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Inspection on 27/01/10 for The Meadows

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

This inspection was carried out on 27th January 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

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 interaction between staff and people that lived at the home was caring, respectful and professional. Staff were attentive to the needs of people. The environment was clean and well maintained. The home was comfortable and attractively furnished and decorated.

What has improved since the last inspection?

The care plans were more person centred. However, there remained areas for improvement, such as increased detail for information provided in the care plans with people`s dietary needs and well being relating to diabetes. All staff had been provided with a one to one supervision meeting, where they discussed the way that they worked. This needed to be sustained over time to ensure that staff were appropriately supervised to meet people`s needs. Since the last key inspection 23rd September 2009, two random inspections had been undertaken, which focused on the areas of concern, which included medication. At the random inspections it was noted that there were some areas of improvement, however, there continued to be shortfalls in the home`s medication processes and procedures. At this key inspection it was noted that the home provides a service to some very dependent people requiring high levels of care. In the main, medication is stored and administered in accordance with the prescriber`s directions and records are clearly maintained to indicate this. Printed protocols are kept with the medicines records to assist staff where prescribing direction requires further decision, for example, "when required". There had been work undertaken to ensure that all people in the home were provided with the opportunity to participate in activities. Staff were provided with an ongoing programme of training, which provided staff with information that they needed to meet people`s needs. However, the improvements were ongoing and shortfalls remained, such as with the provision of an induction course which incorporates the Common Induction Standards. The Statement of Purpose had been amended and reviewed and it provided accurate information to people with an interest in the service, such as the management details and contact details of CQC (Care Quality Commission).

What the care home could do better:

Further attention needed to be given to care plans, such as the investigation of the reasons for people`s displays of aggression and the support provided to people with their behaviour, to improve their well being. Attention is required to keep to the required time for administration of medicines and to ensure that all records for the administration of medicines are accurately entered. Better use of medicines in relation to their temperature control is indicated. Although medicines are generally stored correctly with attention to stock control, there is inadequate space for Controlled Drugs storage on the ground floor. The home was registered 1st October 2008, the registered manager had left the service before the first key inspection 17th March 2009. Since then the home had been managed by two different managers, both had not been registered. The home continued to have no registered manager at the time of this key inspection. The current manager told us that they would be making a registered manager application for the service and that they were planing to take their CRB documents to the London CQC office the day after the inspection. The manager explained the improvements that they felt had been made to the service, including with the care planing, staff training, staff supervision and medication. However, whilst it was positive to note the improvements we found that there was still work to be done to improve the service and there continued to be shortfalls with care planning and the consistent management and monitoring of medication. The home and management needed to ensure that they continue to make improvements and to sustain them to ensure that people`s needs are met and that their health and safety is appropriately promoted and protected. The improvements to the outcomes of the care provided to people was reflected in the move from the poor to adequate rating.

Key inspection report Care homes for older people Name: Address: The Meadows Hatchett Village Brybank Road Haverhill Suffolk CB9 7YL     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Julie Small     Date: 2 7 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 42 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) 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 Care Homes for Older People Page 3 of 42 Information about the care home Name of care home: Address: The Meadows Hatchett Village Brybank Road Haverhill Suffolk CB9 7YL 01440712498 01440762524 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Minster Haverhill Limited care home 53 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is 53 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 Date of last inspection Brief description of the care home 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 Care Homes for Older People Page 4 of 42 Over 65 0 53 0 53 0 53 Brief description of the care home dementia andor 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 previous key inspection stated 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. At this key inspection, the manager told us that there had been no fee changes. Subject to conditions, people are able to bring their pets in with them. Care Homes for Older People Page 5 of 42 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The unannounced inspection took place Wednesday 27th January 2010 from 09:30 to 17:50. The inspection was a key inspection, which focused on the core standards relating to older people and was undertaken by regulatory inspectors Julie Small and Tina Burns and pharmacy inspector Lawrie Allum. The manager, the provider and a member of the organisations management team were present during the inspection. The requested information was provided promptly. Eight staff members, five people that lived at the home and two relatives were spoken with. We tracked the care and care records of four people that lived at the home. Further records that were viewed are identified in the main body of this report, which included four staff recruitment records and training records. Prior to the inspection an Annual Quality Assurance Assessment (AQAA) was sent to the home and was returned to us within the required timescale. The surveys from one Care Homes for Older People Page 6 of 42 health care professional, one service user and five staff members were received. At the last key inspection 23rd September 2009, the home continued to be rated as providing poor outcomes for people. Since the key inspection, we had carried out two random inspections, 8th October 2009 and 8th December 2009, which focused on the issues of concern, such as care planning and medication. Due to our concerns about the service we met with the homes providers 2nd December 2009 to ensure that improvements were made to the service provided to people. Issues that had been identified included with medication, care planning, reporting safeguarding issues and poor management. The provider was keen to ensure that they improved the service that was provided to people. They provided us with an action plan, which identified their plans for improving the service. As a result of safeguarding alerts that had been made there had been ongoing support provided to the home by Suffolk County Council Outcomes and Quality Monitoring Team, which included unannounced visits. Care Homes for Older People Page 7 of 42 What the care home does well: What has improved since the last inspection? What they could do better: Further attention needed to be given to care plans, such as the investigation of the reasons for peoples displays of aggression and the support provided to people with their behaviour, to improve their well being. Attention is required to keep to the required time for administration of medicines and to ensure that all records for the administration of medicines are accurately entered. Better use of medicines in relation to their temperature control is indicated. Although Care Homes for Older People Page 8 of 42 medicines are generally stored correctly with attention to stock control, there is inadequate space for