Inspection on 06/03/09 for The Red House

This inspection was carried out on 6th March 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Red House 11/03/07

The Red House 07/03/06

The Red House 27/06/05

The Red House 28/02/05

The Red House 05/11/04

Extracts from inspection reports are licensed from CQC, this page was updated on 21/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Red House 8 The Village Kingswinford West Midlands DY6 8AY     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Tina Smith     Date: 0 6 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 48 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 48 Information about the care home Name of care home: Address: The Red House 8 The Village Kingswinford West Midlands DY6 8AY 01384291757 01384291757 davidjodonnell@hotmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mrs Shirley Nita O`Donnell,Mr David John O`Donnell care home 8 Number of places (if applicable): Under 65 Over 65 1 1 6 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 0 0 The Red House is a 200 year old Grade 2 listed building next to the local church, where there is car parking. It is accessible from the main Kingswinford to Dudley Road, where there is public transport. Care and accommodation is provided for up to 8 older people, some of whom have confusion and memory loss. The owners (one of whom is also the registered manager) and a family member have rooms on the 2nd floor and share all communal areas with people in the home. On the ground and first floor there are 4 single and 2 double bedrooms for people, some with ensuite facilities. Access is by a passenger lift or staircase. Uneven floors and the staircase may pose a risk to people unsteady on their feet, or mean that they cannot leave their room without a staff escort. There is a dining room and a lounge for communal use. Assisted bathing and shower rooms are on the ground and first floor; communal toilets are throughout the Care Homes for Older People Page 4 of 48 Brief description of the care home home. There is a small enclosed patio garden, and the owners have two dogs that bark. Information should be sought from management about fees and additional charges that may apply, as the home does not publish this information. Care Homes for Older People Page 5 of 48 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The home was last inspected on 11/03/07. Prior to our visit the home supplied legally required information to us each year in the form of its Annual Quality Assurance Assessment (AQAA). Information from this and from other sources was also used when forming judgements on the quality of service provided at the home. We received surveys each year from people, relatives and staff. One inspector visited the home for 12 hours over two days. On the first day we were joined by an Expert by Experience for four hours, who saw each person privately and shared a meal with two people in the home. They have knowledge and personal experience of caring for people and of care services. The Expert works for a voluntary organisation and has training and prepared a report to assist CSCI to identify outcomes Care Homes for Older People Page 6 of 48 for people in the home. The home was not informed that we would be visiting. During our visit we examined records of all six people living in the home and spoke with them, staff, and a visiting professional. Their rooms and equipment were seen, and the building was toured. Medication was inspected with the manager. We sampled other records about staff and the running of the home. The inspection was extended over a weekend so that we could see people again, discuss our findings. We would like to thank people in the home, visitors and staff for their assistance. There were 2 requirements from previous inspections; one was fully met. We left 1 immediate and 7 urgent requirements on our second visit about peoples health, welfare and safety. None were fully met, and two were replaced after information was provided by the manager. A full list of requirements and recommendations is at the end of this report. Compliance will be checked and our regional improvement strategy will be used. What the care home does well: What has improved since the last inspection? What they could do better: Written information is not accurate, and there can be a lack of clarity about fees for people funding their own care. People and relatives have been dissatisfied about the home and management. Rooms are changed without consultation and care plans are not signed and agreed with people or their representatives. Few choices are offered. People mainly stay in their rooms all day and for meals. There are no activities or exercise, no religious services or contact with the community unless visitors take people out. Visiting is restricted, and management are suspicious of professional visitors and the Expert by Experience seeing people alone. Basic facilities for privacy and security are not provided, so there are no door locks, staff do not knock before entering, there is no access to a telephone or safe storage for peoples money. The medication system does not protect people and staff competence is not regularly checked. Health conditions are not satisfactorily monitored. Most people are sedated and have not had medication reviews about this. People with hearing and sight impairments, confusion and memory loss do not have appropriate mental or social stimulation, aids and equipment, and staff do not converse with them. Specialists have not been sought to advise the home and improve their quality of life. People appear depressed and oppressed, and choices made by the home for some incapacitated people may not be in their best interests. People are restricted in bed by furniture and room layout, and radiator covers pose a risk of burns. Some people have Care Homes for Older People Page 8 of 48 no access to the call system, or a commode at night. We had reports that there are no waking night staff, and that people have fallen or not been able to raise help, which are denied by the owners. Regulators have not been notified about falls, injuries and pressure sores, and there is inadequate risk assessment, prevention and monitoring in these areas. Care plans do not have details to guide staff, especially about manual handling, and we had reports that people have been roughly handled. Adult protection concerns were reported under the local council protocol as a result of our visit. We had several reports that people are shouted at, intimidated and belittled and they feared us discussing concerns with the owners. People and relatives cannot have confidence that complaints and concerns will be acted upon, and have no way to express their views about the running of the home anonymously. The home is not run in peoples best interests. The manager does not keep up to date. Policies and procedures are not always followed. Staffing and skill mix does not meet the needs of people living in the home, especially at night, and there is insufficient training and supervision of staff. New staff are not checked to ensure that they are safe to work in the home, and are not inducted to safe working practices and peoples needs. Environmental risks have not been managed. Infection control needs to improve to prevent the spread of infection. Immediate and urgent requirements were not met to our satisfaction for peoples health, safety and welfare. Further action will be taken so that The Red House complies with the law in a timely way, and makes people safe. