Inspection on 20/04/09 for Treetops Care Home

This inspection was carried out on 20th April 2009.

CQC found this care home to be providing an Adequate 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Treetops Care Home 09/11/09

Treetops Care Home 24/07/09

Treetops Care Home 07/01/09

Treetops Care Home 28/05/08

Treetops Care Home 15/11/07

Treetops Care Home 16/04/07

Treetops Care Home 01/08/06

Treetops Care Home 03/01/06

Treetops Care Home 08/03/05

Treetops Care Home 04/11/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 10/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Treetops Care Home 23/25 Station Road Epping Essex CM16 4HH     The quality rating for this care home is:   one star adequate 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: Michelle Love     Date: 2 0 0 4 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 39 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 39 Information about the care home Name of care home: Address: Treetops Care Home 23/25 Station Road Epping Essex CM16 4HH 01992573322 01992570241 treetopsepping@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Epping Care Home Ltd care home 52 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 52 persons) Date of last inspection Brief description of the care home Treetops Care Home is a large detached property set in a residential area within five minutes walking distance of the town centre of Epping. Epping Care Home Ltd owns the home and the manager is Hayley Dawkins. Treetops Care Home is located close to the railway station and a bus service runs regularly. Local shops, banks, post office, library and other facilities are within easy reach in Epping Town centre. This is an adapted property that provides accommodation for older people on four floor levels, which are serviced by passenger lifts. Premises refurbishment work is currently taking place. The home provides a residential care service for older people. Care Homes for Older People Page 4 of 39 Over 65 52 0 0 7 0 1 2 0 0 9 Brief description of the care home The fees at Treetops Care Home range from between 550.00 and 600.00 per week. There are additional charges for items of a personal nature. These should be discussed directly with the home. Care Homes for Older People Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key inspection. The visit took place over one day by two inspectors and lasted a total of 22 hours, with all key standards inspected. Additionally, a pharmacist inspector examined the homes medication practices and procedures. Progress against previous requirements and recommendations from the last key and random inspections were also inspected. Prior to this inspection the manager had submitted an Annual Quality Assurance Assessment. This is a self assessment document, required by law, detailing what the home does well, what could be done better and what needs improving. Information given in this document has been incorporated into this report. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. A partial tour of the premises was Care Homes for Older People Page 6 of 39 undertaken throughout the day, residents, peoples representatives and members of staff were spoken with and their comments are used throughout the main text of the report. Prior to the site visit, surveys for residents, staff and healthcare professionals were forwarded to the home for distribution and for people to complete and return to us. Where surveys have been returned to us, comments have been incorporated into the main text of the report. The manager, deputy manager and other members of the staff team assisted us on the day of the inspection. Feedback of the inspection findings, were given as a summary to both the manager and deputy manager. The opportunity for discussion and/or clarification was given. Following the last key inspection to the home on 23rd October 2008, where concerns were raised in relation to poor care planning/risk assessing, poor care delivery by staff and poor medication practices and procedures, copies of documents were taken under Code B of the Police and Criminal Evidence Act 1984. As a result of the above, a Statutory Requirement Notice was served on 11th December 2008, in relation to breaches of regulation pertaining to poor medication practices and procedures. We undertook a random inspection to the care home on 7th January 2009 and found improvements in the practices and procedures for the safe handling and recording of medicines. Whilst we recognised the improvements, there remained some minor deficiencies in record keeping but not sufficient to warrant further action. However, we saw that medication in one persons room was unsecured and openly accessible to other residents and visitors to the home. Additionally not all of their medication was listed on their medication records. Previous requirements had been made concerning the security of medication in the home and both photographic evidence of the medication and copies of documents were taken under Code B of the Police and Criminal Evidence Act 1984. As a result of 5 safeguarding referrals made to Essex Social Care and subsequent meetings with the registered provider, a decision was made by the placing authority in January 2009, to place an embargo on the home, whereby Essex Social Services would not refer anyone to Treetops Care Home for a placement (respite and long term). This will be reassessed at future meetings. As a result of continued non-compliance and concerns, we wrote to the registered provider advising that we were considering a proposal to cancel the homes registration. A meeting between us and the registered provider took place on 30th January 2009, whereby they were advised as to the above proposal, relating to continued concerns and breaches of regulation. We advised that should continued noncompliance and sufficient improvement not be made at the next key inspection, the proposal to cancel the homes registration would be pursued. What the care home does well: What has improved since the last inspection? What they could do better: Ensure that further development of the care planning and risk assessing processes continues. Ensure that records for all residents are up to date and provide clear guidance for staff as to individuals care needs and risk areas. Systems must be put in place to ensure that other associated documentation e.g. daily nutritional records, body position records are completed regularly and there is a clear audit trail depicting Care Homes for Older People Page 8 of 39 staffs interventions. Further training, specifically centred around those conditions associated with the needs of older people, are provided to all members of staff. Whilst we acknowledge that recruitment procedures are generally sound, further effort is required to ensure that procedures are robust and that all records as required are sought, for example, particular attention must be given to ensure that people newly recruited are given a vigorous induction that meets Skills for Care requirements. The registered provider must ensure that both the manager and deputy manager are appropriately supervised. 