Controlled Drugs storage on the ground floor. The home was registered 1st October 2008, the registered manager had left the service before the first key inspection 17th March 2009. Since then the home had been managed by two different managers, both had not been registered. The home continued to have no registered manager at the time of this key inspection. The current manager told us that they would be making a registered manager application for the service and that they were planing to take their CRB documents to the London CQC office the day after the inspection. The manager explained the improvements that they felt had been made to the service, including with the care planing, staff training, staff supervision and medication. However, whilst it was positive to note the improvements we found that there was still work to be done to improve the service and there continued to be shortfalls with care planning and the consistent management and monitoring of medication. The home and management needed to ensure that they continue to make improvements and to sustain them to ensure that peoples needs are met and that their health and safety is appropriately promoted and protected. The improvements to the outcomes of the care provided to people was reflected in the move from the poor to adequate rating. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 42 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 42 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect to be provided with the information they need to enable them to make decisions about if the home is the right place for them and to have their needs assessed. Evidence: People were provided with the information that they required about the home in the homes Statement of Purpose. Since the last key inspection an updated Statement of Purpose was sent to us. The amendments had been made to address a requirement that was made at the last key inspection. The improvements made in the document included the details of the people that the home were able to care for, that the registered manager post was vacant and the updated contact details of Care Quality Commission (CQC), should people wish to contact us. The Statement of Purpose also included information such as the services and facilities provided at the home, facilities provided in the local area, the arrangements for Care Homes for Older People Page 11 of 42 Evidence: meeting peoples spiritual needs, the fees, the aims and objectives and philosophy of care, fire safety, the arrangements for dealing with complaints and the staffing levels and training. The AQAA stated the home has a comprehensive service user guide and statement of purpose which is made available to all prospective residents and they are encouraged to visit the home prior to admission. A service user survey said that they had been provided with enough information to help them to decide if the home was the right place for them, before they moved in. Since the last key inspection two people had been admitted into the home and we tracked the care that they were provided with and their care records. Each held a needs assessment, which identified the support that they required and preferred to meet their needs, such as with mobility, health, communication and physical and mental wellbeing. Each had been dated and signed by the person who completed the assessment. As well as the care records of the two people above, we tracked a further two peoples care and it was noted that their care records also held needs assessments. The AQAA stated the home consistently ensures pre-placement assessments are carried out and new service users are only admitted following discussion and research into their care needs and requirements. The assessment is person centred and where necessary relatives friends and health and social care professionals are involved and once the assessment is complete a decision will be taken as to whether the home is able to meet the service users assessed needs. All four care records that were viewed held a care plan which identified how the peoples assessed needs and preferences were met. However, there were some areas for improvement that we identified, which are further discussed in the health and personal care section of this report. Care Homes for Older People Page 12 of 42 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate 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 to be treated with respect. They cannot be assured that they will be fully protected by the homes medication and processes and that their care records fully detail the support and care that they require to meet their assessed needs and improve their well being. Evidence: We viewed the care records of four people who lived at the home, the care records held care plans which identified how their assessed needs and preferences were met. Since the last key inspection the care plans were more person centred. This means that they identified the specific needs and preferences of individual people, which took into account of their history, preferred routines and likes and dislikes. A person that was spoken with told us that they had been helped to write their person centered care plan by a staff member. Their person centred care plan included information such as my name is..., I was born on ..., I like... and I dont like.... The care plans also held a life story, which identified each persons personal history, such as their family, previous work, interests and hobbies. It was noted that the Care Homes for Older People Page 13 of 42 Evidence: person and their relatives had been consulted with about their life story and that this would provide a good understanding of the person to the staff who were supporting them. During the inspection we observed staff talking with people about their interests that were identified in their person centred care plan and life story, which showed that they were used to ensure that peoples preferences were acknowledged and respected. The care plans held information such as peoples mobility, which was clearly detailed to ensure that they were supported appropriately and safeguarded from falls. They included the aids and adaptations that people routinely used such as mobility aids and hearing aids or spectacles. The care plans also identified the support that people required with areas of their care, such as personal care, health and social care, how they made choices in their daily living, for example with their clothing, activities and food, and the areas of their care that they could attend to independently to ensure that their needs and preferences were met. The AQAA stated the home is developing a person centred approach to care planning documentation. This has focused on looking at the individual strengths of the service user and how the staff can support residents to achieve maximum independence and all aspects of personal care are documented in the service users care plan which are evaluated on a regular basis and any changes documented. Two carers that were spoken with told us that the care plans were more person centred and they identified the support that individual people needed and preferred. The staff survey asked if they were provided with up to date information about the needs of people that lived at the home, two answered always, two answered usually and one answered sometimes. The survey asked if the ways that they passed on information about people between staff worked well, one answered always, two answered usually and one answered sometimes. The survey asked what the home did well and one stated meet the entire needs if residents, welcoming the relatives and loved ones, physical needs, psychological needs, special needs, spiritual. At the previous key inspection we identified that a persons communication needs were not fully identified in their care plan. It was noted at this inspection that the care plan identified their communication needs and abilities and the ways that staff should communicate with them to ensure that their choices acknowledged and respected. Whilst it was noted that the care plans had improved, there remained some shortfalls, which needed to be addressed to ensure that peoples needs and preferences are fully identified and to improve their well being. Care Homes for Older People Page 14 of 42 Evidence: One persons care plan stated that they were to be weighed on a weekly basis to enable their weight and eating to be monitored, however, it was noted that they had been weighed on a monthly basis. We were told that the person had a good appetite, there