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 48 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 48 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information about the home and service is not accurate, and there can be a lack of clarity about fees for people funding their own care. People can visit and try the home to decide if it is suitable. Everyone has an assessment but this is not thorough, and people have unmet or inappropriately met needs. Evidence: People and relatives told that that they have ...known the Red House...for many years and that The Red House has always had a good reputation in the area. One person told us the home and management used to be better and has changed. Surveys said there was enough information so that decisions can be made about the home. There is a service user guide with no fee information as required by law, but there is information about fire safety and complaints. From our observations and discussions with the owners the information about visiting, opportunities and facilities Care Homes for Older People Page 11 of 48 Evidence: are not accurate, discussed elsewhere in this report, and will not help people make informed decisions about the homes suitability. The guide would be more accessible to older people if available in large font and other formats. Since the last inspection we had a report that people on short stays were told they did not need assessments and that families should not visit for three days after admission. On our visit, this was not the experience of the newest admission. Their relative chose the home, and they are having a trial period. There are six people living in the home, and two vacancies in a double bedroom. Most people have been in the home over 12 months; one for many years. We had a report that one person left without notice the week of the inspection, due to dissatisfaction. Two people have limited communication. We spoke to everyone and only one person able to tell us is fully satisfied with the home. Two people said that the home is not meeting all their needs. We looked at everyones records, and found there is an assessment for each person, and most people have representatives. However assessments are not thorough, and reviews do not monitor key risks and peoples health conditions, and we found poor night time care. People seeking social stimulation, or who need facilities for sensory impairments, memory loss/confusion or care at night may not find this currently at The Red House (see other report sections). An owner said that two people in a shared room were moved into other rooms several times, including the day before the inspection, but there is no mention of this in their care records. There was no satisfactory explanation for the moves, and both people are likely to lack the mental capacity to make or challenge this decision. For example, one became distressed by another person and was moved back, although the reason for the move was to have more space to care for someone bedfast. Both have representatives, and one has a valid Power of Attorney, but there are no records of consent or consultation with others, or decision showing why the moves were in each of their individual best interests. On this occasion they were moved from a room with en-suite facilities to one without, which may affect fees and contracts need review. People with confusion and memory loss can become disoriented, need stability and the Expert reported during our visit that a person was distressed and could not establish why. Staff said in front of the person that there was no point in speaking to them as they could not respond. This person had just moved; no extra staff support was planned or seen on our visit, to orient both people with memory loss, sensory impairments and limited communication to the new room. The Expert by Experience expressed concern to us that people so vulnerable can be insensitively treated, and Care Homes for Older People Page 12 of 48 Evidence: moved like this. We found that peoples rights are not respected by management in a number of regards. There are unrecognised and unmet needs and risks, and others inappropriately met. This is discussed later in this report and was fed back to management. Relationships with the person who left and their family broke down over time, and an owner told us about a fee dispute. We advise people funding their own care to ensure they or their representatives sign a robust contract. Some people in the home have a legal right to an Independent Mental Capacity Advocate, and there is no information provided about local advocacy services to help people make decisions about moves, facilities or care. Care Homes for Older People Page 13 of 48 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot have confidence that all their needs are recognised and met appropriately, with privacy and dignity, or that they have access to specialists or aids to retain their abilities, health and wellbeing. The medication system is not fully protecting people. Evidence: Eight surveys told us that care, access to health and support is provided that people need and relatives expect, and that staff are available when needed. This does not match reports we received and findings on our visit, where only one person was fully satisfied. We sampled all six care records - there is a care planning system in place, but it is not thorough and management are not up to date on best practice to prevent falls, malnutrition and pressure sores or to provide dementia and mental health care. Concerns in particular about emotional and psychological wellbeing, independence and medication were discussed with the manager. Urgent requirements were made so that individual needs are recognised and met and systems are improved. Care Homes for Older People Page 14 of 48 Evidence: Screening tools about malnutrition and pressure sores are used but not re-visited after initial assessments so increased risks are missed when there are changes in peoples condition, appetites or mobility. We found several examples where peoples mental and physical health is not adequately monitored, so changes are not noted and health advice is not always sought early or built into care plans when given. Staff do not have detailed instructions and signs to watch for and report. It is unclear for example, how pressure sores are prevented when people lose mobility, which affects several who sit in a chair all day. An owner directed us not to sit in one chair because it is too hard. We found an open un-prescribed cream and an owner could not tell us who it was for; if it is shared, infection can spread and we had to insist it was discarded. No care plans identified creams in use. Although the AQAA says that no one had sores, one person has been bedfast for months following a fracture and pressure sores we were not notified about. There is no food or fluid monitoring to ensure hydration and nutrition and the person has not been weighed since 2007. The Expert said there is an appropriate cup but drink in their room was not left within their reach. A visiting nurse said that severe pressure sores, Grade 4 are under treatment but are now healing; they provided and check a ripple mattress and the home were told to turn the person every two hours. There are no turn charts and the manager said the person is not always turned two hourly at night and tends to revert back to the same position, which has not been discussed with the nurses. This means that NHS instruction is not fully followed and positioning aids have not been sought. The home is unable to determine this persons risk of malnutrition without regular weighing or body mass index measurement, but the manager is not up to date on readily available government advice about this. Healing may be prolonged rather than promoted. Changes in appetites are not noted for others, and the manager confirmed most people have not been weighed since 2007, although care plans say this should be done monthly. There are no nutritional records and we did not see any food fortification plans, for instance, to increase calorie content for people who eat small portions. Along with medication problems we found, this means that peoples health and wellbeing cannot be effectively monitored. The only person currently weighed lost 7 lbs in two months; the home contacted a doctor but no outcome is noted from their involvement. Doctors are sought for peoples pain and when people ask. Specialists are not readily sought for aids, or to help people arrest progression of dementia, retain physical and mental abilities, social skills, mobility and independence. One person has not seen a doctor since 2007, did not have a flu vaccination or health checks in 2008 although changes in memory were noted. The managers review of their social needs and relationships in 2009 states so limited as to be non-existent, with no actions to be Care Homes for Older People Page 15 of 48 Evidence: taken. Staff do not have detailed guidance about communication, and meaningful activity is not assessed or provided for individuals, or in the home or community. This makes depression more likely. We agree with the Expert that functional care is provided people appear physically cared for, clean and most are dressed in keeping with preferred clothing styles staff told us about. Most people have poor quality of life, and healthy lifestyles are not promoted (see Daily Life). Best interest decisions have been made by management that people with limited communication share a room and do not leave it, and most staff seen did not converse with them. One person lost the ability to judge their own body temperature, and the Expert saw that staff did not check on this. They were cold when touched and confirmed they were cold, although the room and home was warm. Two people did not have any socks or tights on, and one did not have a cardigan on. There were no lap blankets for anyone in the home, and people who sit all day can feel cold. Most people are sedated