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 39 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 39 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who come to live at the home can be confident that their needs will be assessed, however they may not be provided with up to date information about the service, which will enable them to make an informed choice about where to live. Evidence: There is a formal pre admission assessment format and procedure in place, so as to ensure that the management and staff team are able to meet the prospective residents needs. Records showed that in addition to the formal assessment procedure, supplementary information is provided from individual residents placing authority and/or hospital. Two staff spoken with, stated they are given sufficient information about new people admitted to the care home and this is generally provided by senior staff members at handovers. Additionally they have the opportunity to look at individuals care files. Out of 3 staff surveys returned to us, 1 survey recorded sometimes in relation to being given up to date information about the needs of the people living at the care home. Further comments recorded were, Care Homes for Older People Page 11 of 39 Evidence: both some senior and junior carers are not aware of some of the needs of the residents, because the work load for staff is too much, we dont have the time to look at the care plan properly to know all the needs of the residents. So if at handover the needs could be given, it will help. This means that some staff working within the care home may not have sufficient information about how to meet the needs of the prospective person admitted to the care home. At this site visit, the care files for the 2 newest people admitted to the care home were examined. Records showed that a pre admission assessment had been completed for both people, prior to their admission to Treetops. In general terms the information recorded within both pre admission assessments was seen to be informative. The care file for another person evidenced that following a recent interval in hospital they returned to the care home without being reassessed. This was discussed with both the manager and deputy manager and we were advised that a re-assessment was carried out by the deputy manager, however this was not recorded. Records showed that both people and/or their representative were given the opportunity to visit the care home prior to admission. This was confirmed by one persons relative at the time of the site visit. From discussions with the manager, we were advised that currently no written confirmation that the home can meet the individual persons needs following assessment is completed. We observed that the Statement of Purpose and Service Users Guide was not readily available. The manager advised that currently both documents are in the process of being reviewed and rewritten. The relative of one person newly admitted to Treetops in December 2008, confirmed they had not received or seen a copy of the Statement of Purpose and/or Service Users Guide. The previous key and random inspection report for the home were not displayed, however we were advised by the deputy manager that these are available from the office if requested. The AQAA details that within the next 12 months both documents will be updated and a more user friendly admission pack will be devised. The home does not provide intermediate care. The AQAA details that people are accepted for short term and respite care. However, often after a series of respite visits, the resident and family make the decision to formally extend this and to become a permanent resident. Care Homes for Older People Page 12 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the care home can expect to have a plan of care, which identifies their care needs and how these are to be met. Evidence: There is a formal care planning system in place to help staff identify the care needs of individual residents and to specify how these are to be met by staff who work in the care home. As part of this site visit 2 care files were examined in full and 4 care files were partially examined in relation to specific healthcare areas. We noted that following the last key inspection and random inspection, care files for individual people have been audited, reviewed, updated and where appropriate rewritten. Evidence at this site visit showed that efforts have been made by the management team of the home to improve the quality of the care planning processes and to record individual peoples care needs and how these are to be met by care staff. The AQAA details under the heading of what we do well, all residents have a comprehensive care plan, we have reassessed all our residents risk and included a risk management section giving clear instructions to Care Homes for Older People Page 13 of 39 Evidence: staff. We have received care plan training and implemented a key worker system to review the care plans monthly. Of those people case tracked, each individual person was noted to have a care plan. The general recording was observed to be more detailed, informative and person centred, providing a good basis to staff so as to ensure that care provided was reflective of individuals care needs. However, this would be enhanced by the involvement of the resident and/or their representative in the development and review of the care plan. Two people confirmed that they had not been involved in the process. Whilst we recognise the improvements, further development of individuals care files and associated documentation is required. For example the care file for one person made reference to them being at risk of falls. Although some basic information was recorded within the mobility section of their care plan, no risk assessment pertaining to falls was devised. During the site visit, the resident was observed to mobilise with the aid of a walking frame, however they were seen to negotiate 3 steps with their walking frame in hand. No staff were on hand to provide assistance on the first occasion and on the second occasion when the resident attempted to descend the steps, it was the cook who intervened and not a member of staff who was close at hand. The care file for one person recorded them as experiencing problems with their blood pressure. Although there was general information recorded, this was not person centred and not reflective of the individuals care needs. Information recorded did not include specific information as to the persons needs, how this was to be