had been no issues with their weight and as a result they had decided that monthly weight checks were sufficient. This decision and the reasons for the decision had not been included in their care records. The daily records of one person showed that they had displayed aggressive behaviour and while the incidents had been recorded in their daily notes, there were no records to show how the staff at the home had reflected on the persons behaviour and the support that had been provided to them, such as the events that lead up to the incident and how they planned to monitor and support the person during and after aggressive incidents. During the inspection we observed that a person had injuries on their face, which a staff member advised that they were self inflicted. The care records identified that the injuries were self inflicted and that the staff at the home were working with health care professionals to support the person to manage their behaviour. However, there were no body maps, which reflected the injuries and the care plan did not make it clear what carers should be doing to support the person with their behaviour. A carer was spoken with and agreed that the care plans did not provide instructions of how to work with the person regarding self harm. However, we observed care staff attend to the person promptly and they provided one to one support to endeavour to keep any anxiety low. Carers spoken with told that the person had been prescribed creams for their injuries. One persons records stated that the person had diabetes, which was tablet controlled. It did not include information that identified the possible changes in their condition that staff should be aware of which related to their condition to ensure that they were provided with the care that they needed, should they become unwell. The care plans that were viewed held risk assessments, which identified the risks in areas such as manual handling, mobility, nutrition and skin viability. The care plans identified methods of minimising the risks. However, it was noted that the risk assessments and the methods of minimising the risks were not robust enough to identify and address the issues explained above, which provided potential risks to the well being of the people that lived at the home. There had been a safeguarding alert made regarding the pressure areas of two people Care Homes for Older People Page 15 of 42 Evidence: and visits to the home by Suffolk County Council Social Care professionals identified that whilst the risks and the care provided to people was currently clearly recorded, the records that were viewed prior to the safeguarding alert did not clearly identify how peoples pressure areas developed and the care that they had been provided with to minimise them. A training matrix was viewed and the staff that had been provided with pressure area care were one of six nurses, ten of twenty three care staff, three of six night staff and the activities coordinator. During the inspection we spoke with a nurse who told us that there were three people that lived at the home that had pressure areas and they clearly explained that support and care that they were provided with. They told us that nursing care was provided to people who lived on the ground floor and for those on the first floor, district nurse support was accessed. They told us that the manager was in the process of arranging for nursing staff to be provided with phlebotomy and catheterisation training, which they had identified as a need in the home. The manager was spoken with and confirmed that they had asked various health care professionals about the provision of the training and was awaiting confirmation that it would be provided. We spoke with a GP on the telephone after the inspection and they also identified the need for the home to be providing trained nurses to undertaken phlebotomy and catheterisation. They told us that there had been recent improvements in the home, such as the standards of care and the observation and reporting of issues in peoples well being. A health professional survey said that the home usually sought advice and acted on it to meet peoples social and health care needs and that people were usually supported to live the life they choose. The care records that were viewed identified the medical support that people had been provided with, such as from the doctor, and the outcomes from their appointments. The AQAA stated the home has promoted good working relationships with G.Ps from local surgeries this enables us to deal quickly and effectively with residents health care needs. The home works closely with all other health and social care professionals to ensure that an holistic approach to care is delivered and visits by health and social care professionals are appropriately documented within the residents care plan. People that were spoken with told us that their needs were met at the home and that the staff listened and acted on what they said. They told us that their medical needs were met and that a doctor would be called if they felt unwell. Two people told us that call bells were answered promptly and that the staff were attentive to their needs. A Care Homes for Older People Page 16 of 42 Evidence: person who told us that they were not happy with their spectacles at the last inspection was spoken with during this inspection and they showed us their new spectacles and said that they had been provided with support to purchase a new pair that they were happy with. A service user survey said that they were always provided with the care that they needed, that the staff were always available when they needed them, that the staff always listened and acted on what they said and that they always received the medical care that they needed. The survey stated really happy with the care (the person) receives and do not have any concerns and the level of care is very good. During the inspection two relatives were spoken with and told us that there was no problem with their relatives care, that they were satisfied with the standard of care, that the staff respected their relatives privacy and dignity and when asked about personal care they said wouldnt fault them at all. We asked if their relative was provided with prompt and appropriate attention and they replied yes they are excellent. And theyll sit and talk. Nobody is left out. During the inspection it was noted that the interaction between staff and the people that lived at the home was caring, respectful and professional. People that were spoken with told us that their privacy was respected and that the staff treated them with respect. It was noted that peoples dignity was respected, people looked well groomed and clean. We noted improvements in a persons appearance and well being, since the last key inspection. They looked healthy and smiled, they laughed and interacted in a positive manner with the care staff. The care staff interaction with the person had improved, they sat and chatted to them. However, during the medication round it was noted that a staff member placed the drugs trolley in front of them when they were watching television, which obstructed their view. We told the manager about this and they addressed it promptly with the staff member. The AQAA stated service user privacy and dignity are respected at all times in all aspects of care delivery. A health care professional survey said that peoples privacy and dignity was usually respected. At the previous key inspection it was noted that people were not safeguarding by the homes medication procedures and processes. There had been two random inspections undertaken since the key inspection which focused on areas such as medication. Whilst we had noted some areas of improvement, for which the progress that had Care Homes for Older People Page 17 of 42 Evidence: been made was slow, there continued to be areas of concern and we identified shortfalls in this key inspection. This showed that people were not fully and consistently protected by the homes medication procedures and processes. The manager told us that they had improved on the ordering of medication to ensure that peoples prescribed medication was ordered and received in a timely manner to ensure that they did not run out. The manager told us that daily medication checks were made and that there were no omissions in the MAR (medication administration record) charts. In the ground floor unit, the morning medicines administration round was not completed until 11:50am. When the lateness of the round was questioned the cause was said to