact had not’. The AQAA informs us that that ‘the home has a clear line management structure which is effectively utilised to ensure the smooth running and operation of the home on a daily basis’. The AQAA also informs us that ‘the management team at the home have been working closely with the staff employed, and outside professionals, promoting an open and transparent management style for the home to promote confidence in the service and develop good working relationships with outside authorities’. However, feedback from a local doctor’s surgery shows that they have not yet been able to gain their confidence. When we asked a member of staff their views on the management, they said they are “not telling staff” going on to say “it’s just not knowing – we want to do a good job” saying staff “don’t get enough guidance”. They said that they did not see the manager “much”, and felt that sometimes they were “not approachable”. They told us they see more of another member of the management team who “helps out more”. Staff told us that a staff meeting had been planned that day. The management told us it was to discuss dementia care, and that staff had been given information sheets on the subject. The care staff told us that there are some nurses who are very good, and controlled the running of the floor, that they worked efficiently and ensured that they were updated in changes, and others did not. A staff member told us that the care provision at the home has improved, and that previously there was “no structure, no communication - was a mess”. They gave an example of how it had improved, where a nurse sometimes has meetings with the staff, and feedback any issues to the manager, to try and get them sorted. Four staff members we spoke with told us that the communication from the home’s management was poor and that they were rarely updated on issues and changes in people’s care. We were told by a member of staff that they had requested equipment, such as kylie sheets, slide mats and larger beds for two people, however, they had not been acted upon. A staff member said that the manager was very good and supportive if they had personal problems, but they were slow to act on issues in the home. Staff felt the management did not listen to them. Staff told us that they had made the manager aware that staff had spoken to each other in a language, other than English in the presence of staff and people that lived at the home, but this had not been acted upon. They reported that some nursing staff had shouted at them (including a senior The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 39 member of the team) in front of their colleagues and people who lived at the home. During the inspection we were talking and laughing with a group of people and a member of staff, who was then called out of the room by the visiting consultant. When they came back they asked us if they looked stressed, as they did not feel it, but had been told by them not to be stressed in our presence. However, a member of staff did ask why we kept visiting so much. We explained that this was due to the ‘poor’ rating they had been given in March 2009, and we needed to do follow up inspections to ensure they are addressing the issues raised. We asked if the management had given feedback on our inspections, or if they had looked at our inspection report. They said “no”, but they had managed to find the report on the CQC website. Another member of staff asked how they could locate our report, as they wanted to see it. We could not see the report in the reception area, and the staff we spoke with, were not aware of its presence. At the last key inspection the manager told us that they were planning to ensure that all staff will be provided with regular supervisions. However, at this inspection one member of staff said they had not received supervision, one had received one, two said that they had two since they started. The manager told us that staff were being provided with regular supervision meetings. However discussions with the management before this inspection, and observations made during adult care services reviews, shows that the home has been slow in instigating regular supervisions sessions, until July this year. This reflected the two carer’s recruitment files we looked at, which showed that they had both received one to one supervision during July. The manager said that they were planning to improve how they recorded discussions with staff members, which developed into supervision meetings. We looked at the accident records, which are being summarised by the manager on a monthly basis. However, it was noted that none referred to incidents of assaults on staff members, for which we had been told about and observed during the inspection. It was noted that all accidents by people that lived at the home were not reported, this is further discussed in the ‘complaints and protection’ section of this report. Findings during our random inspections has identified that although requirements made to improve medication procedures within the home are acted on, there is not sufficient management systems in place to ensure it does not happen again. Information supplied in the AQAA confirmed that equipment used in the home to ensure the health, safety and welfare of the people living and working in the home, is being regularly serviced and tested to ensure it is in safe working order. We looked at a hoist located on the ground floor which is used to The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 40 transfer people, and saw a sticker attached, which stated that it had been serviced on the 6th July 2009 and was next due, on the 5th January 2010. As we mentioned in our March report, the AQAA states under what they could do better ‘that the home aims to increase the formal quality assessment gathered from service users, relatives and visitors to the service. Although we have not been sent any analysis of any formal quality assurance work being undertaken, the manager confirmed that residents and relatives meetings were being held. Also, at the time of our visit, the home was using a consultancy service, as part of their quality assurance work, to feedback on the home which areas they are doing well in, and areas that require further development. Adult care services shared with us some of the comments they had received during their reviews of people living at the home, from their relatives which included “can’t speak highly enough, can’t fault the carer’s I’ve seen an improvement (in their next of kin)”. The AQAA informs us that ‘all financial transactions whether relating business or service user finances are comprehensively documented within the home’. During our last key inspection we checked the systems the home has in place for looking after people’s monies and found them to be safe. We have not received any concerns from people living at the home, or their relatives about any financial transactions. The manager confirmed that there had been no changes in the systems used. The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 41 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 2 X 2 1 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 2 3 3 3 2 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 3 3 2 2 2 The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 42 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 OP9 Regulation 13 Requirement Requirements 1 to 4 were made following the random inspection undertaken on the 7th September 2009, and will be checked for compliance when the given timescales have elapsed. Timescale for action 25/09/09 2. OP8 15 3. OP9 13 Medicines of a psychotropic nature prescribed for occasional ‘PRN’ use must only be given to people prescribed them when clinically justified. This must be demonstrated by record-keeping practices. Care plans must give staff clear 25/09/09 instructions, based on the resident’s individual physical and mental health needs, on the use of occasional ‘PRN’ medications. The cabinet used for the special 25/09/09 storage of controlled drugs must be secured to the wall by at least two bolts in line with Misuse of Drugs (Safe Custody) Regulations. This is a repeat requirement following the 5th June 2009 Random Inspection, which had not been met. DS0000072735.V377642.R01.S.doc Version 5.3 Page 43 The Meadows 4. OP9 12 5 OP1 4 6. OP7 15 7. OP18 13 8. OP27 18 9. OP31 9 Prescribed medicines must be available at all times. This is to ensure people receive their medicines as scheduled. The contents of the Statement of Purpose must be reviewed, to ensure it is factual, and gives prospective service users a clearer understanding of the age range and the needs of the people they are able to look after. To reduce the chance of people being isolated and becoming anxious, care plans must give staff clear guidance on how to support people with their individual communication and behavioural needs. To safeguard the interests of people living at the home, any safeguarding issues must be reported in a timely manner. To ensure people’s assessed needs are being met, a review of the staffing levels against people’s dependency needs must be undertaken, and a copy of the report sent to The Commission. To ensure the home is run in the best interests of the people living there, the home must be managed by a competent person, who has the required skills and knowledge. 25/09/09 25/11/09 25/11/09 31/10/09 25/11/09 25/12/09 The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 44 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. Refer to Standard OP12 Good Practice Recommendations The home should undertake a review of their current activity programme, to ensure they have a range of daily activities available to support people’s range of skill levels, abilities and interests. A review of the current furnishings and equipment, provided by the home, should be undertaken by an Occupational Therapist, to ensure it meets the current needs of the people living there, and supports people to maintain their independence. The way staffing issues are being managed at the home should be reviewed, to ensure it is undertaken in a private, supportive and professional manner. 2. OP22 3. OP31 The Meadows DS0000072735.V377642.R01.S.doc Version 5.3 Page 45 Care Quality Commission Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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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