Inspection on 25/02/09 for The Royal Star & Garter Home

This inspection was carried out on 25th February 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Royal Star & Garter Home Tudor Coppice Monkspath Hall Road Solihull West Midlands B91 3DE     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: Karen Thompson     Date: 2 6 0 2 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 35 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 35 Information about the care home Name of care home: Address: The Royal Star & Garter Home Monkspath Hall Road Tudor Coppice Solihull West Midlands B91 3DE 01217116329 02084398002 solihullenquries@starandgarter.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): The Royal Star and Garter Home Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 60 Number of places (if applicable): Under 65 Over 65 0 60 0 dementia old age, not falling within any other category physical disability Additional conditions: 60 0 60 The maximum number of service users to be accommodated is 60. The registered person may provide the following category 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 (OP) 60 Dementia (DE) 60 Physical Disability (PD) 60 Date of last inspection Brief description of the care home The Star and Garter is a purpose built nursing home. Residents accomodation consists of four wings over two floors with all residents areas accessible by lifts, located in the centre of the building. All bedrooms are single and have an ensuite facility.Communal spaces include lounges and a dining room on the ground floor. The home provides Care Homes for Older People Page 4 of 35 Brief description of the care home twenty-four hour nursing care for up to sixty people. there are a range of aids and adaptions designed to assist in the management of residents with restricted mobility. Fees at the time of the inspectin ranged from £522 to £815. For up to date fee information the public are advised to contact the home. Care Homes for Older People Page 5 of 35 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 focus of this inspection undertaken by the us is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information to plan the inspection, which included notifications received from the home and an Annual Quality Assurance Assessment (AQAA). This is a questionnaire that was completed by the manager and gave us information about the home, staff, people who live there and any developments since the last inspection and their plans for the future. Two inspectors undertook the fieldwork visit carried out over two days. They were assisted by a pharmacy inspector on the first day who under took a medication Care Homes for Older People Page 6 of 35 inspection. The registered manager was available for the duration of the inspection. The home did not know we were coming on the first day. At the time of the inspection forty five people were living in the home and information was gathered from speaking to and observing people who lived at the home. Three people were case tracked and this involved discovering their experiences of living at the home by meeting and observing them, looking at medication administration and care files and reviewing areas of the home relevant to these people in order to focus on outcomes. Case tracking helps us to understand the experience of people who use the service. Staff training records and health and safety files were looked at. At the time of the inspection three people who lived in the home, two visitors and four members of staff were spoken to in order to gain their views and comments. Surveys were distributed by the inspectors and by the home to people living at the home, relatives and staff at total of twenty in each category. A total of forty one surveys were returned to us. Following the inspection we sent a warning letter to the organization about medication, care planning, risk assessments, safeguarding awareness and notifying us of any events that effect the well being of people living in the home. The provider has advised us that they are taking these concerns seriously and there has been a review of the management structure in the home. We will continue to monitor the home to determine the progress in meeting peoples needs and take appropriate action where necessary. The weekly fee to live at the Star and Garter is between 540 and 680 pounds for people. Items not included are hairdressing, chiropody and toiletries. For up to date fee information the public are advised to contact the home. What the care home does well: What has improved since the last inspection? What they could do better: The medicine management must improve to safeguard those people that live at the home. All the systems must be improved to ensure that all the medicines are administered as prescribed and records reflect this. Care planning records must be an accurate reflection of the care being provided in what ever form it is kept in either paper or electronic. Care planning needs to reflect the individual needs and be based on a comprehensive a assessment. Robust risk assessments must be carried out and finding of these linked into the delivery of care which promotes those living at the homes rights and risks. Communication between the staff teams and within teams needs to improve to ensure that persons living at the home have their needs fully meet. Staff knowledge about safeguarding, mental capacity, complaints and whistle-blowing needs to improve and be supported by a comprehensive training program me. Care Homes for Older People Page 8 of 35 Records of all staff and the emploment process must be kept at the home. An overview of training that has occurred must be available in the home to demonstrate training has taken place and so that shortfalls can be identified and acted upon. Accurate accounts of events in accordance with regulation 37 to us so that these can be monitored in between inspections. It is important that the home keeps up to date infomration at the home of all aspects that impact on the lives of people who live there and inform us of serious accident and incidents. Management systems need auditing to identify those that are failing and the appropriate structures put in place to rectify these. 