be due to the unpredictably low staffing level on the unit that morning. When indicating that poor punctuality in administering medicines may affect a medicines therapeutic effect we were informed that steps would be taken to minimise any effect by adequate spacing of subsequent doses. The nursing unit included a resident who was unable to receive medicines orally and required administration by tube directly into the stomach from their abdomen (PEG). Where medication is required to be administered outside the conditions of a medicines product license, for example, crushing a tablet or emptying a capsule to achieve administration by this route, then the medical practitioners written authorisation to permit use of the medication outside the conditions of the license should be obtained. However, there was no such written authorisation for the currently prescribed tablets gliclazide or loratidine. In the ground floor unit we were unable to audit tramadol 50mg capsules prescribed for a resident at the variable dosage of one or two to be taken four times a day. This was due to the administration not being recorded at 22:00 hours on 18, 19, 20, 21 and 23 January 2010 and there was no indication as to whether one or two capsules were administered on other occasions. Reconciling the quantity available with the medicines records is seen as a check to indicate administration is in accordance with the prescribers direction. The administration of medicines for topical administration, such as creams or ointments, was usually recorded by a tick mark as opposed to signed initials. For accountability signed entries for the administration are required on the medicines administration record (MAR) chart. If a secondary MAR document is used for convenience to record the administration away from the usual place of handling medication, for example, the bathroom, then reference to this should be made on the Care Homes for Older People Page 18 of 42 Evidence: primary MAR chart and both charts archived together when completed. The when required dosage for the administration of Oramorph solution, prescribed for a resident on the ground floor unit, had been increased from 2.5ml to 5ml since being dispensed on 8th January 2010. This was changed in writing by the staff on the MAR chart entry and on the dispensing label on the medicine bottle, however, there was no accountability for the entries with the date of change or the signed initials of the person making the entry. Directions printed on the dispensing label are not to be changed, however, it is good practice to indicate reference to the dosage change that is entered on the MAR chart. Controlled Drugs (CD) are stored in small CD cupboards fixed within the main medicines cupboard in both of the homes units. The CD cupboard in the ground floor unit was full requiring some medication that was no longer prescribed and awaiting disposal, to be stored in the CD cupboard in the upper floor unit. The acting manager informed us that it was practice in the home to store less used CDs from the ground floor unit in the upper floor CD cupboard when the CD cupboard is full on the ground floor. It is highly recommended to provide larger storage for CDs on the lower floor nursing unit where the demand is greater. As discussed, this can be a CD cupboard fixed independently of the main medicines cupboard, bolted directly to the wall. There is a dedicated medicine storage room for each of the homes units with adequate security, however, the temperature of the rooms is usually 1 or 2 degrees above the maximum 25 degrees C temperature licensed for medicines storage. A mobile air conditioning unit was operating in the upper floor medicines room but proved inadequate to reduce the temperature, which currently was 26.5 degrees C. Although neither room appeared to have direct heating or exposed hot water pipes, there was a lack of ventilation with no outside walls accessing direct entry to cooler air. Steps are therefore required to maintain the rooms temperature within the maximum of 25 degrees C. Each medicines room included a lockable medicines fridge for which daily temperature records were kept. Both fridges had integral maximum/minimum thermometers fitted, however, only the current temperature was recorded. To ensure that the correct temperature is being maintained at all times it is recommended that the maximum and minimum temperatures are also recorded. The insulin that was currently in use for a resident in the ground floor unit was stored in the fridge, contrary to the directions on the container to store at room temperature when in use. The date that the cartridge was started was neither recorded nor Care Homes for Older People Page 19 of 42 Evidence: indicated on the insulin pen and although the dosage would normally ensure usage within the in use expiry of 4 weeks, it is good practice to record the date started in case of any interruption to continued use, for example, the resident being admitted to hospital or other reason to suspend usage in the home. The fridge also contained eye drops where storage at room temperature is licensed and would improve administration by reducing the risk of expelling the drop by reflex blinking of the eyelid on entry of a cold drop to the eye. A health care professional survey said that the home sometimes supported people to administer their own medication, or manage it correctly where this was not possible. A training matrix was viewed and showed that staff who had been provided with the safe handling of medication training were no nursing staff, two care staff and one night staff. Staff that were provided with Boots MDS (monitored dosage system) were one nurse, three care staff and one night staff. However, the manager told us that the staff who were responsible for administering medication had recently been provided with training. Care Homes for Older People Page 20 of 42 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect to be provided with the opportunity to participate in activities that interest them, to be supported to maintain the contacts of their choice and to be provided with a balanced diet. Evidence: Since the last key inspection the provision of activities in the home had improved. The home continued to provide a full time activities coordinator, who was spoken with. The activities coordinator was clearly passionate about their role and keen to tell us about the improvements that had been made since the last inspection, which included outings that people had chose to go on, such as to a local zoo, an activities room was in place on the first floor, they had purchased items to use in activities, such as a parachute, karaoke machine and budgies and there were regular visiting entertainers to the home. They told us how they had encouraged people to participate in activities, who had not previously done so. For example, a person who was noted to not be included in the activities at the last inspection had taken part in baking, for which photographs were seen. The activities coordinator also worked with people upon their admission to the home in compiling a life story, which identified their likes, dislikes, hobbies and interests. They told us that they used the information from people to plan activities that they enjoyed and during the coffee mornings people could put their Care Homes for Older People Page 21 of 42 Evidence: ideas forward about the activities that they would like to be provided. The AQAA stated that improvements made in the last twelve months included the home has organised church services for a variety of denominations in order to meet individual service users requirements. This was confirmed by the activities coordinator who was spoken with. We tracked the care provided to four people that lived at the home, we viewed their care records and it was noted that the life story was present in each. Also in place was a person centred care plan, which is further discussed in the previous section of this report and it was noted that the staff discussed the interests that people had identified in the documents with them. The daily records that were viewed showed where people had participated in activities. The care plan of one person, which had recently moved into the home was viewed and it stated that they should be encouraged to participate in activities to ensure that they did not become isolated. An activities programme was displayed in the ground floor lounge. The daily activities included coffee mornings, relaxation, singing, art group, crafts and bingo. During the morning of the