at night, which is chemical restraint; reasons and informed consent are not clear in records, and the manager confirmed that medication reviews by doctors have not been requested. When medication is changed, an increased risk of falls has not been assessed. There are no tools to identify people at risk of falling. Two people we know of sustained fractures from falls, and their assessment, equipment and care plan have not been reviewed to prevent recurrence. Falls are recorded as the persons own fault and verbal accounts differed from written records. No one has assessments for falls out of bed. Mobility aids have not been reviewed for people unsteady on their feet, and a walking aid for a person at known risk was not readily available to them on our visit. Personal safety from environmental hazards has not identified and planned for. Immobility is encouraged rather than movement. Care plans and reviews are unsigned by people and their representatives. They are not always clear, detailed or up to date about what people can do for themselves, equipment and aids in use and how staff should assist. There were no annual reviews recorded in 2007. In 2008 the manager reviewed care plans monthly, but we cannot confirm that people and families are consulted. People cannot be sure that personal care and manual handling will be provided the way they want. New staff are delivering personal care without an induction to safe working practices. They are under supervision of others who are not fully trained in peoples conditions, dementia and mental health care. The Expert assisted a person on Care Homes for Older People Page 16 of 48 Evidence: the stairs having difficulty when the new worker did not support them adequately. We had two reports about rough handling, and the layout of rooms shows us that best practice in manual handling is not in use. One person was bruised, which they could not explain and this was not noted in care or incident records. There was no satisfactory explanation to our query why all but one person is washed in their bedroom, or why and when incontinence pads are used rather than providing staff assistance to use the toilet. One person did not know the shower was on the same floor as their room. Another described degrading night time care which they do not consent to and have to put up with and their care plan does not show restrictions we saw preventing them calling for help or getting out of bed to the commode. People confirmed reports we had that requests are sometimes ignored or denied, and people are shouted at especially at night for asking for assistance or to have a drink. The AQAA told us that there are people who need two staff day and night, and we are not satisfied with staffing arrangements to meet their needs. There are no night time care plans. There is a general lack of respect for people and their rights to privacy and dignity. For example, the inspector and Expert saw that an owner and staff do not usually knock before entering peoples rooms. Two people with similar names are referred to by numbers. People are talked about as if they are not in the room, and others are talked about in loud voices in the hallway using stigmatising and objectifying language. This can have a negative effect on peoples self esteem, and does not respect confidentiality. Staff and an owner avoided talking to the most vulnerable people. Most peoples only source of daily social contact is with staff as they do not leave their rooms. Only one staff member was seen by the Expert to talk to people in a caring and supportive manner. Not all restrictions and restraints are known about by people, their representatives or professionals, as these are not in care plans (see Complaints and Protection). There are satisfaction surveys in care records that we cannot trust as one, for example, appears as if completed by a person with advanced dementia who could not have understood the questions or written the answers. The manager is responsible for the medication system, and told us they were not following the homes procedures. They could not clarify the frequency or when an external audit by the homes pharmacist last took place. We found that medication is not auditable and stocks for two people did not tally with the homes records; drug receipt and disposal records were missing or incomplete. Medication can go missing in such circumstances affecting people and public safety. The room temperature is not taken where medication is stored, but the room gets very hot. This can alter the Care Homes for Older People Page 17 of 48 Evidence: stability of medication and it may not have the effect the doctor intended. One persons medication administration was not fully recorded because the manager said the page ran out of lines. The manager and staff confirmed that medication records are not accurate as they are not always completed at the time it is given by the staff who administer medication to people. Few refusals are noted. Staff instructed to administer medication during our visit did not know what they were administering or why because the manager prepares it, but knew that they should know this. We saw secondary dispensing of drugs into tots, in advance of their administration, which is unsafe as people can be given the wrong drugs. We therefore cannot confirm that people are having medication as prescribed for their health and wellbeing as records are not accurate. There are no protocols agreed with clinicians about prescribed medication for occasional use, and we found they are regularly administered. The manager confirmed this was not checked with the doctor and did not know why this was necessary. We explained that combinations of drugs can have toxic effects, addiction to sedatives should be prevented, and pain relief may no longer be strong enough. Long-standing staff could not answer all our questions. We found that competence regarding medication practice has not been checked since the manager and staff attended accredited training in 2002, and their knowledge is not regularly updated. There was out of date information about drugs and conditions they treat, but no side effects to watch for. This did not match drugs currently prescribed for people in the home, and staff told us they do not usually have access to where this information is kept. The medication system is not fully protecting people. Care Homes for Older People Page 18 of 48 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are treated as individuals but there are restrictions on their lives, visitors and there are no activities. People go on outings only if visitors take them, mainly eat and remain in their rooms. There are few choices and opportunities for exercise, mental and social stimulation or religious worship so that people maintain control of their lives, abilities and beliefs. There is concern about the quality of peoples lives and depression. Food is excellent but there is no choice. Evidence: We are uncertain whether there are flexible routines but people are treated as individuals. During our visit we requested that breakfast continue as usual, when this was delayed unnecessarily for several people, and we could not establish usual bedtimes. Assessments note likes, dislikes and interests but staff told us important details about people that are not in care plans seen. For example, preferred clothing style, and what to do when a person does not cooperate. This is important so staff on each shift consistently meet peoples needs in the way they want, especially new staff. People are offerred very few choices, and some peoples lives are controlled by staff, especially when mental capacity is lost. Care plans do not have enough detail agreed Care Homes for Older People Page 19 of 48 Evidence: with people, or to guide staff about what they are able to do and choose for themselves, and how to offer the choice accessibly. We found that personal property is not respected, and basic choices for privacy and security are not provided to anyone in the home. No one manages their own finances, apart from personal allowance but there is no security for money and valuables. Inventories of peoples possessions are not detailed, and are not updated. People are asked to sign waivers on admission so that lockable facilities do not need to be provided, or door locks (see Environment). National minimum standards for care homes are met by offerring choice and facilities as per Care Home regulations, not by asking people to give up their rights. We saw a lack of privacy by staff and owners failing to knock on peoples doors before entering. Peoples sensory and communication needs and modes are not fully assessed and catered for. For instance, Talking Books were cancelled when peoples hearing deteriorated, rather