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 35 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 35 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. Pre-admission assessment was consistently comprehensive but not all staff were aware of the needs of people moving into the home. People can not be fully assured that they have all the necessary information so they can make an informed choice about moving into the home. Evidence: The certificate of registration was clearly displayed for people to refer to. We were given a copy of the Statement of Purpose and Service Users Guide. These documents provide prospective users of the service with information about the services that the home provides to assist them in decision making. The Service Users Guide did list what was include in the fees to be paid but needs to include the range of fees the home charges. The home provides care for people who require long term nursing care. One person living at the home was unsure whether they had received a Care Homes for Older People Page 11 of 35 Evidence: Service User Guide. The home has a moving in co-ordinator who deals with initial admission enquires and liaises with both the prospective person who wishes to live at the home and other people concerned. The home has an admission and discharge policy and procedure. People are encouraged to visit the home before moving in to view facilities, meet staff and other people living at the home in order to sample what it would be like to live there. One set of relatives spoken to stated that they had been able to visit the home on a Saturday. They had found the moving in co-ordinator helpful. Not all care staff spoken to knew who the moving in co-ordinator was or what their role entailed. On the first day of the inspection a person was moving into the home, staff did not know what potential care needs this new person had. Staff should know the needs of people on admission to ensure that moving in is as smooth as possible and well being is promoted and protected. Contracts were not seen on files of people who lived at the home, we were however provided with a draft copy of the contract which meet the standard. This should be given to each person on arrival or their relative and a signed copy kept by the service. Care Homes for Older People Page 12 of 35 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. The arrangements for meeting peoples health and personal care needs including medication are not always being adequately, consistently and appropriately met which may result in needs not being met. Evidence: The care records of three people living at the home were looked at in detail and other records sampled. The home has two sets of care records one paper and one stored on computer. The home also have separate records kept by the physiotherapists. Not all staff have access to the computer records. There have been a number of the homes own staff and agency staff providing care who did or did not have access to the computer care records and the paper care records did not match with the computer records. This means staff providing care for people living in the home do not have a comprehensive picture of how to care for someone. Carers were asked what they would do if a trained agency member of staff had a query about someone living in the home. They informed us that they would send them over to speak another member of trained staff orking on another wing. Whilst in some instance this is good practice, it is Care Homes for Older People Page 13 of 35 Evidence: important that information is easily available to all persons working at the home to ensure that they know the needs of people living in the home. Some staff were able to tell us what the care needs of people living in the home were and we could be confident that their needs would be meet but in some instances this was not the case. Staff do receive handover and this was observed to be taking place, handover sheets were available with basis information but despite this some members of staff were unsure of peoples needs. It is concerning on two levels in that planned for needs may not be met and any changes in condition may go unnoticed and led to a reactive approach to care. It was seen that written care records were not always signed or dated. A number of risk assessments had not been completed in both the computer and written care records. Some risk assessments completed for bedrails were not always completed properly which made them invalid and may possible place people living at the home at risk injury. One person living in the home with high levels of confusion was found to have bedrails in place but the risk assessment had only been partially completed, therefore it could not be demonstrated these were in place for this persons benefit. The bed rails risk assessment is accompanied by restraint form these were found not to be completed as is required in the policy and procedure in