monitored and/or their treatment. Another care file detailed that the person was diabetic. Records detailed the specific type of diabetes experienced, however no information was recorded as to how this should be monitored and/or their treatment. The same file recorded the person as having recently lost a considerable amount of weight whilst in hospital and suffering with ill-health. Records showed the persons weight was being monitored regularly and that they were eating and drinking, but only small amounts. Records detailed that the persons nutritional intake should be monitored daily. On inspection of their nutritional records, these showed they are inconsistently completed by staff and not all meals eaten and/or nutritional supplements (prescribed) or alternatives to the menu, had been recorded after each meal. The manager, deputy manager and members of staff confirmed to us that nutritional records for all residents should be completed after each meal. The above was not an isolated case and on inspection of nutritional records Care Homes for Older People Page 14 of 39 Evidence: for a further 3 people, inconsistencies in recording were highlighted. The care file for one person recorded them as requiring to have their body repositioned every 2 hours, as a result of spending a significant period of time in bed and being at high risk of developing pressure sores. Records showed these were completed each day, however the above instruction from healthcare professionals was not always being followed e.g. on one day the last recorded time the person was turned was 22.00 p.m. and the next day the first recorded time was 09.00 a.m. Other anomalies were also highlighted. Two staff spoken with, confirmed they knew the person required regular positional changes, however the frequency was incorrectly stated by one person. During the lunchtime observation one person was observed to refuse their lunchtime meal. On inspection of their care file this recorded them as having a personal preference for eating some meals more than others. Other records showed the person had lost over 6KG in recent months. On inspection of the homes nutritional policy and procedure, this recorded a number of specific measures and actions being put in place, so as to meet the individuals nutritional care needs. This included food and fluid intake charts being completed, staff offering snacks between meals, food supplements being offered if meals are missed, malnutrition screening tool being completed and a risk assessment to be devised. We observed following the persons refusal of their lunchtime meal that no alternative to the menu was offered and no snacks were offered during the morning or in the afternoon. Records showed that no risk assessment or malnutrition screening tool had been compiled. Additionally, food and fluid intake records were inconsistently completed. Records showed that people living at Treetops have access to a range of healthcare professionals and services as and when required, both at the care home and within the local community. These include, GP, attendance at hospital appointments, Optician, District Nurse Services etc. One healthcare professional spoken with, stated that there has been a big change in staffs attitudes and care practices over the past 4-5 months and the number of referrals for skin tears and other minor issues has reduced significantly. The AQAA details that improvements have been made to ensure that peoples healthcare needs have been clearly identified and that staff are aware of the specific needs of individuals. Staff interactions with residents at this site visit, were observed to be much improved and positive. Staff presence within the communal areas were more frequent and staff were noted to engage better with residents and to spend time sitting and talking to people. Where support and assistance was provided by staff in relation to individuals personal care, this was conducted with respect and sensitivity. Residents and relatives spoken with throughout the site visit, were Care Homes for Older People Page 15 of 39 Evidence: complimentary regarding the care and support provided at Treetops Care Home. Eight resident surveys were completed and returned to us. Of these, 4 recorded that staff are available and that they received care and support when needed. The remaining 4 surveys recorded that they receive care and support, however usually staff are available when needed. One survey recorded under the heading of, are the staff available when you need them, but not so much in the evenings. Of 3 staff surveys returned to us, 2 stated they met the individual needs of the people at the care home. One survey returned recorded, The work load is too much that we rush to do things e.g. washing residents. There is never enough time to listen and talk to residents. Regarding disability there are appropriate equipment, like stand aid hoist and handling belts. We have to pull and handle residents which puts them in distress. Carers are left to move and handle residents alone-which need 2 carers to do. The reason for which one carer performs a task instead of two carers is that there isnt enough staff. If you ask for assistance you dont always get it because the other carer is busy doing something else. During the site visit 3 relatives were spoken with and all were complimentary regarding the care and support provided at Treetops for their member of family. Comments received included, marvellous care, we are more than happy and the home provides good care. Medication is stored securely for the protection of residents. Medication stored in one residents room is also now stored securely and not accessible to other people. Medication storage temperatures are satisfactory and recorded regularly so to maintain the quality of medicines in use. We looked at medication and medication records for several residents and, on the whole the records made when medicines are received and disposed of and those made when medicines were given to people are of a reasonably good standard and much improved over previous inspections. We found that for one person who looks after his own medication, there was a medicine in his room which was not listed on his medication record. Whilst we recognise since the last key and random inspections, risk assessments have been devised for those people who self administer their medication, this was not completed for one person case tracked. When discussed with the manager they stated, oh, I forgot about that. The home carries out its own audits of medication records on a regular basis and some minor deficiencies have been found, investigated and resolved. We also found a few deficiencies such as the timing of a medicine for three people which was recorded Care Homes for Older People Page 16 of 39 Evidence: inaccurately. This could result in people receiving