than seeking a specialist and sensory aids, providing more staff support or seeking a community resource or volunteer to maintain their quality of life and stimulation. One person with hearing and sight loss had no stimulation at all and told us they get bored. Another told us that their TV remote control was removed, so they are unable to adjust the volume or channel and cannot hear it. No one has a care plan about mental and physical stimulation; there are no activities in the home and although we were told that one person is taken out occasionally there are no records of this. There are small TVs in peoples rooms, but only one person could see and hear it. One persons assessment says they are sociable and like company, however we found little opportunity for people to meet or even share a meal in the home. The manager watches TV in this persons bedroom, we are told, rather than in the communal lounge. We did not see magazines, books and other objects or activities matching peoples needs or interests. Some people are likely to need one to one staff support, but this was not assessed. One person told us they asked for staff to tell them the day of the week and the news headlines, but were told staff do not have time to do so. There are people who have no exercise to retain or improve their mobility, and most never leave their bedrooms. An owner described how staff escorts prevent people visiting each others rooms, but there are no recorded incidents warranting this and people told us they like to talk with eachother. We cannot confirm that religious needs are met. Peoples religion is noted in their care records, but it is not always clear whether and how they wish to practice their beliefs, culture and lifestyle. Staff said that no one wants a religious service but that some people used to. The home is located next to a church, where staff confirmed there is a social club that no one attends. There is no religious service attended, and no service Care Homes for Older People Page 20 of 48 Evidence: in the home. The Expert noticed the person bedfast had rosary beads displayed but out of reach. Care records do not show that preferences are reviewed with people, and there are no end of life care plans. Some people have visitors who take them out, otherwise people do not have contact with the community. There is no information about a private telephone for peoples use. We queried visiting hours seen in the the homes published information, 10 am 4pm, and were told that visitors are also not allowed at mealtimes, further restricting this. The owners differed on why this is. It should be based upon the service users views and needs, and not the owners values or culture, with regard to the security of the home. Some people eat better with visitors present, and most homes have more open visiting policies. An owner said they do not discriminate against visitors who work because they can make an arrangement in advance to visit at other times. Our view is that this is unnecessarily restrictive of peoples rights to maintain their relationships; it could be off putting and unwelcoming to visitors. The Expert by Experience and people told us that the food is excellent: tasty, suitable for soft diets, and nutritious with fresh vegetables, but there is no choice of meal. Management told us that people prefer to eat in their rooms, but some people told us they want to choose this daily and want opportunities to socialise. There are no nutritional records and we did not see any food fortification plans, for instance, to increase calorie content for people who eat small portions. People told us they are happy with the food. (also see Environment). Care Homes for Older People Page 21 of 48 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints and concerns are not acted upon, and abuse is not taken seriously. Vetting checks do not ensure people are safe. Peoples rights are not promoted or protected and relevant laws and duties are not known. Adult protection concerns arose during the inspection. Evidence: There is a complaints procedure but no complaints have been recorded since 2006. People and relatives told us of several concerns they raised with management since the last inspection, but none were in the homes log. The matters ranged from a fee dispute to degrading continence care at night, removal of access to the call system or help at night, which are serious matters. Peoples rights have not been promoted or recognised, and risk of abuse or neglect has not been prevented. Management told us that one persons call system was removed after the cord was found around their neck. This was not in the homes accident and incident log and we have not been notified. No alternative has been provided to this person, who has a history of fractures from falls and serious illness. There is an adult protection procedure, and on the office wall there is chart about the local council multi agency protocol. Staff, we are told, have general training about abuse and neglect, but not about this protocol. Staff said they would report any concerns to the manager. The home has a whistle-blowing and bullying procedure, and Care Homes for Older People Page 22 of 48 Evidence: the AQAA said there have been no adult protection concerns. We had recent reports about people being bullied, belittled, intimidated and roughly handled in the home, some of which are plausible from our findings. The day after the inspection we had a report alleging that staff concerns about peoples wellbeing have been ignored and concealed, and that some staff did not have training but have certificates. During the inspection we raised a number of concerns with management, and with the council under their protocol. There are ongoing multi-agency investigations about peoples health, safety and welfare from alleged abuse, neglect and unauthorised deprivation of liberty. The home has an oppressive atmosphere and systems (see Environment). We are concerned at the number of people sedated at night, having restraints and restrictions upon their movement in bed and within the home (by furniture, room layout, door alarms, staff escorts). We found covert liquid medication in the home which did not accompany a person who left with their other medication, and an owner told us they stopped using this in case they were accused of doping people. These are physical and chemical forms of restraint, and without appropriate consent they constitute abuse. Risk assessments do not always include peoples personal safety, including for example wandering, falls day and night, addiction to medication. We saw in 2 peoples care records formal social services review minutes expressing concern in August 08 about restrictions on where meals are taken and visiting arrangements. When we queried what has been done about this, the manager told us that it was not true and that social services agreed to remove this from the minutes. Social services confirmed to us that two workers came to the same conclusions with two separate people and their families, as well as more serious recent concerns. Restraints and restrictions are not recorded in care plans with reasons why they are necessary and proportionate, who has consented or been consulted on least restrictive alternatives in best interests. They are applied regardless of peoples capacity, and complaints have been ignored. The extent of management control of some peoples daily lives and relationships may constitute a deprivation of liberty requiring authorisation if it is necessary. This has not been recognised by staff or management, who are unfamiliar with their legal duties under mental capacity and mental health laws. This is a necessity for homes caring for people with conditions or illness affecting peoples decision making, even temporarily. Access to statutory advocates must also be arranged by the home, as required in law for serious decisions. Care Homes for Older People Page 23 of 48 Evidence: Preventing and safeguarding vulnerable adults from abuse and neglect is not taken seriously by management. We found adults living and working on the premises who did not have the required vetting checks or risk assessment to ensure people are in safe hands. Human and legal rights to confidentiality, privacy, self determination and freedom from abuse, neglect and degrading treatment are not protected. Staff, people and relatives have not been able to report concerns inside the home and have them acted upon, and people feared further intimidation. We saw an owner warning someone to watch what they say to us after we made an immediate requirement. Since the inspection we have not been satisfied that sufficient and timely action was taken to improve peoples wellbeing and safety. Care Homes for Older People Page 24 of 48 