relation to this. We had been informed of a person with a wound, prior to this visit, staff agreed with this information, however the records stated that the wound was in a different site. This may cause confusion and result in poor care. It is concerning that staff had repeatedly recorded on the computer record that was incorrect had either not noticed this or failed to ensure the information was correct. The records were amended during this visit. Care records sampled for people living on the dementia unit made no reference to how their condition impacted on their needs and how staff could help to meet these. Good interaction was observed between staff and people living in the home. People living on the Roundel unit (the unit specialising in dementia care) were observed to have signs of well being. We have been aware of behaviour that is challenging by notifications to us, records did not demonstrate that episodes of this type of behaviour is recorded in such a manner to allow it to be analysed to establish whether any triggers were the cause. This means both the person concerned, other people living at the home and staff are left in a vulnerable position and their well being compromised. The provider has set up a retained GP service who visits twice a week, they have also ensure that collection of possible specimens e.g blood or urine coincides with this GP Care Homes for Older People Page 14 of 35 Evidence: visit. This is to be commended at it ensure that delays are minimized in obtaining a diagnosis. The home also employs a physiotheraphist. This helps to is also to ensures treatment and theraphy to support movement, balance and function and to enhance independence with activities of daily living for people living at the home. The home provides no intermediate care. The pharmacist inspection took place on the first day of the key inspection. It lasted five hours. Three wings were currently open and all were inspected. Eight residents medication was looked at, together with their Medicine Administration Record (MAR) chart and care plans. Three nurses were spoken with during the inspection. All feedback was given to the manager at the end of the inspection. The medicine management was poor, resulting in a warning letter being sent to the provider. Failure to improve will result in further enforcement action. The home has four units all with their own dedicated medication room. The temperature in the three currently used were all too hot to safely store medication in compliance with their product licenses. We, the commission, were assured that quotes were in the process of being obtained for the installation of an air conditioning system in each medication room. There were only two Controlled Drug cabinets in the home, and on was in use. This meant that staff from one unit had to walk through the secure dementia unit to obtain the controlled drugs for residents in the other units. The manager has agreed to purchase and install a Controlled drug cabinet for each unit. The home has installed a system where it sees all the prescriptions prior to dispensing and copies these to check the dispensed medicines and MAR charts received into the home. This though was not undertaken in all units. One unit had no evidence that they safely checked in all the prescriptions and medicines received into the home. Any discrepancies therefore could not be addressed. Not all quantities received or carried over from previous cycles had been recorded so it was difficult to audit and demonstrate whether a medicine had been administered correctly in these instances. The home should be accountable for the safe handling of medicines and be able to demonstrate this at all times. Whilst the manager has installed a quality assurance system to confirm that the medicines are administered as prescribed, this failed to identify the errors evidenced Care Homes for Older People Page 15 of 35 Evidence: during the inspection. Many medicines had been signed as administered when they had not been. Some were unaccounted for and it could not be demonstrated where they were. Medicines had not been administered if the resident was asleep and in the morning when rising late, there was no information to show that the medication was offered later in the day. One resident did not receive his prescribed medicines which may be detrimental to his welfare. In one instance nursing staff administered medicines from two boxes present in the trolley. As no quantities received had been recorded it was not possible to confirm that this had been administered correctly. A second resident had two strengths of medicines prescribed, but only one strength had been recorded on the MAR chart. A full box of the 16mg capsules was counted even though staff had signed to record they had administered 17 of these. Another box of the same medicine but half the strength was counted. This had not been recorded on the MAR chart as it should have been. The dose was 2 x 8mg( = 16mg). One capsule was counted left from the 28 dispensed in this box indicating that a some point only one was administered and not two. Again it was difficult to demonstrate exactly what had been administered. One medicine had the liquid dose written in milligrams and not the liquid equivalent of milliliters. Each dose would then have to be worked out. This may lead to errors in the administration as the nurses may inadvertently administer the incorrect dose. All doses should be clearly recorded to remove any risk of potential error. The home had a homely remedy policy enabling nursing staff to administer medicines for minor