medication inappropriately. There were some hand-written additions and changes to the printed medication records but no indication of who made the change or when, nor are they checked for accuracy by a second person. Also when people regularly refuse their medication, there is no record that this is always discussed with their GP despite the home having a policy which states if medication is refused over a period of time, refer to GP. Ask why they are refusing. Ensuring all recordings are in place. Medication is only given my trained staff and we saw evidence of recent training. We watched medicines being given to some people at lunchtime and this was undertaken professionally, with regard to the residents personal choice. The AQAA details that within the next 12 months it is hoped that an external pharmacist will undertake an audit of the homes medication records and staff practices and procedures. Care Homes for Older People Page 17 of 39 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all people who live at the care home can expect to have their social care needs met, however they can expect to receive a varied diet. Evidence: We were advised there are 2 activities co-ordinators employed at Treetops Care Home, Monday to Friday. A list of activities for the week was displayed on the notice board in the dining area, however not all residents spoken with were able to confirm the activities available on the day of the site visit or for the following week. Consideration should be given to provide a larger print and/or pictorial format, so as to enable residents to make an informed choice and for this to be more readily accessible within the home environment. Records showed that some people over the past 4 weeks have participated in activities such as bingo, games, exercises, skittles, ball games, 1-1, arts and crafts, personal choice, Wii game and general knowledge quizzes. The activities person on the day of the site visit, confirmed that more often than not the same people tend to participate in activities available. Consideration must also be afforded by the activities coCare Homes for Older People Page 18 of 39 Evidence: ordinators to include those people who have poor cognitive ability, poor communication and who spend long periods of time in their room. This was agreed by both the manager and deputy manager when discussed during feedback. Newly implemented weekly audits had picked up matters relating to the latter and the deputy manager is to meet with the activities co-ordinators to ensure that all residents are treated equally. One resident spoken with advised, I love it relating to the Wii game and also confirmed they had enjoyed the recent Easter Parade at the care home. The AQAA details under the heading of what we could do better, we are going to organise trips out i.e. to Southend, Garden Centres and Pub Lunches. A recreational activity record is completed for each resident, depicting activities undertaken. Of 6 people case tracked, no activity record was evident for 5 people. Additionally information relating to individuals social care needs (both past and present interests) were limited. Residents spoken with confirmed that they can choose whether or not to spend time in their own room or to join the others downstairs. They also can choose whether or not to join in activities or pursue their own interests in their own room, such as listening to music. There remains an open visiting policy whereby visitors to the home can visit at any reasonable time. Residents and relatives spoken with on the day of the site visit, confirmed this. People living at the care home also stated that they are supported and enabled to maintain friendships and contact with family members. All residents spoken with said their visitors were welcomed and one person said, they can come and go as they please. The dining experience for people living at Treetops Care Home was observed at this visit during the lunchtime period. Dining tables were attractively laid with tablecloths, placemats, serviettes, cutlery and condiments. A choice of drinks was available and people were offered more, as and when required. Meals provided to residents was observed to be plentiful and attractively presented and since the last key inspection, the manager has introduced vegetables being served in terrines so that people can make individual choices. Comments from residents regarding meals provided were positive and these included, Oh I cant grumble, its quite good, passable and the food is very good, I have nothing bad to say. Where people required assistance to eat their meal, this was provided with due care and was not rushed. A resident confirmed that they can choose to eat some of their meals in their own room, but to eat lunch downstairs. Care Homes for Older People Page 19 of 39 Evidence: We were advised that people choose their personal preferences for a meal the day before. No menu was readily available, depicting the choices available and staff were not observed to remind people of their chosen meal, choices available and/or possible alternatives to the menu on the day. Out of 6 people spoken with, only 2 people were able to advise as to the choice of meals available. Consideration should be given to provide a larger print and/or pictorial menu, so as to enable residents to make an informed choice. Drinks were served to residents during the morning and afternoon. People were observed to be given a choice of tea or coffee. One person said they prefer coffee and though they have told staff, they are still given tea. They also stated that they do not have a cooked breakfast, though occasionally they would like that. Care Homes for Older People Page 20 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect their concerns to be listened to and dealt with appropriately and that they would be safeguarded by staff knowledge and supporting policies and procedures. Evidence: The complaints procedure was displayed in the entrance hall and so was readily available to visitors. It provides information on the timescales that people will receive responses at the various stages, so that they know what to expect. It did not provide information on the option of taking the complaint to Social Care (Social Services) who have the duty of care and the manager was recommended to include this. The manager confirmed they were in the process of changing the Commissions contact details to reflect the recent changes. In the AQAA, the manager told us that one formal complaint had been received in the previous 12 months, before they took up post. This had been subsequently referred under safeguarding procedures and investigated, a review of the persons care and placement had been undertaken by social services, and the person remains a resident at the home. The manager advised that as far as they knew the complaint