Inspecting for better lives Key inspection report
Care homes for older people
Name: Address: Tregenna House Pendarves Road Camborne Cornwall TR14 7QG 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: Diana Penrose
Date: 2 4 0 7 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: Tregenna House Pendarves Road Camborne Cornwall TR14 7QG 01209713040 01209715356 enquiries@tregennahousenursinghome.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Trecare Group Limited care home 44 Number of places (if applicable): Under 65 Over 65 0 0 dementia mental disorder, excluding learning disability or dementia Additional conditions: 44 44 Identified service users only, currently in residence, category OP nursing. The maximum number of service users who can be accommodated is 44. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia (Code DE) to a maximum of 44 Mental disorder (Code MD) to a maximum of 44 Date of last inspection Brief description of the care home Tregenna House is a large two storey Victorian property with a modern single storey extension. A further extension is being built to include six new bedrooms and a shower room. The building is situated in large grounds close to the town of Camborne with parking to the front of the home. The enclosed garden to the rear is out of use due to building work in progress but the registered providers hope to design this specifically for people Care Homes for Older People
Page 4 of 35 Brief description of the care home with dementia. There is another large area of garden at the side of the home which is to be levelled and made safer for residents. The home provides nursing care for up to forty-four elderly people with a mental disorder or dementia and accommodation is over two floors. The ground floor provides for 28 residents and one area is dedicated to men who receive rehabilitation and activities that may enable them to return to the local community. There is a large lounge with a dining area and a small lounge in the male wing. There is also a dining facility in the male wing kitchen. The main kitchen is on the ground floor with a hatchway opening into the dining room. The first floor, Bluebell Wing, provides accommodation for 16 residents with more limited mobility. There are two lounges upstairs with dining facilities incorporated. There is a kitchenette for making snacks and drinks. Information about the home is available in the form of a residents guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees range from 425 to 2,100 pounds per week, this includes payments for special needs. This information was supplied to the Commission by the deputy manager during this inspection. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. 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: 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: An Inspector visited Tregenna Nursing Home on the 23 and 24 July 2009 and spent fifteen and a half hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that the needs of people using the service are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that peoples placements in the home result in good outcomes for them. It was also to gain an update on the progress of compliance to the requirements identified in the last inspection report dated 27 July 2007. All of the key standards were inspected. On the day of the inspection forty people were residing in the home. The methods used to undertake the inspection were to meet with people using the service, the deputy Care Homes for Older People
Page 6 of 35 manager, one of the registered providers and staff to gain their views on the services offered by the home. Some relatives were also contacted by telephone following this inspection. Records, policies and procedures were examined and the inspector toured the building to observe life in the home. The deputy manager returned an Annual Quality Assurance Assessment which has also been used to inform this inspection. This report summarises the findings of this inspection. What the care home does well: What has improved since the last inspection? A physiotherapist has been employed to help to keep people mobile and to assist with physical activities and training for staff. Activities staff have increased but these people only work in one part of the home. A new vehicle has been purchased to take people out. The registered providers have continued to invest in the refurbishment of the home and a new lift has been installed. They have installed toughened glass to all downstairs windows where it was previously missing. They have also fitted a new hatch into the kitchen to separate fresh food from dirty dishes. Fish tanks have been provided in several parts of the home and staff said they give a relaxing feel to the environment. A specialist male rehabilitation unit has been developed. Care Homes for Older People Page 8 of 35 The registered manager has completed the Registered Managers Award. The registered providers have engaged the assistance of an outside agency to interview staff and obtain an impartial view on the training provided by the company and any additional training the staff would like to undertake. What they could do better: The statement of purpose and residents guide must be reviewed and updated. Care plans must include social, religious and cultural needs and they must be in sufficient detail to inform and direct staff on the care to be provided. People using the service must be risk assessed for the use of bed rails with consent obtained from relatives and the multi disciplinary team. Any scoring system used for assessing risks should be incorporated into the care plans to direct staff on the care provision. The medicines policy must be updated to state the actual process used in the home and an updated copy of the handling of medicines in social care document, produced by the Royal Pharmaceutical Society should be available to staff. To help to avoid errors, when handwriting instructions on the charts, they should be witnessed with two signatures recorded. Level 1 training for care staff needs to be formalised and included in the induction programme. There need to be suitable care plans in