inspection, people on the ground floor were engaged in watching a DVD about the history of Haverhill. People chatted and laughed about their memories and what they thought about the DVD when they had watched it. Care staff and the activities coordinator assisted people to position themselves in the room which ensured that they could see and hear the DVD. We spoke with a person who had recently moved into the home and they told us that the activities coordinator had encouraged them to participate in the activities and they were interested to see what the DVD was about. They said that they had met several of the other people who lived in the home as a result of joining in with the activities. A person who lived at the home and the activities coordinator was observed to plan to make greetings cards for the persons relative. Which showed that as well as group activities, people were supported to undertake individual activities. Three people that were spoken with told us that they enjoyed the activities in the home and that there was plenty to keep them occupied. A service user survey said that there were always activities that they could take part in if they wanted to. On the first floor the communal Turner Lounge was being used as an activities area. There were lots of activities out ready for people to use as they wished and they could use the items spontaneously with or without the assistance of staff. The activities available included colouring, card making, musical instruments, karaoke, puzzles and Care Homes for Older People Page 22 of 42 Evidence: board games. The room provided a pleasant environment, which provided a mix of tables with chairs and more comfortable arm chairs. There was also a kitchenette facility behind a screen that could be used as required. A staff member told us that this was also available for relatives to help themselves to refreshments. We observed a person being assisted by a carer with the card making activity. They were also keeping a log of activities undertaken and by whom, which evidenced the activities taking place and to track what people were choosing to participate in or use. In addition to the above, further activities recorded included household tasks such as washing and drying up, folding laundry and playing cards. Feely boards had been made and were provided in the Turner Lounge and in the corridor by the main lounge. A range of soft toys had been provided and were located near a large window in a corridor, which were easily accessible to people. One person was observed carrying a teddy bear with them wherever they went, which seemed to provide some comfort. Three people with dementia were seen walking the corridors on and off throughout the day it was positive to see that they were free to use the environment as they pleased, with no constraints placed upon them. They appeared to have a sense of purpose rather than looking lost and aimless. Staff interacted with them whenever they passed, for example smiling and saying hello and sometimes stopping for a chat. The Rembrandt Lounge was a larger communal lounge/dining area, which was where the newly acquired budgies were situated. It was noted that the environment was warm and comfortable and people chatted with each other and staff. It was noted that at least one staff member was present at all times. We observed the activities coordinator painting several peoples nails. They clearly enjoyed the one to one attention and opportunity to chat. The activities coordinator clearly knew them well and was able to engage them about matters of relevance to them. A person showed us their bedroom which was personalised with their own furniture and belongings, such as ornaments, photographs, pictures, fresh flowers, lamp, clocks, trophies and shields for sporting achievements and a television. It was noted that the personal items provided a sense of familiarity and security. The person said that they were happy. The persons friends visited and spent time with them in the privacy of their bedroom. Care Homes for Older People Page 23 of 42 Evidence: The AQAA stated the home encourages service users to personalise their rooms by bringing with them important belongings and bedrooms can be decorated to suit individual requirements. People told us that their relatives and friends were always welcomed into the home. This was confirmed by two visitors to the home that were spoken with, they told us that they were always made welcome. A service user survey which had been completed by their relatives on their behalf stated we visit (the person) frequently and have had no cause for concern. The care records that were viewed, showed the contacts that people chose to maintain and where their family and friends had visited. The AQAA stated visiting times at the home are very flexible, allowing friends and relatives to visit their loved ones as frequently as they wish. Visitors are also offered the opportunity to dine with their relatives should they so wish. People were provided with a balanced and varied diet. The menu was viewed and it was noted that it provided an alternative to each meal and a vegetarian option. The cook was spoken with and they told us that if people did not want what was on the menu they could request an alternative, which would be provided. The cook told us that they were made aware of peoples specific dietary needs and of any changes in peoples dietary needs, for example if they were unwell and needed a softer diet on a temporary basis. They showed us the information that was provided to them from the care team, which identified if people had diabetes, allergies etc. The cook told us that they attended resident and relative meetings and spoke with the people who lived at the home regarding their preferences for meals. The care plans that were viewed identified peoples dietary requirements and the specific needs that they had, for example with eating their meals. However, one care plan that was tracked identified that the person was diabetic, which was tablet controlled. However, it did not include information about how staff should observe changes in their condition, which related to diabetes and the actions that they should take to ensure their well being. The menu for the day was provided on the dining room tables, which was in larger print to ensure that it was accessible to people. The menu showed that breakfast was toast, cereals or porridge. Lunch was roast leg of lamb with mint sauce, roast potatoes, cabbage, cauliflower and trifle. Supper was soup, sausage rolls and Care Homes for Older People Page 24 of 42 Evidence: sandwiches, fruit cake, fruit, biscuits and soft drinks. It was noted that people were offered plenty of fluids throughout the day. There were jugs of cold drink and glasses available in the communal areas and in peoples bedrooms, which they could help themselves to and hot drinks were provided as people requested and with the tea trolley. During the inspection we observed that a person had their breakfast of cereal and tea at 11:00am. We asked a carer why they were having breakfast so late and they told us they preferred to get up at 10:00am. They told us that they had a light breakfast and always managed their lunch and that they had a good appetite. It was noted that the carers interaction with the person was good and they were attentive to their needs. It was noted that the experiences for meal times had improved since the last key inspection. It was positive to note that the tables were laid with table cloths, place mats, glasses, cutlery, fruit juice and condiments. People were offered clothes protectors and paper napkins. Most people ate their meal and left little on their plates, however, one person loudly complained about the meal saying I cant eat all that gravy. Its spoiled my dinner. The care staff asked them to eat what they could. We asked if they could have a dinner without gravy on but the meat had been served in gravy. Staff sat at tables eating with people, which provided a good atmosphere and the opportunity to chat and supervise and assist people. We asked a carer what the dinner was like and they said that the gravy was too thick and salty. Another person said dont stop making it because I love it. We discussed this at the feedback of the inspection and it was agreed that people should have an option of if they were provided with gravy on their meals in the future. People that were spoken with told us that they enjoyed the food at the home, one person said its about the same as I make myself. Two people told us that there were two cooks at the