related to the call bell not being accessible and on two occasions no drinks being available to the person. They advised they have requested a formal outcome from the safeguarding team to complete their records, but this is still awaited. Care Homes for Older People Page 21 of 39 Evidence: Formats were available for recording formal and informal complaints. A number of informal complaints had been logged and showed they had been addressed promptly. They related for example to lost laundry or a lounge window that had stuck following redecoration. A monthly record of the number of complaints received was maintained and it was recommended that complaint information be used as part of the homes quality assurance system and development plan. The AQAA details that both the manager and deputy manager has an open door policy and residents, staff, relatives and others can report any concerns. Residents spoken with said that they would feel able to tell staff if they were worried or concerned or had a complaint and one person said I could tell any of them if I wasnt happy with something. Of 8 resident surveys forwarded to us, all but one recorded that they knew how and to whom to make a complaint/raise any concerns. Several cards of thanks and compliment had been received. More recent ones included comments such as I would like to say how happy I am with the way my relative is looked after , and thank you for all your kindness and attention given to my relative and I realised that it was time that I wrote to you and your team to say how happy the whole family have been with (relatives) care during the time they have been resident at Treetops. The Commission were aware of five additional safeguarding referrals and investigations since the last key inspection of October 2008. One of these relating to medication was not investigated by Social Care. The other four were upheld and included issues such as poor pressure area care/management of transfers/positioning and resultant accident to the resident who was not checked for signs of injury by the carer, lack of personal care in relation to positive management of continence for a resident, a resident ignored by staff and the collapse of a residents wheelchair. The manager was able to demonstrate through their records that they were aware of each of the issues and advised that reviews of placements for each of the residents had been undertaken. Two residents were no longer at the home. The manager was able to provide information on actions taken for example in relation to a medication review for one person with noted improvements to their mobility, nutritional intake, continence and sleeping pattern and so their quality of life. In another instance, one carer has left and the manager stated they addressed the poor practice issue with the staff member concerned. It was disappointing to note the managers confirmation that they had not recorded this on the staff members file. The manager stated that they understood that some wheelchairs are supplied to Care Homes for Older People Page 22 of 39 Evidence: residents, a company regularly inspects them, but again confirmed that no records of this was available. The manager confirmed that they had not implemented a system in the home for routine visual checks of the wheelchairs to be undertaken and recorded, including for those who are not regularly inspected by an outside company. The manager confirmed they have undertaken recent training in safeguarding vulnerable adults, had access to appropriate documentation to support referrals and the knowledge to support these to ensure residents best interests. The manager demonstrated this with records of three additional safeguarding referrals they had made recently in response to resident falls or bruising noted by staff. Accident records had been completed where appropriate and the Commission notified. Policies and procedures were in place relating to protecting vulnerable people and whistleblowing, signed by the previous manager. The whistleblowing procedure was written in clear language and provided information for staff of the people they may contact both within and outside the organisation. The manager was recommended to sign the documents to demonstrate that they agreed with the content. The manager advised they may consider implementing a system where staff sign to confirm receipt and understanding of these policies and procedures. The managers training matrix demonstrated all but three of the staff team have attended training on safeguarding vulnerable people within the last nine months. The manager stated that these staff have been offered training but have been unable to attend. In the interim, the manager and deputy manager have provided written information on this area to the staff. Staff spoken with confirmed that they had received safeguarding training, were able to identify types of abuse and advise of appropriate reporting procedures. Care Homes for Older People Page 23 of 39 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. Residents can expect to benefit from a generally improving and pleasant environment that may not meet all of their needs in terms of safety and facilities. Evidence: There were noted improvements to the environment since the last inspection. The communal lounge, dining room and activity room have been completely redecorated and refurbished and presented a spacious and restful place for people to sit and eat. Seating arrangements were more informal and presented as less institutional. New flooring or carpet has been fitted in several areas of the home. The manager confirmed completion of the refurbishment of all the communal areas. It was noted that there was no call bell point fitted in any of the large downstairs communal areas of lounge, dining room and activities room to allow residents to call for assistance if for any reason the area was left unsupervised. Additional car parking had been provided. The garden area was well maintained. Minutes of a recent resident meeting suggested they have chairs and tables in the garden and the manager said this had been done. Some white plastic chairs and tables were seen to be stacked in one area of the garden. These were in need of a good cleaning before they could be used and, although the day was warm and pleasant, no residents were seen to use the outside space. Care Homes for Older People Page 24 of 39 Evidence: The deputy manager advised that some bedrooms had also been redecorated and refurbished. The manager advised that the next stage of the premises upgrade is that as bedrooms become vacant they will be redecorated fully before being occupied. The manager was asked if there was a planned programme that therefore included the 16 currently unoccupied bedrooms which present an ideal opportunity, but they advised that no clear programme is in place for this