ailments for a maximum of 48 hours before the doctor is informed. Is was seen that the nursing staff routinely administered one homely remedy for four days and no doctor had been informed. This is in breach of their own policy and of concern. During the inspection one resident required a medicine to treat his symptoms. The nurse went to the medicine trolley and prepared the medicine and took this to the resident. At no time did she check the medicine chart to confirm whether it had already been administered before the administration. The care plans were poor. Not all the clinical information had been recorded and those that had were recorded under obscure headings. For example, one resident had his prescribed medication for angina and a diuretic recorded under the end of life care plan. A second entry regarding these medicines was also under pain control. It was unclear why they were recorded in these sections and not under a specific care plan for angina and heart disease. Other information was just not available. Many residents had changing clinical needs as you would expect in a nursing home but these were not reflected on the care plans. Some clinical conditions had no supporting care plans at all. It was not possible for example to track why some residents had been prescribed Care Homes for Older People Page 16 of 35 Evidence: some of their medication. Regular reviews of the care plans that had been completed information in relation to changes in condition had not been recorded. For example, one resident needed two inhalers, one to prevent and one to relieve the symptoms of asthma. The reliever was administered on a regular basis. The records stated she was more breathless but to continue to give the inhalers. No review had been sought with the doctor to discuss her declining clinical condition with a view to changing her inhalers. Agency staff have no access to the electronic care plans. This means that they are looking after the residents without any knowledge of their clinical conditions. This has also resulted in agency staff not recording in the electronic said that the doctors book was not always completed and therefore she was unsure if the doctor had visited or the outcome of the visit so it cannot be guaranteed that all the information is being recorded at all. Care Homes for Older People Page 17 of 35 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 living at the home benefit from a wide variety of activities which enables them to live a stimulating and fulfilling life. A varied and nutritional balanced diet is available ensuring that people living at the home have they dietary needs met. Evidence: The home has arrangements in place to provide a range of activities for people living in the home. The home has an activities coordinator who we spoke to during the inspection and who was able to demonstrate that they were aware of peoples activities and social needs and how they were being tailored to meet these needs. A list of planned activities was observed on notice boards in the home. The reception area in the home is large and airy with tables and chairs distributed around this space. People visiting the home were observed to be using this space. A number of activities were observed to be taking place in the home. On the first day of the inspection people had gathered to hear a piano player while on the second day people living on the Roundel unit were seen watching a Charlie Chaplin film together. Similary in the reception are there was an uncompleted jigsaw which the manager Care Homes for Older People Page 18 of 35 Evidence: explained was there for anyone to have a go at completing. Tea and coffee were also available to anyone visiting the home. The home was in the process of recruiting volunteers to enhance the lives of people living in the home, this will be discussed further in the staffing section of the report. There was no evidence of rigid rules or routines in the home and people who live there can go outside on their own or with friends, family or care staff as they choose, depending on their ability. There is flexible visiting at the home to enable people living at the home to maintain contact with friends and family at times that suit them and relatives confirmed this. Lunch was observed on both days in the main dining room area on the ground floor of the home. The inspectors had a meal in the main dining room at lunch time which was well presented. Staff were observed to assist people living at the home discreetly and appropriately. The menus were shown to the inspectors and this demonstrated a good variety of choice. The kitchen closes at 19:00hrs a choice of snacks is available after this time for people living in the home. The kitchen was observed to be both well run and clean. A good supply of fresh fruit and vegetables was seen observed in the kitchen ensuring a variety of food textures which enhances a meal. There was a range of comments in relation to food these included: very nice, menu could be improved. Meat not up to standard necessary for residents of advanced age. Supply of yohurts not consistent., poor chocie for people of our age and disability , food is very good. Surveys result from thirty three people living at the home when asked to comment on whether they liked the meals found that twenty said they always liked the meal, one usually liked the meal, four said they sometimes like the meal and eight did not answer this question. Care Homes for Older People Page 19 of 35 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems for picking up and recognizing complaints