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean but measures are needed to prevent the spread of illness and infection. Some rooms are personalised but facilities and equipment prevent independence and access to help. Communal areas are rarely used and do not meet peoples needs. There are risks of slips, trips and falls from the environment, risk of burns from radiator covers, and an oppressive atmosphere that are not being managed. The home is not part of the local community. Evidence: The Expert s first impression of the home is that it is clean, homely, quiet and comfortable, almost luxurious. The location is lovely, by the church which has paths for walks, but it was a surprise to find there are no links with the church or community, and that people are not taken out, even in the homes 3 wheelchairs. There is a busy main road, and people with confusion who may wander could be at risk if they turned the wrong way outside on their own. During our visits an outside door was left unlocked when people were brought downstairs, whom staff told us had confusion. We were never asked to sign a visitors book, which is a fire and safety precaution, and there are no records of visitors to the home. Security and fire safety is not being managed. We saw one person in their bed early morning, which was wedged between an Care Homes for Older People Page 25 of 48 Evidence: armchair and a radiator hot to our touch. The radiator cover has holes near a frail persons hands. There was a risk of burns if they used this to raise themselves in bed. No one is assessed to be at risk of falling from bed, and there is no identified need to use furniture and beds against walls and radiators to restrict peoples movement in or out of bed. Restraints and restrictions such as these, and door alarms on all first floor rooms do not appear on assessments or care plans and they have not been assessed for other risks they may pose. For instance, manual handling can only take place from one side of a bed, which could cause injury to the person and staff. Some peoples rooms are more personalised than others, but some recently moved. People have not participated in decisions about sharing rooms. They do not have all the equipment they need i.e. sensory and mobility aids, access to wheelchairs, bedrails or alternatives if at risk of falls risk from bed, which is likely. Hearing aids and walking aids were not readily available to people. We were told that most people do not have access to the call system, particularly at night. This is not safe in light of other environmental risks, but especially in case of fire, illness, getting trapped or someone falling (some of which has occurred). Waivers about door locks and lockable drawers were reported on earlier. Some waivers date back to 2006 and have not been reviewed with people. They are not accurate about national minimum standards and show us that management do not accept accountability for providing basic secure facilities for peoples valuables or privacy and dignity. Communal toilets have locks, but some peoples toilet and washroom is their bedroom, and there are also no privacy screens in shared rooms. We had reports before and during our visit that there is often a lot of shouting in the home especially at night, including people being shouted at. During our visits it was unusually quiet in communal areas for a care home. When the dogs barked they were shouted at occasionally. An owner often spoke in a loud voice in the hallway or on the stairs to us or staff and about people in an inappropriate manner, or shouted messages to staff or the manager. The atmosphere in the home was not welcoming and was oppressive for people living there and ourselves. We explained that the Expert was there to learn about outcomes for people and would see individuals privately, but three people were brought to the lounge looking frightened and staff remained. This does not usually happen during inspections. We were followed around, our intended whereabouts were asked for several times, and we were interrupted by the owners and staff unnecessarily when talking with people or each other privately. The owners said they didnt think it was right that the Expert sees people alone. Care Homes for Older People Page 26 of 48 Evidence: We had a report before our visit from a professional about being denied privacy and access to people, which was confirmed by our experience. There were no relatives or friends visiting during the inspection, and we wondered if they and people in the home have similar experiences. We noted that no one has access other than through management to a telephone, so cannot speak privately to friends and family. Two people were brought down to dinner or an owner would be upset, said staff. People told the Expert that they had never been in the dining room before, and that this room and the lounge were only used by the family or for special guests, so we must be special. Both wanted to freely choose where they eat in the home and socialise, and could not do so. One felt they were intruding on the owners family space. We explained this to the manager. On our second visit these two people were using the lounge at tea time, but for others there was no change. Two people choose to remain in their bedrooms, but like social visits from others in their rooms. One owner told us how door alarms are used to elicit staff escorts to prevent this (unnecessarily). The Expert advised that the communal lounge and dining room are not furnished and laid out to meet peoples needs for higher seating, removal of hazards, discreet incontinence protection, and foot stools, games and magazines, etc. There is a larger TV in the lounge, appropriate for peoples sensory needs. However it would not be possible to get a wheelchair in either room easily. The Expert advised that older people often prefer armchairs rather than sharing personal space on a sofa, and would find the low soft settees hard to get in and out of, and uncomfortable over long periods. The environment is maintained by the owners or contractors. It is clean with no odours. We sampled water, freezer and fridge temperature checks and found them to be in the safe range, except for medication. We toured the building separately and with the Expert identified various environmental safety risks for people in the home. We discussed falls, slips and trip risks with the manager. The staircase has only one banister and it is too low for some people; carpets are thread bear in places and floors are uneven. A light was out in a toilet. There is buckled lino in the kitchen and in a narrow hallway a stack of kitchen floor tiles is a hazard. There is an outstanding council Environmental Health requirement about this floor. The manager told us on our first visit of various delays relating to costs and claims, and that the contractor could not give a date, but was in the home on our second visit. The AQAA told us that there is an action plan based on best practice for infection control, but we found unnecessary safety and infection control risks which we raised with the owners. The shower has a broken seal. An owner showed us shared toiletries in use for people using the service and family members. These are left out in Care Homes for Older People Page 27 of 48 Evidence: bathrooms along with mops and cleaning materials and pose safety risks to people with confusion, dementia, mental health and sensory disabilities. There was no storage facility in these rooms. We queried toiletries left in the shower, and an owner confirmed a family member left them there - could tell this by the colour and brand. There was no liquid soap, and cloth hand towels were in use in two toilets. We were told that no one in the home has had a contagious infection or illness, but preventative measures needed urgent attention and were not being recognised by quality monitoring checks or health and safety risk management. Care Homes for Older People Page 28 of 48 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff qualifications meet standards, however people cannot have confidence that their needs will be understood and met day and night by competent and knowledgeable staff, and in an emergency. Recruitment, induction and staff development processes do not protect people. Evidence: The AQAA was unclear about the number and gender of staff working in the home, and the number of care hours provided by 5 or 6 staff was low at 40 care hours per week, and 36 support hours. On our visit we were told that there are 4 care staff, and two owners who provide care to people. Most staff have worked in the home for many years, and are related. Agency staff are not used, which provides consistency. Long standing staff have checks that pre-date the Protection of Vulnerable