place for people prescribed medicines on an as required basis. There also need to be care plans for diabetic people that include blood sugar monitoring and the use of insulin. Insulin injection sites should be recorded. The medicines fridges should be monitored with the temperature recorded regularly. The disposal of medicines must comply with legislation. Suitable activities and entertainment should be provided for all people using the service with suitable records maintained for each person. Extra attention needs to be made to ensure the home is clean and hygienic throughout. Equipment used between residents and hoist slings should be washed appropriately with records maintained to show this is being done. Furniture in some parts of the home needs to be replaced. Bathing facilities must be reviewed to comply with the National Minimum Standards and toilet facilities must be accessible to people using the service. The use of vinyl flooring needs to be reviewed to ensure that a homely environment is maintained for residents. The garden needs to be made safe so that people using the service can spend time outside. The skills for care induction standards should be incorporated into the care staff induction programme. The registered providers must ensure that sufficient staff, with the relevant knowledge and skills, are on duty at all times to meet peoples individual needs. They also need to ensure that staff maintain a more organised and consistent approach to their work. Quality assurance systems need to be in place to enable residents, relatives and stakeholders to air their views and promote improvements. Care Homes for Older People Page 9 of 35 The registered providers must ensure that the residents account is run so that money is not shared between people who use the account. 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 10 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 11 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is not enough information about the home available for prospective residents to enable them to decide if the home is the right one for them. People are assessed prior to admission to ensure the home can meet their individual needs. Evidence: The full statement of purpose was not available for inspection. An abridged version was seen in the residents guide. The deputy manager told us that the statement of purpose was in need of updating and it did not include information about the male wing. A review needs to be done promptly and a copy of the updated document sent to the Commission for approval. The residents guide is also in need of review. We saw that enquirers visiting the home during this inspection were given a colour brochure about the home. The care files of two new people using the service were inspected. The files included
Care Homes for Older People Page 12 of 35 Evidence: an assessment of their care needs that was undertaken prior to their admission. The information was variable in content and the deputy manager said the form needs to be improved to give more space to record in detail. The forms were dated and signed and indicated who was involved in the assessment. Some other files included assessment information from outside agencies. Care Homes for Older People Page 13 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The healthcare needs of people using the service are generally met however care plans are disorganised and lack detail so staff are not fully informed or directed on the care they have to provide. There is a medicines system in place; an updated policy, specific care planning and extra attention in some areas will provide a safer system and provide more protection for people using the service. Evidence: The care files of four people were inspected in depth and a further four in less detail. The files inspected spanned all areas of the home. Each file held a care plan, risk assessments, details of visits from healthcare professionals and other information. The files were disorganised and the care plans lacked detail to direct and inform staff on the care to be provided. Staff instructions include the words encourage and assist without specific detail on how to do this; some people using the service have complex needs and challenging behaviour and the care plans do not detail how to deal with this appropriately. New employees and agency staff in particular require good instruction on how to care for the residents. The care plans do not include social, religious and
Care Homes for Older People Page 14 of 35 Evidence: cultural needs. Risk assessments were seen and most included a scoring system to indicate the level of risk, the care plans do not include the relevance of the scoring or subsequent care needs. The manager told us that a risk assessment is used for the use of bed rails but the files inspected did not include this. She said she would ensure that risk assessments are included for bed rails and that consent is gained from relatives and the multi disciplinary team. We saw that care plans were reviewed on a monthly basis with a signature of the person undertaking the review. The manager told us that the Liverpool Care Pathway is used when required but the work on the Gold Standard Framework has not continued. We saw that both nursing and care staff write and sign the daily records and where completed these were informative. One person did not have records maintained every day; gaps of up to five days were noted. The manager told us that she would like to change the format of the care plans and re-organise the files, she has not been able to do this yet due to staffing difficulties. The AQAA states that staff have begun life story books and they continue to get more families to sign the care plans, although this does at times remain difficult. Most of the people using the service were unable to tell us about the care they receive. Those that could said the staff are kind and they are happy at the home. Staff were observed to be patient and caring and had a good rapport with the residents. Relatives told us that the care is good at the home although sometimes communication between staff is poor and information is not