sometimes work and sometimes dont. Not all residents are safeguarded appropriately and this can affect their health and well being. Evidence: The homes complaint log contained a variety of complaints. We received thirty three surveys back from people living at the home, twelve stated they knew how to make a complaint, seven did not know how to make a complaint and five did not answer. They were in relation to medication management, care practice and social concerns. The home has a complaints policy and procedure and the Service Users Guide contained a copy of this. This procedure however needed to be amended to reflect the change of the Commissions title. The home has a system in place to record the investigations and the outcomes of any concerns or complaints. Relatives told us they had no concerns. Staff were found in some instance not to be aware of the complaints procedure and how to assist people living at the home to facilitate this. The homes policy and procedure in relation to safeguarding people who live at the home met the standard. The policy and procedure referred to the need to follow the local guidance, this was not available in the home at the time of the inspection. The Care Manager assured us that they would obtain a copy of the local guidance. We are however aware that the home has initiated a safeguarding referral recently. Care Homes for Older People Page 20 of 35 Evidence: Staff spoken to had not received mental capacity training and were not aware of this important piece of legislation and its impact on how care needed to be delivered. Staff at induction should have received safeguarding training. Staff knowledge on safeguarding was varied ranging from good to poor. Knowledge deficits were in relation to types of abuse, knowing what to do and the process. On further investigation it appears that not all staff may have attended the safeguarding training during their induction period due to other work or life commitments. Staff were also found to be unaware of the whistleblowing policy and procedure. The home has a restraint policy and procedure which identifies the use of the restraint risk assessment form. There was no evidence to indicate that the policy and procedure had been followed. Care Homes for Older People Page 21 of 35 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. This is a purpose built home built to a high standard. People living at the home live in a comfortable, clean and pleasant environment. Evidence: The home has been built to a high standard. The home has three floors. The first two floors are devoted to people who live in the home. These two floors are split into wings. There are four wings of which three are occupied at present. One wing of the home is devoted to caring for people with dementia. Each wing has a kitchenette area for the making of drinks and light snacks which were being used by staff to provide refreshments for people living at the home. The corridors are wide and spacious. Armchairs were observed around the home as well as on the wings. This means people can move about and rest if needs be. The home has a roof area which people can go out onto. A premises and grounds risk assessment needs to be carried out however and this was discussed with the manager. The home has an overhead hoisting to assist people living in the home with moving and handling. During the inspection we discovered that the call bell system had not been working on a number of occasions. Care Homes for Older People Page 22 of 35 Evidence: The homes laundry is on the third floor of the home. This was found to be clean and well organised with all the appropriate machinery to ensure clothes are laundered to a high standard. Care Homes for Older People Page 23 of 35 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. It can not be guaranteed due to insufficient evidence at the time of the inspection as to whether staff numbers, training and knowledge meet the needs of people living at the home. Evidence: Staff files were not available for us to inspect recruitment practice. We were informed that these were at the Richmond home. Following the inspection we were informed that all staff files in relation to recruitment for staff working at this home were now being held at the home. All records pertaining to the running of the home must be kept at the home unless permission has been given by us. At the time of the inspection permission had not been granted by us. Staff recruitment will be looked at at the next Inspection. The home was unable to supply the original copies of staff rotas we asked for, for the months of December and January. The home has adopted a policy of destroying rotas after six weeks. All paperwork pertaining to the running of the home must be kept for a minimum of three years from the date of the last entry. We wanted to look at the rotas for these months to check the staffing levels as we were aware of a number of incidents occurring around this period. From our observation of the two days however staffing levels appeared to be meeting the current needs of people living in the home. Care Homes for Older People Page 24 of 35 Evidence: During the day there was a trained nurse on each unit along with four to five care staff. Care staff were supported by ancillary staff such as catering, laundry and domestic. Staff spoke positively about their induction. Staff knowledge about safeguarding was found to be poor for some members of staff. When this was discussed with the management team at the time of the visit it appears that even though staff receive safeguarding training