Adults Scheme (POVA List), and the manager confirmed that none have changed position since 2005. We queried the AQAA, as it told us that a worker had been reported to this government list for abuse, but the manager confirmed that the AQAA was inaccurate and he had not understood the question. The AQAA states that all the people who have started work in the home in the last 12 months have had appropriate and satisfactory employment checks, and induction Care Homes for Older People Page 29 of 48 Evidence: training to Skills for Care standards. We were told that a worker left without notice recently but we could not clarify when in their staff file or with the manager. So we could not check if their vetting was undertaken before they started work to confirm the AQAA and records did not confirm competence from a Skills For Care induction. We found other people working and living in the home that have not had required police checks or written risk assessment, which does not protect people. The manager said that a new worker started the week of the inspection to replace a carer who left in February 2009, and that the vacancy had not been advertised. The new worker did not have a file or required documents, and the manager confirmed he had not followed their own recruitment procedure. We were told that the carer was working under the Seniors supervision, trying the job and we are trying her out as she has never worked in care before. However we learned that the new carer starts a shift two hours before the Senior, when she is supervised by an owner and is providing personal care without vetting checks. We could not clarify who was providing an induction to safe working practices. The Expert had to intervene to ensure a persons safety on the staircase as the new worker was not supporting them as they needed and they were having difficulty with the low banister. There is a family member living in the home we were not aware of, who uses communal facilities and left an infection control risk in the shower. We had a report that this untrained family member assisted with manual handling when the manager felt unwell. The manager said that this does not occur for anyone currently in the home. We made an urgent requirement for peoples safety from anyone in regular contact with people in the home. Care staff also clean, do laundry and cook, and an owner shops. During the day there are two staff on duty between 7 am and 9 pm, but we cannot confirm this is seven days a week. Staff assist people to eat in their rooms. We had reports that there are no waking night staff, and although the manager said that the owners take turns, this would be insufficient to meet the needs of a person in the home who requires two staff during the night for safe manual handling. The manager said female staff perform all the personal care, while he does the manual handling, but this cannot be so if there are waking night staff. Although staff have first aid awareness training, this is insufficient to save lives. Only one day shift has a carer trained to be a first aider (for staff), and the owners covering at night are not trained to emergency aid standards. Staffing levels and skill mix do not meet peoples needs. There are no rotas and we cannot confirm that there are waking night staff in the home. Care Homes for Older People Page 30 of 48 Evidence: We confirmed that half the staff have basic NVQ 2 qualifications, that the manager completed his NVQ 4 and registered managers award. Staff have mandatory training, but it was unclear how often this is refreshed and whether all staff have the required three training days per year. Staff have dementia awareness training, which is a basic level course, and should go on to do mental health training, and be familiar with government dementia care strategy so that they can understand the conditions of people in the home and new ways of working. Management and staff also need to understand new laws and duties in respect of mental capacity and deprivation of liberty - there is free training from the council and sources of guidance on the Social Care Institute for Excellence website. Care Homes for Older People Page 31 of 48 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is an experienced and qualified manager, but timely action was not taken to risks and poor systems we identified. Policies are not up to date or followed. People cannot have confidence that the home is run in their best interests with their health, welfare and safety protected. Evidence: The manager has qualifications and long experience in running the home. The Red House is a partnership, and roles are shared by the owners. The manager is responsible for the paperwork, medication system, manual handling, recruitment and formal training, supervision and staff appraisal, health and safety. His partner is responsible for care, shopping and domestic roles and supervises new staff. They are supported by a Senior. However we found a lack of clarity on the Seniors role, particularly regarding oversight and induction of a new worker. No one appeared to be responsible for quality assurance, and satisfaction surveys cannot be trusted. Care Homes for Older People Page 32 of 48 Evidence: The manager completed the AQAA on time but it was not used as an opportunity to assess and compare the homes quality and development of specialist services. The AQAA told us that management are doing things in the way they have for many years, and are not up dating and changing, which we confirmed on our visit. Policies and procedures are not dated, revised in line with legal, regulatory changes and local protocols, and the manager told us that he is aware they are not being followed. The AQAA was found to be inaccurate in a number of regards. This is a legally required record that we use to assess provider fitness, and to form our judgements of service quality and development plans. The home is no longer run in peoples best interests, shows signs of being harmful and must improve. There is a closed culture, including a lack of community links, suspicion of professionals and outsiders, restrictions on visitors, lack of delegation of roles to staff and a lack of transparency. Whilst people told us that the manager is kind, there is a controlling and oppressive approach shared by both owners and that affects every person in the home, whether satisfied or not. A blurred boundary between a personal and professional relationship led to one familys departure and has affected everyone in the home. The approach to dementia care, sensory and mental health and medication shows there are skill and attitude deficits and poor practice that needs to change. People, staff and stakeholders are not sufficiently consulted about choice on offer and about the running of the home. There is no fun in the atmosphere and life of people and staff at the Red House. They have been ignored when they have tried to express views, and frail people have become fearful of managements ability to act - to improve their experience, staff attitudes and behaviour. This is unacceptable. Family style care appears to be inhibiting change and peoples use of the premises. This came as a shock to management. Accountability and quality of care have lapsed at the Red House. Systems and ways of working do not sufficiently benefit people; their quality of life and control over their lives is poor. Recruitment practice puts the needs of management and staff before the needs of vulnerable people to be safe. Staff we spoke to and records we saw show there is insufficient staff supervision and its quality is not meaningful. Staff did not recall having supervision or appraisals but recall signing documents. Training opportunities and staffing levels are reduced to the bare minimum, making only functional care possible, and to improve the service and meet all peoples needs, this will need to be reviewed. Most records about people and staff are not up to date and lack accuracy, particularly about how personal care is provided. Responsibility for record keeping is not shared Care Homes for Older People Page 33 of 48 Evidence: with staff, so the onus is on the manager to consult staff in order to update peoples records. Monitoring records are not used where necessary so that peoples health is protected. Confidentiality is not maintained verbally, but records are securely kept. There are examples in this report of audits and monitoring systems that are not identifying and acting quickly to manage risks, including fire safety, environmental health and safety, infection control, risk assessments, care planning. There are missing services, facilities, policies and forms. Best practice and regulator guidance is not known or used. We have not always been notified about significant events