passed on. The brother of a resident on the male wing said he is well cared for and looks tidy and respectable since moving to Tregenna. Relatives told us they did not have any involvement with residents care plans. The manager said there are good links with local healthcare professionals and specialist nurses visit when required. We spoke to a visiting tissue viability nurse specialist who said she comes to the home when invited to advise on wound management. One of the nurses at the home has an interest in tissue viability and is a link with the external specialists. We spoke to him during this inspection and he has a keen interest in the subject. It was apparent from talking to staff that nurses do not always follow the wound care plans and this could be detrimental to the healing of wounds. This was discussed with the manager who said she would address this with the nursing staff. We were told that three people have pressure sores and suitable mattresses and cushions were seen in use for pressure relief. We were told that people needing a hoist have an individual sling, there was no policy for washing the slings but staff said they are washed regularly. The manager told us that hoists and standaids should be washed down between use but there was no evidence to show that this was being done. The home employs a physiotherapist and he told us about his work in the home. He said he gets involved in exercising residents and has provided some training
Care Homes for Older People Page 15 of 35 Evidence: on Parkinsons Disease. The manager said the speech and language therapist visits and assesses residents as necessary and assessments were seen. We were told there is no problem with the purchase of incontinence pads but that the individual bladder diaries need updating. We were shown a medicines policy that requires updating to state the actual process used in the home. The copy of the guidelines set by the Royal Pharmaceutical Society in the home was out of date. The manager said she would obtain a new copy and ensure it was available to staff. Various medicine reference books were seen and the manager said that there is a copy of the Nursing and Midwifery Council guidelines for the use of medicines in the home. Patient information leaflets (PIL) were also seen. A monitored dosage system of medication was seen in use and the storage was appropriate. We were told that no residents administer their own medicines. Records were examined for the receipt, administration and disposal of medicines in all areas. They were generally satisfactory but some gaps were seen on the administration charts upstairs. We noted that for medicines, not re-ordered, the number of tablets remaining are not carried forward on the charts. This makes auditing very difficult. We saw that handwritten instructions on the medication administration charts were not witnessed with two signatures recorded as was the case at the previous inspection. Photographs of each resident were seen with their medication administration charts. We saw that some people are prescribed insulin but the injection site was not recorded on the administration chart. Blood sugar monitoring takes place and we were shown that each person has an individual machine for this. We were told that no specific care plans are in place for people with diabetes. For people prescribed to have medicines administered, when required, we found that there were no care plans in place about the use of this medicine, or any directions on how to make an assessment if this medicine is required. Controlled medicines are stored and recorded appropriately. An ampoule of diamorphine 10mg was in the cupboard upstairs with no records to justify it being there, the manager said she would ensure it was disposed of. Two medicines fridges were seen; the records of temperature monitoring could not be found downstairs and the last daily recording upstairs was 18 July 2009. The medicine disposal tubs were seen and contained medicines removed from the packaging which does not comply with legislation. The manager agreed to ensure that the nurses are informed of the correct method for disposing of medicines. Level 1 medicines training for care staff has not yet been formalised and included in the induction process as agreed at the last two inspections. Care Homes for Older People Page 16 of 35 Evidence: A recent medicines audit in the home has identified some of the issues raised in this report and the manager is planning to hold a staff meeting to discuss them. The privacy of people using the service was observed to be upheld during this inspection and staff knocked on doors before entering. Relatives told us that staff are respectful and they have had no issues regarding privacy and dignity at the home. Shared rooms are provided with appropriate screens. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a varying amount of activities, more in some areas of the home than others, some personal preferences are taken into account, family and friends visit but there is a lack of social care plans so individual needs may not be met. Dietary needs of residents are well catered for with a varied selection of food that aims to meet their taste and preference. Evidence: The Annual Quality Assurance Assessment (AQAA) told us that activities staff have increased from 1 to 4. The manager told us that all four are employed to work on the male wing and that she is trying to recruit a co-ordinator for the rest of the home. Individual activity programmes are in place on the male wing and independence is actively encouraged. An activities file is held for this wing and individual activity records are maintained. We saw activity staff working with men in the lounge and individually, we were told they cook their own meals on weekdays and we saw this happening. The AQAA states that a new vehicle has been purchased to take residents out either individually or in small groups. We were told that some activities take place in the other areas of the home but it is