during induction, this may not have occurred in all instances. We were informed that staff may not have received the comprehensive training package that was in place due to other commitments. Induction programmes are vital to laying the foundations for good care and whilst the induction programme looked impressive if it is not carried out in a comprehensive way staff will have gaps in their knowledge which may ultimate effect the well being of those living in the home. The training matrix we were told was held at head office, we were advised we could have a copy of this but it was not up to date. We decided not to have a copy as this would not give an accurate picture. Staff did tell us they had received manual handling training and advised us they did not transfer or assist anyone with out this training having taken place first. The home supplied us with figures that indicate that approximately fifty percent of employee have National Vocational Qualification (NVQ) 2 or above. Evidence to support this will be checked at the next inspection. Care Homes for Older People Page 25 of 35 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. People can not always be confident that the service is run in their best interest. Evidence: At the time of the inspection we were assisted by a Care Manager. Following this inspection we have been informed by the providers representative that the homes Care Manager had left. The provider has been informed of a number of concerns that we identified both in writing and via telephone discussion following the inspection. The provider had put in some good management systems for the running of the home however these were not found to be working in a number of instances. For example the home was new and employment of a moving in co-ordinate to cope with the high volume of people moving in, is to be commended. This provided everyone involved with one point of contact. Relatives of people who had lived in the home for some period informed us they had no concerns but if they did they would go to the moving in co-ordinate while staff on Care Homes for Older People Page 26 of 35 Evidence: the other hand were unaware that the home employed a moving in co-ordinate. Not all relatives we had contact with were aware of the management structure. Relatives and people living at the home should be familiar with the rest of the management team to raise concerns with and staff should be aware of how the admission process works for new people coming into the home at all. Ther quality assurance systems were not looked at in depth due to the home only being open for six months. A variety of quality assurance auditing systems were in place. We did encounter problems with record keeping. Record keeping was problematic in this home as evidenced in health and personal care,complaints and safeguarding and staffing. Whilst there is some very good management practice occurring in the home, others could be seen as very poor and reactive to situations. Concerns were expressed at the time of the inspection and with the provider representative post inspection about reporting to the Commission of incidents that effect the health and well being of people living at the home. We received a number of regulation 37 notifications which were checked at the inspection with records held at the home such as accident records and daily report records. It was concerning that information for all three of these records was not consistent. One example was a regulation 37 sent to us for an incident that read as a minor event. However on reading the accident and care records for this particular event it was quite clear it was a serious incident but both these records contained different information about the same event. This brings into question the validity of the record keeping in the home. Good audit trails feed into the quality assurance systems of the home and if these are poor or flawed then ultimately the health and well being of people living at the home is compromised. Staff informed us that on occasions staffing morale had been low. In some instances this was put down to the use of agency nurses but staff also could not or would not pin-point the actual cause of this. The Annual Quality Assurance Assessment was returned to us in timely manner. Clarification was sought on a number of issues and this was not immediately obtained at the inspection, indicating that the form was not necessarily completed with full understanding of how the home worked. The home only manages a small number of peoples money and they do not act as appointee for anyone living at the home. There are good systems in place for management and safe keeping of peoples money with records being kept of transactions along with receipts. It is recommended that for all transactions two signatures are recorded. Also the hairdressing receipts should be individual and not grouped Care Homes for Older People Page 27 of 35 Evidence: Health and safety records were not looked at during this inspection. The building is new and has been signed off by the building regulator and fire service. These records will be looked at in detail at the next inspection to ensure maintenance and servicing is taking place. Care Homes for Older People Page 28 of 35 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 29 of 35 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 7 15 People and staff living at the 26/06/2009 home should have access to all their records at a time of their choosing. Staff should be able to facilitate this in a timely manner so that information about how to meet needs is available. This to ensure the health and wellbeing of people living in the home. 2 7 12 Care plans must be based on a though assessment of needs and show how care is to be delivered. Care plans must be accessible to the staff delivering the care and be a reflection of the care being given. Care plans must be reviewed and amended at the point where a persons needs change or routinely and staff must be aware of these changes. 