happening to people in the home, such as falls, pressure sores and hospital admissions, so the home are not working with regulators to protect people. The Commission have only been notified of deaths, and we found unreported incidents and accidents that may have been preventable. People cannot be blamed for becoming frail and more dependent; management must provide for the necessary systems, staffing, tools, skills, and knowledge of community services to help them anticipate and meet the needs of people with progressive and end of life conditions. The home no longer assists people to manage their finances, but will occasionally shop for people and we saw that their representatives are billed. One family told us that they have not been asked for any replacement clothing and hope their relative has enough underwear. Vulnerable people in the home are not protected by recruitment and vetting of people in regular contact with service users at the Red House. The manager confirmed during our visit that action will be taken to improve this, and did not think it necessary to have a good practice policy of re checking long-standing staff to promote safety. There are no recruitment strategies to give people choice of gender for help with personal care, and choice is not offered from care records seen. People are being handled by untrained staff, and room layout is making rough handling (and staff injury) more likely. The Commission will be taking further action to ensure there is compliance with the law and improvement, effective leadership and accountability. We are working with the home and with the multi-agency safeguarding process to ensure that peoples safety and needs are met. Care Homes for Older People Page 34 of 48 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 9 13(2) Medication stored in the fridge must be kept in a locked container inside the fridge, keys held by the person in charge (Not Assessed on 06/03/09) 01/06/2007 Care Homes for Older People Page 35 of 48 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 1 18 12 12, 13(6): The registered 09/03/2009 persons must prevent service users being harmed or placed at risk of harm or suffering from abuse. They must conduct the home and maintain good professional relationships with service users so they are not fearful or emotionally pressured, bullied, ignored or roughly handled. Privacy and dignity must be respected at all times. (Not met by 09/03/09) People have a right to live abuse free. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 Up to date comprehensive 29/05/2009 assessment records must include: all needs, abilities and conditions, mental capacity; risks of malnutrition, pressure sores, falls day and night; necessary aids and equipment. Assessments must be reviewed with people regularly, and when there is a change of Care Homes for Older People Page 36 of 48 circumstances; and reflect agreed revision of needs and/or risks. Decisions about moves to, from or within the home must be in keeping with the Mental Capacity Act code of practice. Peoples needs and changing risks should be identified, lawfully agreed, planned for and met. 2 7 15 15(1), 13(7)(8): Up to date 29/05/2009 care plans must be agreed and revised with appropriate consent/consultation about how needs and risks are monitored and met day and night, including all areas in standard 3.3. Detail must include staff roles and instruction on manual handling, aids, equipment and any restraints or restrictions; communication and medication guidelines. They must be known by staff. Peoples needs should be met the way they want, with least restriction, safety and clear instructions for staff. 3 8 13 13(1)(b): The registered 13/03/2009 person must make arrangements for people to access NHS and specialist social care services as necessary so that sensory and mental health needs are assessed. Care Homes for Older People Page 37 of 48 People need good quality of life to maintain or improve their abilities, communication and mental wellbeing. 4 8 13 13(5): Registered persons 29/05/2009 must make suitable arrangements to provide a safe system for moving and handling people who use the service. People and staff need a system of work that will prevent injury. 5 9 13 13(2): The registered 03/04/2009 person must make arrangements for appropriate recording, handling, safekeeping, storage, safe administration and disposal of medicines received into the care home. This includes: - the quantity of all medicines received and any balances carried over from previous cycles are recorded on the medication administration record (MAR); -the practice of secondary dispensing must cease. The right medicine must be checked and administered to the right person at the right time and dose as prescribed; medication records must be accurate and reflect who attempted or administered the Care Homes for Older People Page 38 of 48 medication, completed at the time it is given; -the reason for medication being discontinued and/or quantities disposed of is clearly marked on the MAR, and disposal records must be up to date; -- appropriate daily checks are made of the temperature of the room medication is stored in so that the stability of medication is maintained; - the registered person must ensure that all medication is auditable, and that regular drug audits take place to confirm safety of the medication system and staff competence. People need stable medication for their health, that is administered as the doctor intended. The homes systems must prevent medication going missing for public safety. 6 9 18 18(1)(a): Staff and 03/04/2009 management involved in the medication system must be regularly assessed to be knowledgeable and competent. The registered persons must ensure that safe working practices are known and used by staff, including the induction of new staff. Care Homes for Older People Page 39 of 48 People are protected by safe practice and their health can be effectively monitored. 7 12 16 16(2)(m)(n), 12(2)(3)(4): 29/05/2009 Care planning must promote healthy lifestyles, maintain peoples abilities, interests, relationships and independence. Opportunities for exercise, mental and social stimulation and religious worship must be provided, with individual support if necessary to participate. People must be consulted about a programme of activities. This is so that peoples wellbeing, abilities and beliefs are maintained and they remain in control of their lives. 8 13 12 12(2)(3): Registered persons must not impose restrictions on visits unless requested by people, whose wishes are recorded. Policy and practice must be reviewed and revised. People should be able to have visitors at any reasonable time, social contact with other service users, and private discussions should not be interrupted unnecessarily. 9 16 22 22(8): Registered persons must review circumstances under which complaints will be logged and investigated. 29/05/2009 29/05/2009 Care Homes for Older People Page 40 of 48 People must be informed in writing of their findings and action taken. This is to ensure that concerns raised by people and their representatives are taken seriously and there is action taken to their satisfaction. 10 18 13 13(8): Restraint and restrictions must be recorded, including the circumstances and their nature. Restraint and restrictions must be recorded, including the circumstances and their nature. This is to ensure peoples rights are protected and abuse is prevented if it is proportionate, consented to / justified as necessary. 11 26 13 13(3)(4): Unnecessary risks 13/03/2009 to people from shared toiletries and cloth towels, room layout and radiators must be reviewed and action taken to minimise risk of cross contamination, burns and scalds. (Not met by 13/03/09) People need to be protected from the spread of infection and illness, room layout and radiator covers. 12 27 18 18(1): Suitably qualified staff in sufficient number must be on duty at all times that matches peoples needs, the statement of 29/05/2009 29/05/2009 Care Homes for Older People Page 41 of 48 purpose and the homes layout. The manager must assess and arrange for the level of training staff need in first aid. People need to have confidence that their needs will be met 24 hours a day, with appropriate assistance in an emergency. 13 29 19 19: Risk assessments must 13/03/2009 be put in place and the appropriate level of criminal records bureau/POVA applications made for new people employed or those in regular contact with service users in the home. New workers must not commence in the home until all information and documents specified in Schedule 2, Care Home Regulations 2001 and amendments are obtained. They should not be confirmed in post until there are full satisfactory recruitment checks, including police and government lists, two appropriate references, their authenticity checked and explanations of employment gaps explained. (Not met by 13/03/09) Peoples safety must be ensured at all times. 