Care Homes for Older People Page 18 of 35 Evidence: not regular. People upstairs were sitting in the lounges, one person was receiving one to one care and was involved in word search game, he was also interested in the television programme. People downstairs were sitting in the lounge or wandering around the corridors. Information about visiting entertainers was seen and a violinist was entertaining people downstairs during this inspection. At the last inspection in 2007 the registered manager said she would implement a sheet specifically for recording social activity and each resident would have one in his or her file. This has clearly not happened as records are still kept in the daily records making it difficult to assess how much activity is taking place. Staff told us of activities that include foot bathing, manicures, hand massage, baking, reading to people and one to one chats. Some said reminiscence takes place but not regularly. There appear to be no visits from religious ministers. Relatives told us that to their knowledge no activities take place upstairs and others said they were not sure what goes on downstairs apart from the entertainers. Staff said residents are encouraged to live the lives they wish as much as they can and this is more possible on the male wing. Peoples personal preferences regarding getting up and going to bed were seen in the care files. Breakfast was observed to go on throughout the morning indicating that people are not all woken up early. The manager said that preferences in respect of the gender of care staff were recorded but these were not seen. The manager told us that mental capacity assessments have been undertaken for all residents but the care plans have not been updated accordingly. She said that two deprivation of liberty authorisations have been made. People were seen moving freely around each area of the home, keypads were used between each area for staff and visitors to access. Systems are in place to deter residents wandering into other peoples rooms; for example some residents have a gate across their doorway and bedroom doors are locked whilst people are in the lounge. A gate was used as a form of restraint for someones safety in one area. It is not clear that risk assessments have been carried out for the use of gates and that consent has been sought. We were told that toilets are kept locked and this was discussed with the manager as people should have access to toilet facilities. The visitors book showed that people visit regularly however the book has been moved from the entrance of the home to the staff desk in the lounge so the records may not be accurate. Relatives told us it depends who opens the front door as to whether they are asked to sign the book. Relatives said there are no restrictions on visiting times although some said the home prefers mealtimes to be avoided. One man said he has meals with his wife. Some relatives said they are made welcome others said the home is not a welcoming place. We were told that visiting had to be stopped on more than one occasion this year due to outbreaks of diarrhoea and vomiting. Relatives said this was very annoying.
Care Homes for Older People Page 19 of 35 Evidence: The cook told us there is a three week menu in use and she showed us the food records she keeps. It is a set menu but the records show that people do have alternatives. The lunchtime meal was written on a board in the downstairs lounge. The cook has worked at the home for many years and she said she knows peoples preferences and the food is good home cooking. A new assistant cook has been employed, she told us about her interest in cooking and she was given some information during this inspection about cooking for people with dementia. Fresh fruit and vegetables were seen and a cake had been made for a residents birthday. Lunchtime was observed and dining facilities were noted to be limited as some chairs and tables need replacing (see the environment section). Some people were seen continually walking around and staff encouraged them to eat as they went. Some people sat at dining tables and some men in the male wing sat at a table in the small kitchen. A majority of people sat with tables in front of their armchairs and quite a number of people required assistance which was given appropriately in a relaxed manner, the mealtime was not rushed. People using the service seemed to enjoy the food provided at lunchtime and staff and relatives told us the food is to a good standard. One relative said the food is very nice indeed, he would recommend it. Care Homes for Older People Page 20 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable policies in place for complaints and adult protection and staff receive training to ensure that people using the service are safeguarded. Evidence: A suitable complaints policy was seen and there is a method for recording complaints, the action taken and the outcome. There has been one complaint to the home in the past year which was upheld. Relatives said they could approach staff if they had a problem, some said they did not know who the manager was. There have been concerns raised to the Care Quality Commission recently from a nurses agency and from an anonymous agency worker. The concerns were in respect of the care of residents and they allege inappropriate wound care, inadequate toileting and pad changes, privacy not being respected and liberty being deprived. There were also issues around the attitude of staff working in the home. These issues have been investigated during this inspection and reported on in the relevant sections of this report. Some of the issues have been upheld and the manager is aware of improvements that are needed. The manager said she will talk to the registered manager at the agency to discuss the matter further. The home has a whistleblowing policy that refers to the No Secrets document and an adult protection policy. The manager said they have a copy of the Local Authority inter