26/06/2009 Care Homes for Older People Page 30 of 35 This is to ensure the health and well being of people living in the home 3 7 13 Where bedrails are fitted 19/06/2009 and used there must be a risk assessment that determines that this is the best option and ensures that they are fitted covered and maintained This is to make sure that everyone is kept safe 4 9 13 All nursing staff must read 26/06/2009 the medication polices. Further training must take place if staff fail to adhere to them. This is to ensure that all staff follow safe and correct procedures to handle medication safely. 5 9 13 A quality assurance system 19/06/2009 must be installed to assess staff competence in their handling of medicines. Appropriate action must be taken when these indicate that medicines are not administered as prescribed and records do not reflect practice, to ensure that all medicines are administered as prescribed and this can be demonstrated. This is to ensure that individual nursing staff practice is assessed on a regular basis and appropriate action is taken if audits indicate that nurses Care Homes for Older People Page 31 of 35 do not administer the medicines as prescribed. 6 9 13 All medicines must be stored 19/06/2009 in compliance with their product licenses. This is to ensure their stability 7 9 13 The medicine chart must 19/06/2009 record the current drug regime as prescribed by the clinician. It must be referred to before the preparation of the service users medicines and be signed directly after the transaction and accurately record what has occurred. This is to ensure that the right medicine is administered to the right service user at the right time and at the right dose as prescribed and records must reflect practice 8 9 13 A system must be installed 19/06/2009 to ensure that all nursing staff check the prescription prior to dispensing and check the dispensed medication and the medicine charts received against the prescription for accuracy and all discrepancies are addressed with the healthcare professional. The quantity of all medicines received and any balances carried over from previous cycles must be recorded to enable audits to take place Care Homes for Older People Page 32 of 35 to demonstrate the medicines are administered as prescribed. This is to ensure that the audit trail for all medicines is seen and all medicines are administered as prescribed at all times. 9 16 3 The home must ensure that staff are trained and knowledgeable about the safeguarding procedures. To ensure all peoples are protected. 10 32 8 Regulation 37 notifications must be an accurate reflection of events occurring in the home so that the Commission can monitor the home appropriately in between inspections. 26/06/2009 19/06/2009 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 2 1 3 The Service User Guide needs to contain the range of fees charge by the home. Staff need to be provided with information that will ensure they are aware of new peoples needs on moving in so these can be meet in a timely manner. Staff need to be aware of the role of the moving in coordinator so that this ensure smooth transition for people moving in. Risk assessments must be completed accurately and when a course of action has been determined this must be adhered to or the reasons why not recorded. Page 33 of 35 3 3 4 7 Care Homes for Older People 5 6 7 8 9 16 Training must be provided to staff that work with people who are assessed as having behaviour that challenges. It is recommended that each unit has its own Controlled Drug cabinet that complies with current regulations. It is recommended that the home obtain a copy of the Dept of Health guidance Mental Capacity Act 2005 core training set published July 2007 and staff are provided with training, so that staff are aware of their responsibility and peoples rights are protected. The home should obtain a copy of the local safeguarding policy and procedure to ensure they have all the information available to enable them to make a swift referral. Staff should be familiar with the Whistleblowing policy and procedure so they are aware of how to raise concerns. Staff should be familiarized with the complaints policy and procedure so they can enable people living at the home to raise concerns. Staff should be familiar with the restraint policy and procedure and how to ensure persons living at the home have their rights and risks protected. A grounds and premises risk assessment to ascertain formally whether there are any risk and what measures need to be put in place to reduce these risks. The home should obtain individual hairdressing receipts for people whose money it is looking after, to comply with data protection. The home should obtain two signatures for any persons money that they are safekeeping to provide a comprehensive audit trail The home should review how information is recorded to ensure that no misconceptions occur and that there is a clear and accurate audit trail of events. 8 17 9 10 18 18 11 18 12 20 13 31 14 32 15 37 Care Homes for Older People Page 34 of 35 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. 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