14 30 18 18(1), 12(1)(a)(b) : 29/05/2009 Registered persons and staff must have training Care Homes for Older People Page 42 of 48 appropriate to their roles, length of service and peoples needs. Staff must not undertake roles beyond their training and competence: New staff must have a progress record and appropriate timescale to complete foundation training to Common Induction / Skills For Care standards. Staff employed beyond six months must have a minimum of three days training per year, and mandatory training must be updated at appropriate regular intervals. Lack of knowledge, and skills in new ways of working should not leave people vulnerable or their expectations unmet. 15 33 12 12(1): Policies and procedures must be dated, regularly reviewed, known to staff and followed by management. People need confidence that there is accountable leadership, the home is run in their best interests and using best practice. 16 37 17 17(1), Schedule (3): 29/05/2009 Accurate and up to date records of service users, incidents and accidents must be kept. 30/06/2009 Care Homes for Older People Page 43 of 48 This is for the protection of people, accountable leadership, and effective running of the service. 17 38 37 37: Notifications to regulators, including the Commission and under Riddor, must be made in accordance with current guidance. This is to comply with the law so that health, safety and welfare are protected. 18 38 24A 24(A): Registered persons 08/05/2009 are required to produce an improvement plan with timescales, and keep the Commission updated on progress from the inspection report and in complying with the law. The AQAA requires accuracy. People need to have confidence that the home is run by accountable management in their best interests, with timely action for their health, safety and welfare. 29/05/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The statement of purpose and service user guide should be available in accessible formats, and set out accurate information about fees, visiting, staffing and night time care arrangements so that families can decide if the home Care Homes for Older People Page 44 of 48 is suitable. 2 2 Contracts should be renewed and signed by people / representatives if there are room changes proposed, and services included in the fee should be clear. This will ensure that there is a consultation process on moves, and disputes can be avoided. Staff need detailed information in care plans to monitor peoples health conditions and medication effects, communicate with people and ensure their sensory and mobility aids are accessible. It is recommended that a Controlled Drugs Register with numbered pages is used to record Schedule 2 drugs, in addition to the medication administration record as an extra precaution so this medication does not go missing. A doctor should be asked to review occasional use or as required medication required regularly so that people have access to sufficient pain relief, and toxic effects and drug dependence can be avoided. Links with the local community should be made by the home so that people have opportunities for participating in community life in keeping with their preferences. The Commission and funding authorities have statutory and contractual rights to visit people in the home privately, without escort, as well as anyone they authorise. Management need to review their approach to all visitors. A visitors register needs to be signed so that the home know who is on the premises in case of fire. Inventories of personal possessions should be kept up to date, and checked so that the need for replacement clothing is decided in partnership with families and representatives. People need to maintain independence and decision making control through access to advocates and daily choices offered by the home for food, where meals are taken, variety and opportunity of activities, exercise, orientation, reminiscence. The Mental Capacity Act 2005 and Mental Health Act 2007 and codes of practice must be known and used as necessary so that peoples rights are met with least restriction, and Deprivation of Liberty Safeguard authorisations are sought when necessary. A new policy and procedure is needed and access to national forms. The adult protection and whistle blowing policy and procedure need revision so that it matches and ensures there is a link to the multi-agency council protocol. Training 3 8 4 9 5 9 6 13 7 13 8 14 9 15 10 17 11 18 Care Homes for Older People Page 45 of 48 of staff should include how this local protocol works. 12 20 The design and layout of communal areas should be reviewed so that it is accessible to people with disabilities. The use of wheelchairs for people unsteady on their feet should be considered so that people are encouraged to use communal areas and have short outings in the churchyard. Storage facilities need review for so that hazards from toiletries, mops and cleaning materials are avoided for people with sight impairment and confusion. There must be an accessible call system in rooms people use, where people have a need to reach help. Sharing a room should be a positive choice, and a privacy screen should be used for peoples dignity. Door locks should be readily available so that people have daily choice about privacy. Each room should have a lockable facility for people to store money, valuables, and medication if assessed to be safe. The council Environmental Health office has advice on health and safety risk assessment in Care Homes, including the safe range for radiator surface temperatures and making heating sources safe. This should be used to review the homes health and safety monitoring system. Fire safety precautions and security arrangements of doors that lead outside should also be reviewed. The Health Protection Agency and Department of Health websites have information on infection control best practice. This should be used to review and improve the homes health and safety monitoring system. It is strongly recommended that planned and actual rotas are kept so that staff roles and hours are clear and there is a record of how this has been revised to meet peoples changing needs and the smooth running of the home. Sufficient staff hours, knowledge and skills are needed to provide stimulation and exercise so that people with complex needs maintain communication, mental capacity, social skills and healthy lifestyles. It is recommended that staff have opportunity to learn and rehearse new ways of working to provide dementia and mental health care. The manager should keep up to date on changes in law, regulations, statutory duties, regulator guidance, best practice and new ways of working for accountability and leadership. Opportunities should be reviewed to obtain the views of people, visitors, professionals and staff about the running of the home. Staff meetings should be held for mutual Page 46 of 48 13 22 14 15 16 22 23 24 17 25 18 26 19 27 20 30 21 31 22 32 Care Homes for Older People support and continued learning. 23 35 Policies and practices should be reviewed so that peoples money and valuables, interests and choice are promoted and safeguarded. Staff should be clear on their roles, be supervised at least six times a year, and have meaningful regular appraisals of their knowledge, performance, and development needs. We recommend audits of privacy, safe working practices and quality of care as well as observed practice is used to confirm competence, which is also informed by . The owners competence should be observed and confirmed by an appropriate independent arrangement. The manager should ensure that confidentiality about people is maintained and use of stigmatising and objectifying language is eradicated so that staff demonstrate to people that the homes Charter of Rights is in use. All documents in the home should be dated and indicate who wrote/agreed to them. Incidents and accidents need regular analysis to identify any patterns, systems, practice or environmental action that can be taken to avoid recurrence for peoples health and safety. Systems for monitoring health and safety, medication and infection control should be established and records kept of findings, actions planned and taken. The homes risk assessments must demonstrate regular review, revision and when action is taken so that they are up to date and reflect best practice. Both should be used regularly to learn and develop the service. 24 36 25 37 26 27 37 38 28 38 Care Homes for Older People Page 47 of 48 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 48 of 48 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!