from the registered provider. Bathrooms are also in need of modernisation and refurbishment with for example torn border papers and broken bathroom fittings. The manager was advised of a broken and potentially dangerous toilet cistern, which they arranged to make safe immediately. In another downstairs toilet, the seat lid was on the floor. Residents spoken with said they were satisfied with their own bedrooms and found them quite comfortable or fine, warm and comfortable and stated that they had been able to bring some of their own bits and pieces such as photographs, ornaments and small pieces of furniture. Some residents had their own telephones installed and one person said it was really good to be able to keep in touch with family and friends. Another resident advised that although they knew they could lock their doors they wanted to they were not bothered. Residents spoken with expressed dissatisfaction with the lack of hot water for washing and reference to this was also noted in the minutes of a staff meeting held in November 2008. The manager confirmed that the current system is unable to provide adequate hot water and the registered provider is taking steps to address this. It was noted that wedges were being used to hold open a large number of resident bedroom doors. The appropriateness of this in relation to fire safety was discussed with the manager and requires reviewing. The premises were seen to be clean and no unpleasant odours were noted. Wheelchairs used by residents were not seen to be clean. The manager confirmed they had recently noticed that these were filthy, but no routine cleaning schedule was in place to address this. One resident said their room and the place is kept clean and tidy. The laundry was clean and very tidy and fitted with appropriate equipment. There were appropriate hand washing facilities to promote good management of infection control. Care Homes for Older People Page 25 of 39 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the care home can expect to be cared for consistently by a stable staff group. Evidence: There were thirty six residents living at Treetops at the time of the site visit.The manager stated that staffing levels for the current resident group were five staff plus one senior on the morning shift, four staff and one senior on the afternoon shift and three carers and one senior at night. The manager advised that the new system where the deputy manager is also available on the floor from Monday to Friday providing additional support and supervision for residents, is working very well. Comments seen in a staff supervision record confirmed this for example staff performance is better and they are not sitting around. The rota available reflected accurately the staff on duty on the day of the site visit. A random sample from four weeks rotas demonstrated that the above minimum care staffing levels had been met. There is a cook on duty between 6.30am and 4pm each day, along with kitchen assistants, laundry staff, housekeepers, administrative and maintenance staff who work various hours and shifts. Residents spoke positively of staff with comments that included they are very pleasant or staff are pretty decent on the whole or they are friendly and the girls Care Homes for Older People Page 26 of 39 Evidence: know what I want and need done. Residents also confirmed that staff generally respond to the call buzzer within reasonable time periods. The managers AQAA states that twenty six of twenty nine care staff have achieved at least NVQ level 2. This was demonstrated on the staff training matrix which indicates that thirteen of the staff have achieved NVQ level 3. None of the three staff files inspected, contained evidence to support the information contained in a training matrix in relation to NVQ training. The manager advised that no new staff had been employed since the last key inspection. The managers file and those of three other staff were reviewed to examine if appropriate references and checks were undertaken prior to employment to safeguard residents. All files contained an application, two references, evidence of identity and demonstrated that a criminal record bureau check was in place when the person commenced working at Treetops. One file did not contain a photograph of the person. Two of the files indicated that the second reference was not in place before the person commenced working at the home. On one file there was a two year gap in the persons employment history that was not recorded as explored. Dates of previous employment history could have been clearer on some files to ensure that any additional gaps could have been identified. More recent application forms did include a declaration of health and offences as required. There were no records depicting the evidence of appropriate interview processes, although the manager confirmed that staff are interviewed by themselves and the deputy manager. Induction processes were reviewed to ascertain if new staff had been given appropriate information about, and training to meet, the care needs of the people living at Treetops. The managers AQAA stated that all 29 staff had received an induction to Skills for Care standards. The manager advised that they had continued with the previous managers processes in relation to staff induction training and that they did not have their own policy and procedure relating to staff induction. An induction checklist on a file reviewed indicated a completed first-day orientation sheet, that stage two was to be completed after six weeks and stage three after eight weeks, however both of the latter stages were blank although the person had been employed for some months. Two other staff files indicated some references to Skills for Care Common Induction Standards but this was not clearly evidenced as provided and managed effectively to support new staff. The three staff files sampled did contain evidence to support the training matrix in Care Homes for Older People Page 27 of 39 Evidence: relation to basic topics such as moving and handling, safeguarding, food safety and hygiene awareness, administration of medication, nutrition workshop, dementia awareness, pressure area care, emergency first aid, infection control, health and safety, principles of care (effective communication, role of the care worker/organisation and maintaining safety at work) and person centered planning. The training matrix did not contain any information on management of challenging behaviour training and the manager confirmed that this is not provided although there has been evidence of issues in relation to this identified, including within safeguarding referrals and the monthly reports undertaken by the consultant. Records also showed there is limited evidence of training pertaining to those conditions specifically associated with the needs of older