Care Homes for Older People Page 21 of 35 Evidence: agency procedures and alerters guide. She showed us the safeguarding referral forms used. A flow chart was seen on a noticeboard for staff to reference the procedure more easily. The training records were seen and show that some staff have attended adult protection training, the manager admitted that the records were not up to date. Staff told us they have received training about abuse and what to do if there were a problem. There has been one safeguarding investigation since the last inspection that was upheld. The member of staff received a police caution and is no longer working at the home. Another issue regarding a staff member supplied by an employment agency was referred to the Department of Adult Social Care and the police. Recently there has been a referral that does not concern staff at the home and the manager is awaiting contact from the Department of Adult Social Care. There is a secure facility for the storage of money in the home. Care Homes for Older People Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home appears generally clean and well maintained, redecoration and refurbishment in some areas will provide a more pleasant place for people to live and work in. Bathing facilities are inadequate and toilets are not accessible, at present there is no safe garden area for people to utilise which poses restrictions for people accommodated. Evidence: We saw that the home was comfortable and decorated and furnished to a reasonable standard. There were some areas, particularly upstairs where paint was flaking off of ceilings and chipped off of skirting boards and door frames. A second maintenance person has recently been employed to assist with the workload and two maintenance staff were seen and kept busy throughout this inspection. The home was generally clean with steps taken to control odours, some areas looked grubby and overflows on the hand wash basins were in need of cleaning. Some bedroom furniture is old and dated and several chairs were missing and some tables were broken in the downstairs dining room. The manager told us they are going to purchase more durable dining room furniture. Individual bedrooms were seen personalised with pictures and belongings to varying degrees. People who could tell us said they are happy in their surroundings. The grounds are tidy but the enclosed area
Care Homes for Older People Page 23 of 35 Evidence: is not accessible to people using the service at present due to building work in progress. Subsequently those who wish to smoke do so at the front of the home under staff supervision. We were told that the other garden area needs to be levelled to make it safe for resident to walk on. Bathing facilities were discussed with the manager as these have been reduced since the last inspection. The Parker bathroom has been converted into a treatment room and a bath upstairs has been removed and the room used to store equipment. The manager told us that a more suitable bath will be installed upstairs and she will discuss the remaining facilities with the registered providers to ensure that the National Minimum Standards are met. As previously mentioned toilet facilities were not easily accessible as they were kept locked. The AQAA states that the providers have continued to invest in the fabric of the home with a new lift installed and many previously carpeted areas being enhanced by the use of vinyl flooring more appropriate to the residents needs. They have installed toughened glass to all downstairs windows where it was previously missing. They have also fitted a new hatch into the kitchen to separate fresh food from dirty dishes. They hope to improve by completing the new extension and ensuring that the facilities are fully utilised and to complete the sensory garden. The dining room is to be decorated with murals and so on to help residents identify the area. They are going to change several of the vanity units in the bedrooms where damaged by water and start replacing some of the armchairs and tables with better quality furniture. They also intend to re-decorate and make improvements to main kitchen as recommended by the Environmental Health Officer. We were shown the exterior of the extension that is being built at the back of the male wing which will incorporate six new bedrooms and a shower room. We were told that this is expected to be completed by the end of September 2009. The general manager told us that the laundry facilities are being increased and the existing room may become more communal space. Discussion took place regarding the amount of communal space and dining facilities and the general manager said he would make sure this is checked out. The use of vinyl flooring in the home has increased and we were led to believe that this will be used in the new extension. Discussion took place with the manager in respect of the National Minimum Standards and she said she would ensure the flooring arrangements are reviewed. The laundry was seen and we spoke to the person working in the laundry. She told us that all laundry is done in house. We saw two washers and two driers. There is also a domestic washing machine in a sluice downstairs. We were told this is used by care staff to wash soiled items in dissolvable bags prior to it going through the main
Care Homes for Older People Page 24 of 35 Evidence: laundry system. There are three sluices with washer disinfectors in the home. We saw that hand-washing facilities were appropriate and alcohol hand cleansing gel was in use. We saw plenty of disposable gloves and aprons around the home and staff were seen wearing these. Staff told us they had attended infection control training and there were some records to evidence this. We were told by the manager that there have been outbreaks of diarrhoea and vomiting in the home on more than one occasion. She said she notified and sought advice from the Health Protection Agency and relevant precautions were put in place. She did not however notify the Commission as she said she was unaware that she needed to. Care Homes for Older People Page 25 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a lack of nurses and care staff at the home, however the registered providers try to ensure sufficient staff are on duty by offering extra hours to their staff and employing agency staff. There is a lack of continuity which could mean that people s needs are not always met in a person centred way. Training records have not been kept