home, one who was very good and one who was not as good. One of the people told us that they had told the manager about this and said that they are dealing with it. The manager confirmed that they were aware of the issues and had spoken with people about their choices and preference regarding the food provision at the home. A service user survey said that they always liked the food at the home. Two visitors of the home that were spoken with told us that the food at the home was good. Care Homes for Older People Page 25 of 42 Evidence: The AQAA stated the home offers a wide range of drinks, meals and snacks from a varied menu throughout the day and overnight as the service users requires. Care is offered and dignity maintained at mealtimes, ensuring that all service users are supported to be as independent as possible during meal times. The menus are flexible and a wide range if choices are available to suit the residents requirements. A wide variety of meals are provided to meet the requirements of those service users with special dietary needs. Care Homes for Older People Page 26 of 42 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience 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 have their complaints listened to and acted upon and to be safeguarded against abuse. Evidence: Since the last key inspection a safeguarding alert had been made regarding the pressure area care provided to people. The outcomes for the investigation were not yet available at the time of this inspection. The manager told us that the local authority area safeguarding manager was due to provide safeguarding training to the staff team 11th February 2010. A training matrix was viewed and showed that safeguarding training had been provided to two of the six nurses that worked at the home, twenty one of the twenty three care staff, three of the six night staff, all of the kitchen staff, three of the five domestic staff and to the activities coordinator and the maintenance staff. The AQAA stated that improvements made in the last twelve months included all staff have received further adult safeguarding training during the last twelve months, this is to be repeated on 21st January 2010. At the last key inspection it was noted that staff were unsure of their responsibilities regarding reporting safeguarding concerns. Since then, the home had developed an Care Homes for Older People Page 27 of 42 Evidence: information sheet, Safeguarding Adults Statement which was provided to staff in their supervision meetings. The information sheet was viewed and clearly showed the responsibilities of staff in reporting concerns of abuse. The document stated in most cases you should inform your immediate supervisor or line manager; however you can also go directly to any of the following, if you prefer: your managers manager, Adult Community Services Customer First, Care Quality Commission, Police and the contact details for the above were in place. Supervision records that were viewed showed that the issue of safeguarding had been discussed. Staff that were spoken with confirmed that they had been informed of their responsibilities regarding safeguarding and knew what actions that they should take. The AQAA told us that there had been five complaints made in the last twelve months, four of which were upheld. We looked at the complaints records, which included details of the complaints and the actions taken. It was noted that none of the complaints had been received since the last key inspection, which was confirmed by the manager. The AQAA stated the home has a very open and positive approach to complaint management. Complaints are seen as an opportunity to assess how effectively care is provided to individual service users at the home and how they improve the level of service offered to service users. Each individual complaint is treated seriously and proactive strategies implemented to ensure that the situations do not reoccur. The complaints procedure was viewed and clearly explained how complaints could be made and the actions that they could expect to be taken. The complaints procedure was also provided to people in the Statement of Purpose and it was displayed in the entrance hall to the home. Staff and people that lived at the home that were spoken with told us that they knew about the complaints procedure. They told us that there had been improvement with the management in the home and that they felt that they were listened to. A service user survey said that there was someone that they could speak with informally if they were not happy and that they knew how to make a formal complaint. A health professional survey said that concerns were sometimes responded to appropriately. Five staff surveys said that they knew what to do if people had concerns about the home. Care Homes for Older People Page 28 of 42 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect to be provided with a clean and comfortable home to live in. Evidence: People were provided with a clean, well maintained and comfortable home to live in and it was noted that there were no unpleasant odours. The AQAA stated the Meadows is a purpose built home which has been newly established within the last twelve months. All environmental standards were met during the design and planning stages of the building and adaptations included where necessary. The home is kept clean, tidy, well maintained and odour free. A service user survey said that the home was always fresh and clean. People that lived at the home and visitors that were spoken with were complimentary about the cleanliness of the home. People told us that they could personalise their bedrooms as they wished and this was confirmed by a persons bedroom which was viewed. The person had brought in their own furniture and belongings, including ornaments, photographs, pictures, fresh flowers, lamp, clocks, trophies and shields for sporting achievements, which provided familiarity and security. The home had two floors and at the time of the inspection the ground floor provided nursing care for twenty one people and the first floor provided residential care for Care Homes for Older People Page 29 of 42 Evidence: eleven people. The ground floor held the kitchen and laundry, bedrooms, all of which were en-suite, communal bathrooms and toilets, a large communal dinning/lounge area and there were two small lounges that people could us of they chose to. The first floor held bedrooms, all of which were en-suite, communal toilets and bathrooms, a lounge and dining area and an activities room. All of which were clean and attractively decorated and furnished. The laundry was large, clean and fit for purpose, which provided sufficient washing and drying machines for the numbers of people that lived at the home. Both floors held a sluice room, which provided a sluicing machine where commodes were cleansed. A staff member was spoken with and they told us that the sluice machines were in working order and used daily. During the inspection we noted that a toilet seat was soiled, which we told a member of domestic staff about. They promptly cleaned the area to ensure that the risk of cross contamination was minimised. Each bathroom and toilet and the laundry provided hand washing facilities, which included hand wash liquid and disposable paper towels, which also minimised the risks of cross contamination. Cross infection was further minimised by the staff who were observed to wear protective clothing, including aprons and gloves when supporting people with personal care, undertaking domestic duties and when working with food. Staff that were spoken with had an understanding of infection control. The AQAA stated that the areas that they could improve on included the home will improve infection control training and development of infection control practices with all staff. A training matrix was viewed and showed that the staff that were provided with infection control training were one of six nurses, nineteen of twenty three care staff, two of six night staff, all kitchen staff, four of five domestic staff and the maintenance staff. Care Homes for Older People Page 30 of 42 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect to be protected by the homes recruitment procedures. They cannot be assured that the staff are fully trained to meet their needs. Evidence: The manager told us that since the last key inspection they had increased the staffing levels of the home to ensure that peoples needs were appropriately met. At the time of the inspection the ground floor provided nursing care for