people. The manager has put in place a matrix to monitor the number of staff training hours accumulated by each staff member as the year progresses to help them to monitor this and support the training plan. The manager has also produced a projected matrix of staff meeting dates so that staff can make arrangements to enable them to attend. These issues are noted positively. Staff spoken with confirmed that they received appropriate training, that they have a handover at each shift and regular staff meetings to support communication. They also demonstrated a reasonable awareness of the care needs of each person discussed. Care Homes for Older People Page 28 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect to benefit from developing management systems that will promote positive outcomes for the people who live at Treetops Care Home. Evidence: The manager has been in post for seven months and their hours are supernumerary. Evidence was seen relating to their NVQ3, NVQ4/RMA, plus recent safeguarding, supervision, risk assessment, infection control, administration of medication, food safety and hygiene awareness, moving and handling, principles of care, health and safety and person centred planning training. The manager advised that the ethos of the service is to provide a nice family atmosphere, provide a safe environment, for staff to respect peoples core values and for people to maintain contact with their families. Residents, relatives and staff spoken with, confirmed that the manager is approachable and proactive. The manager and deputy manager work office hours on Monday to Friday only, and Care Homes for Older People Page 29 of 39 Evidence: while they are on call at other times as noted on the rota, there is no formal management presence in the home outside office hours to support the continuous effective running of the service. The manager has as yet to submit an application to be formally registered with the Commission. We were advised that the reason for the delay, was as a result of waiting for the outcome of this inspection and whether or not the quality rating for the service changes. While improvements to the service are noted, including the supervision of staff in daily practice by the availability of the deputy manager on the floor, there is a need for further development within the management team. As noted earlier in the report there was a lack of understanding and ownership regarding for example Skills for Care and Induction or whistleblowing procedures. There was no evidence available of a management system of assessment of resident dependency needs in relation to staffing levels, despite reductions from previous inspections, to support effectiveness of the current staffing level. However the manager advised that they have just obtained a dependency rating tool and will now implement this. We were advised by the manager that an external consultancy agency continues to provide support to the management team of the home. A weekly audit is conducted and this details actions to be undertaken e.g. drafting of AQAA, manager to develop care planning systems etc. Additionally both the manager and deputy manager meet with the registered providers once weekly to discuss issues and progress. The manager keeps an account of matters discussed, however there was little evidence that care practices and care specific issues are discussed. The manager advised that their policy is to survey residents and other relevant people twice yearly together their views on the care and service provided at Treetops. The outcome of the most recent survey of residents of September 2008 is not yet available and it is recognised that the new manager had a number of other issues to deal with in order of priority since taking over the post. Returned surveys sampled demonstrated that they were detailed and for example confirmed that people felt able to raise concerns or complaints. The outcome of the relatives questionnaire was available demonstrating satisfaction with the environment and welcome received and offering suggestions for improvement in relation to appropriate stimulation and activities. The manager confirmed that a survey of staff and professionals is to be implemented and the analysis report from all the surveys and the subsequent development plan will be sent to the Commission as Care Homes for Older People Page 30 of 39 Evidence: soon as it is available. The deputy manager advised that, with the support of the activities coordinator, they had recently led the first residents meeting, which had been attended by 13 residents. The main topics covered included a suggestion from residents that tables and chairs be out in the garden, for various other activities and more outings and also suggestions for the menu. Accident records are now being audited monthly by the manager to help identify trends so that preventative steps can be taken. The consultant currently supporting the home has completed brief monthly records of the required monthly visits and this indicates a reduction in the number of resident accidents, which is positive. These reports do not confirm whether residents or staff have been spoken with or include any outcome of these interviews. The administrator manages residents personal money held on their behalf. It was not possible to review these on the day of the site visit as the administrator finishes work at four oclock and access was not available. The manager advised they had not previously considered how residents would access their money outside the administrators hours or at weekends. The records of four peoples monies held by the home were examined at the last key inspection and found to be satisfactory. The manager attended training on supervision in January 2009. The deputy manager and senior care staff have also had this training. A supervision matrix has since been implemented and the manager advised that all staff will have supervision on a two monthly basis. While a system is now in place for supervision of quality and effectiveness of it as a support tool is yet to be demonstrated. A supervision recording format is in place. Evidence of a first supervision session was seen on one of the files sampled, did not set an agenda as identified, but did review current training to date, the quality of recent training in relation to practice, and considered current and ongoing NVQ training. Two supervision sessions were noted on the other two files sampled and the quality of the information varied. Where the manager had addressed an issue with a member of staff for them to reflect on for example, there was no follow-up to this in the next supervision session or review of the recent care plan training the person had attended. Consideration needs to be provided to both the manager and deputy manager for opportunities to discuss their practice and