twenty one people that was staffed by two nurses and five carers on the morning shift, one nurse and four carers on the afternoon/evening shift and one nurse and one carer during the night. The first floor provided residential care for eleven people and provided four carers during the day shifts and two carers during the night. The staffing levels that we had been told about were confirmed by our observations of staffing during the inspection and discussions with staff that were spoken with. However, the manager told us that one of the nurses that worked on the morning shift was late to work due to an appointment, which affected the medication administration times, which is further discussed in the health and personal care section of this report. Staff that were spoken with told us that the increase in the staffing levels was beneficial to the people who lived at the home and that the care staff had more time to meet their needs and to chat with people. One carer told us that whilst they Care Homes for Older People Page 31 of 42 Evidence: managed with the staffing levels, they could always do with another pair of hands. The staff survey asked if there were enough staff to meet peoples individual needs, three answered usually, one answered sometimes and one did not answer. The survey asked what the home could do better and one stated better level of staff on all shifts and not expecting the remaining staff to cope. It was noted that staff were attentive to the needs of people at the home and interaction was observed to be caring, respectful and professional. People that were spoken with told us that their call bells were answered promptly and that they had recently seen an improvements in the staffing. A service user survey said that the staff were always available when they needed them. We observed a person who was admitted to the home on the day of the inspection, they were introduced to staff and it was noted that they said that they were concerned that they could not remember their names, no staff wore name badges. We discussed this in the feedback of the inspection and the manager told us that they had already identified the issue and were planning on providing all staff with name badges. The AQAA stated the home has a wide range of experienced and skilled staff among the team to support service users using a person centred approached. Active recruitment over the last year to build and establish a settled staff team with bank staff included to minimise the need for agency staff. This has benefited the service users by them having a consistent staff team who are recognisable and more aware of their care needs and the staff levels are clearly documented on the staff rota and are well in excess of those calculated using the residential forum calculations. Recruitment procedures being followed are clearly documented. There was a new lead nurse, who was spoken with and they told us that they were responsible for monitoring that people were provided with the support that they required and the work completed by the nurses and care staff. The recruitment records of four staff members were viewed and it was noted that the appropriate checks had been undertaken prior to them starting work to ensure that people were safeguarded. The checks included CRB (Criminal Records Bureau) and POVAfirst (protection of vulnerable adults), two written references, identification and an application form which identified their work history. There were some shortfalls identified which were discussed in the feedback to the inspection. The recruitment records did not hold the start date for employees and one of the records did not hold a photograph of the staff member, which was addressed immediately, the staff member provided a photograph which was promptly placed on their file. One of the records Care Homes for Older People Page 32 of 42 Evidence: that were viewed did not show evidence that a statement for the reason for leaving their last employment in their application form was explored. During the feedback a member of the management team explained how they had addressed the situation. Five staff surveys said that their CRB checks and references were checked before they started working at the home. One of the staff records that were viewed included details of disciplinary action, which showed that concerns of poor practice were promptly acted upon. A list of carers who had achieved and were undertaking NVQ (National Vocational Qualifications) was given to us and it was noted that the home had almost met the target of 50 of staff to have achieved a minimum of NVQ level 2 as identified in the National Minimum Standards relating to older people. There were twenty three care staff and six night staff that worked at the home at the time of the inspection and nine had achieved a minimum of NVQ level 2 and nine were working on their awards. There had been improvements in the provision of training in the home since the last inspection and they had plans to ensure that the staff team were appropriately trained to meet the needs of people who lived at the home. Since the last inspection staff had been provided with training courses which were the Alzheimers Society Yesterday, Today and Tomorrow and COSHH (Control of Substances Hazardous to Health). On the afternoon of the inspection staff were provided with Deprivation of Liberty training and safeguarding training was booked for 11th February 2010. At the previous inspection it was noted that staff were not provided with an induction course which incorporated the Skills for Care Common Induction Standards. The manager told us that they had obtained information from the local authority to provide the training, which they would be providing when new staff started working at the home. The home did provide a Minster induction course, which inducted newly appointed staff into the home, advised them of the homes policies and procedures and the expectations of their role. This was confirmed in discussion with a recently appointed staff member. The staff survey asked if their induction provided them with everything that they needed to know to do the job when they started, three answered very well, one answered partly and one answered not at all. We were provided with training matrix during the inspection which we took away with us. The matrix showed the training that had been provided to staff. All staff with the Care Homes for Older People Page 33 of 42 Evidence: exception of four nurses had been provided with manual handling and health and safety training. All staff with the exception of one care staff and four nurses had been provided with COSHH training. One nurse, twenty carers, five night staff, all kitchen and all domestic staff had been provided with food hygiene training. Seventeen care staff, five night staff and some of the kitchen and domestic staff had been provided with dementia training, it was noted that none of the nurses had been provided with this training. Care staff that were spoken with told us that the training provision at the home had improved and that they were due to attend more training. A member of staff told us that they had recently attended the Yesterday, Today and Tomorrow training, which they felt was excellent. Four staff surveys said that they had been provided with training which was relevant to their role and that helped them to understand the needs of people and one said that they had not. Three staff surveys said that they were provided with training which provided them with enough knowledge about health care and medication and that kept them up to date with new ways of working and two said that they were not. The AQAA stated staff training has been highlighted as a priority for the home in the coming months and as stated a new training matrix has been devised. Care Homes for Older People Page 34 of 42 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect that that their financial interests are safeguarding and that they are able to express their views about the service that they are provided with. They cannot be assured that the home provides a stable and consistent management structure which enables their health, safety and welfare to be consistently and fully promoted and protected. Evidence: At the last key inspection the home was again rated as providing poor outcomes (0*) for the people who lived there. We had completed two random unannounced inspections since the key inspection and due to our concerns about the service we had met with the homes providers 2nd December 2009, who were keen to ensure that their