development. Records of routine safety checks were requested to ensure a safe environment was maintained for residents and staff. Current safety inspection certificates were available Care Homes for Older People Page 31 of 39 Evidence: in relation to the fire alarm, emergency lighting, where equipment, nurse call system, portable appliances, electrical fixed wiring, passenger lifts and hoist equipment. The gas certificate had expired in March and the manager advised it was booked to be undertaken this week and a copy of the certificate would be sent to the Commission as soon as available. Routine checks of the fire alarm on emergency lighting system were recorded. There was no record of fire drills to show that all staff had routinely been involved in these. The manager was recommended to discuss this at the planned visit later that week by Essex Fire and Rescue Service, along with the appropriateness of the current fire risk assessment and the use of wedges to keep resident bedroom doors open along a fire exit route. A current certificate of liability insurance was displayed. Care Homes for Older People Page 32 of 39 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 7 13 Risk assessments must be devised for all areas of assessed risk. Information must include the specific nature of risk and the steps to be taken by staff to minimise the risks. Previous timescale of 31/1/09 not met. This will enable staff to minimise any risks for residents and to ensure their health and safety. 01/06/2009 2 9 13(4) When people look after and take their own medication, any risks to themselves or other people who use the service must be assessed and managed. This will protect people from harm. Previous timescale of 31/8/08 not met. 15/05/2009 Care Homes for Older People Page 33 of 39 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 3 14 Confirm in writing to the resident and/or their representative, that following a full assessment, the needs of the person can be met. To ensure that the person being admitted to the care home knows that the home can meet their needs. 15/05/2009 2 7 15 The care needs of individual people living at the care home must be clearly identified and recorded, detailing how these are to be met, monitored and treatment to be provided. This will ensure that people receive care accoring to their specific needs. 01/06/2009 3 8 17 Where people are at risk of losing weight, maintain appropriate nutritional records. 15/05/2009 Care Homes for Older People Page 34 of 39 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 So as to ensure peoples safety and wellbeing. 4 9 13 When residents regularly 15/05/2009 refuse to take their medication, the reason must be recorded and it must be discussed with the residents GP without delay. This will ensure residents receive their medication as prescribed and any future decisions concerning their treatment is based on accurate information. 5 9 13 When medication is necessary to be given at a specific time the record of when it is given must be accurate. This will demonstrate that residents are given medication as prescribed and protect them from harm. 6 12 16 All people who live at the 01/06/2009 care home must be given the opportunity to engage in a varied programme of activities. This refers specifically to those people who have poor cognitive ability and who spend the majority of their day in bed. 15/05/2009 Care Homes for Older People Page 35 of 39 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 So as to ensure that people are enabled to maximise their potential. 7 19 23 People who live at the care 18/05/2009 home must be provided with a sufficient supply of hot water at all times. So as to enable people to have a wash, bath and/or shower in the knowledge that the water will be at a reasonable temperature for their comfort. 8 19 23 Adequate precautions must be undertaken against the risk of fire after consultation with the fire authority. This refers specifically to residents doors being wedged open. So as to ensure peoples safety and wellbeing. All staff employed to the care home, receive structured induction training and there are records to support this. This will ensure that staff feel supported and able to carry out their role. 31/05/2009 9 29 18 15/05/2009 Care Homes for Older People Page 36 of 39 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 10 29 19 Ensure that robust recruitment procedures are adopted at all times and all records as required by regulation are sought. This will ensure that residents and others feel assured that they are safeguarded by the homes procedures. 15/05/2009 11 30 18 Staff receive appropriate training to the work they perform. This refers specifically to those conditions associated with the needs of older people. This will ensure that staff have the competence, confidence and ability to meet residents care needs and people will feel assured that their care needs will be met by suitably trained staff. 01/07/2009 12 38 23 All staff to participate in 31/05/2009 regular fire drills and records to support this are maintained. So as to ensure safe working practices and procedures. Care Homes for Older People Page 37 of 39 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 Ensure that both the Statement of Purpose and Service Users Guide are reviewed, updated and available for residents and their representatives. Where people are admitted to hospital, ensure they are reassessed as to their suitability to be re-admitted to the care home and there is evidence to support the decision. Where people require their body position to be changed at regular intervals, records should clearly demonstrate this is being undertaken and in line with healthcare professionals instructions. Hand written additions or changes to medication records should be signed and dated by the person making the entry and checked for accuracy by a second person who should also sign the record. Consider devising the activity programme in larger print and/or pictorial format, so as to enable people to make an informed choice. Consider devising the menus for residents in larger print and/or pictorial format, so as to enable people to make an informed choice. The outcome of quality assurance surveys should be collated and made available for inspection, so as to ensure the home is run in the best interests of the people who live there. Review current arrangements, so as to enable people to have access to their money outside the administrators hours and/or at weekends. Ensure that regular servicing of utilities is undertaken within their timeframes and that a record is available for inspection. This refers to the gas safety certificate. 2 3 3 8 4 9 5 12 6 15 7 33 8 35 9 38 Care Homes for Older People Page 38 of 39 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. 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