service was improved. Issues that had been identified included with medication, care planning, reporting safeguarding issues and poor management. As a result of safeguarding alerts that had been made there had been ongoing support provided to the home by Suffolk County Council Outcomes and Quality Monitoring Care Homes for Older People Page 35 of 42 Evidence: Team, which included unannounced visits. The home was registered 1st October 2008, the registered manager left the service before the first key inspection 17th March 2009. Since then there had been two different managers who had worked at the home, both had not been registered with us. Which resulted in there being an inconsistent management structure in the home to ensure that the monitoring of the service provided to people and that a proactive approach to improve the outcomes to people was undertaken. The current manager told us that they would be making a registered manager application for the service and that they were planing to take their CRB documents to the London CQC office the day after the inspection. They told us that they had achieved several qualifications which would enable them to manage the home effectively, which included RMN and SRN nursing qualifications, a post graduate qualification in management, ENB 953 advanced psychiatric nursing and A1 assessor award. The AQAA stated the current Project Manager is a doubly qualified SRN/RMN with considerable experience, 13 years, in the care of the elderly sector. He has both Masters degree, MSc, and postgraduate management and education qualifications. Currently there is no deputy manager as the structure of the homes management is being revisited. The project manager has a positive approach to training and personal development and this will be cascaded down to the staff team as a whole. The manager told us about the improvements that they felt had been made to the service, which included with the care planing, staff training, staff supervision and medication. However, it was noted that whilst it was positive to note the improvements made, there continued to be shortfalls, which are further discussed in the health and personal care, staffing and this section of this report. The home and management needed to address the issues identified at this inspection, to be proactive in making improvements and to sustain them to ensure that peoples needs were met and that their health and safety was appropriately promoted and protected. The improvements to the outcomes of the care provided to people was reflected in the improved rating, which was 1*, which means that the home provided adequate outcomes to people and they needed to continue to make improvements in the services provided to people. Staff and people who lived at the home told us that there had been an improvement in the home, which included in the atmosphere, care planning and staffing. They told us that the manager was approachable and listened to what they said. Staff that were Care Homes for Older People Page 36 of 42 Evidence: spoken with told us that they had been provided with monthly team meetings and a one to one supervision meeting, where they discussed how they were working and the support that was provided to people. This was confirmed in the supervision matrix that was viewed and the supervision notes that were present in the four staff records that were viewed. Whilst it was positive to note that the staff supervision had improved, the home should sustain the improvements and continue to ensure that all staff are appropriately supervised. The manager told us that they were provided with regular supervision meetings with a director in the organisation, who was also a qualified nurse and a nurse spoken with confirmed that they were supervised by a qualified nurse, which ensured that they were provided with the clinical guidance that they required. The AQAA stated staff supervision will take place with all staff on a two monthly basis thus ensuring six sessions annually. Included within the supervision will be included training requirements and absenteeism. Monthly Regulation 26 visit reports, which were undertaken by representatives of the organisation, were viewed and showed that the home and the services provided to people were routinely monitored. The reports showed that people who lived at the home were spoken with, which provided them with the opportunity to express their views about the service provided at the home. The AQAA stated surveying and evidencing how we are monitoring the approach taken by th home to ensure we are consulting with service users and developing the quality of service provided. Within the coming months the home aims to increase the amount of information gathered from service users, relatives and visitors to inform the company about the necessary changes that need to be made in terms of level of service. People could further state their views in the annual satisfaction questionnaires and the three monthly resident and relative meetings that were held at the home. We viewed the satisfaction questionnaires that had recently been undertaken by relatives and people who lived at the home. The questionnaires asked about the quality of the environment, hospitality, safety, tranquility, meals, professionalism of staff, quality of care, information and communication, dignity and respect and activities. It was noted that the feedback was generally positive. The minutes of a relatives meeting were viewed and they showed that the changes in the home and staffing were discussed. Care Homes for Older People Page 37 of 42 Evidence: The records of peoples spending money were viewed and it was noted that their finances were appropriately safeguarded. The administrator showed us how peoples spending money was stored, which was in individual plastic envelopes, which also held a record and receipts of all their transactions. They told us that regular audits of the money were undertaken and that all transactions were signed by two staff members to ensure that the records and balance of money was accurate. During the morning of the inspection the fire alarm was tested. It was noted that the maintenance worker informed people on the ground floor of the test. On the first floor we observed that the alarm resulted in automatic closure of doors, which caused distress to one person who wanted the door open. It was noted that a staff member held the door open and promptly responded to their distress. We spoke with the maintenance staff member who showed us their health and safety records that they were responsible for to ensure that people were safeguarded. The records were viewed and it was noted that the nurse call system was checked monthly, fire safety checks were checked weekly and the water temperature was checked monthly, the records showed that all were 43 degrees centigrade or just below, which showed that water temperatures were maintained at a safe level to ensure that people were not at risk of scalds from water outlets. A weekly work schedule was viewed which showed that they had completed the tasks that had been identified in the maintenance log book. The records of fridge and freezer temperature checks and the cleaning schedule were viewed in the kitchen which showed that the food was stored at the correct temperature and that the kitchen was routinely cleaned. Care Homes for Older People Page 38 of 42 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 39 of 42 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Insulin is required to be stored at the correct temperature when in use as directed on the container. To ensure that people are protected by the homes medication procedures and processes. 26/02/2010 2 9 13 Medicines are required to be stored at the correct temperature to maintain therapeutic effect. To ensure that people are protected by the homes medication procedures and processes. 27/04/2010 3 9 13 Medication records are 26/02/2010 required to be complete to indicate medicines are being administered in accordance with the prescribers directions. Care Homes for Older People Page 40 of 42 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To ensure that people are protected by the homes medication procedures and processes. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 To increase the storage capacity provided for Controlled Drugs on the ground floor. Care Homes for Older People Page 41 of 42 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) 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. 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