up to date but regular training is provided for staff and 49 of staff have an NVQ qualification, which helps to ensure that residents are in safe hands. There is a reasonably robust recruitment system in place with relevant checks undertaken to offer protection to people using the service. Evidence: We were told that there are staff vacancies for four whole time equivalents on the care side covering both night and day shifts. There is a shortage of qualified nurses in particular at the moment. There is also a vacancy for an activities co-ordinator. We were told that agency staff have been employed for a considerable period of time and that they try to employ the same members of agency staff for continuity. Agency staff were on duty during this inspection and two of these staff said they work in the home regularly. We were told that as a rule during the day there are two nurses on duty. They are assisted by three care staff upstairs, one providing one to one care, five in the main
Care Homes for Older People Page 26 of 35 Evidence: area and two in the male wing. There are also activity co-ordinators in the male wing some of whom are qualified care assistants as well. At night there are one or two nurses assisted by four or three care staff respectively. Care staff are reduced to three in the afternoons in the main area but extras work in the evenings to assist people getting ready for bed. We were told that most of the time shifts get covered by staff working overtime or by agency staff. The rota shows that shifts do not always get covered. On the day of this inspection a nurse went sick so the manager was helping to cover the floor. We were told that advertising is taking place and that they are actively trying to recruit staff ready for the completion of the extension. We were told there are sufficient ancillary staff employed. Staff told us there have been staff shortages but that management try hard to ensure there are enough staff in each area. They said they work across all areas of the home apart from the activities staff who stay in the male wing. Relatives and visitors told us there is a lack of continuity because of the amount of agency staff employed. They said sometimes it is difficult to know who to speak to as some staff do not know what is going on. One person said that a calmer approach to caring for people with dementia may be more beneficial. Staff were observed to interact very well with residents in a patient, kind, relaxed manner. Several male care staff are employed and the manager said this works well. The home is approved to take nursing students but has no placements at the moment. Care staff told us the registered providers encourage them to undertake NVQ qualifications but there have been local funding problems and courses have been stopped. We were told that they hope to utilise another training company soon. We were told that 49 of care staff have an NVQ either at level 2 or 3, this includes activities staff. At the moment two staff are working towards level 2 and one towards level 4. Copies of NVQ certificates were seen in staff files. The AQAA told us that the services of an occupational health adviser are now available if required. Eight staff files were inspected and all bar one held an enhanced CRB disclosure obtained prior to the employees start date. A satisfactory POVA first check was seen for one person dated prior to starting work but no CRB as yet. The manager said this person is supervised at all times but there was no evidence to show this. One person had no references on file and two people had only one. It was noted that the previous employer is not always asked to supply a reference. There were no contracts seen or terms and conditions of employment. Five files held interview records. Nursing staff did not have a copy of their nursing qualification certificate or confirmation of
Care Homes for Older People Page 27 of 35 Evidence: their Nursing and Midwifery Council (NMC) registration other than a copy of their NMC pin card. Some files contained completed induction sheets but these were merely an orientation to the home. There was no evidence that the skills for care induction programme is in use as it was at the last inspection. The manager told us this was to be implemented; at present new employees have three days under the supervision of a mentor who signs off a checklist. Staff told us they receive a good amount of training which they appreciate. We were told that a health and safety consultant is still employed to provide most of the statutory training; undertaken over periods of five days. The training entails, fire safety, infection control, food hygiene and health and safety. We were told that a suitably qualified member of staff provides the moving and handling training and she is presently on the trainers update course. We were shown a printed copy of a training matrix that had been compiled since the last inspection. The master copy is held on a computer at the administration office in Praze and Beeble. One of the registered providers told us that the provision of computers for the managers in the three homes is imminent. It is hoped that the training matrix and other records will be available across the homes for managers to update themselves rather than send the information to the office. The matrix we were shown was not up to date, the manager said she had things to add to it. We saw various booklets provided by the Alzheimers Society and DVDs for training use. The general manager told us about a new training supplier that is part of the local regeneration scheme. They hope to utilise this facility and someone from the company has interviewed all of the staff to undertake a training needs analysis. He said a member of staff working across the group of homes is going to be responsible for coordinating staff training. Nurses told us they are offered external updates, for example, about the use of syringe drivers and subcutaneous infusions. They said that often the courses are cancelled by the training provider due to lack of support. Care Homes for Older People Page 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The deputy manager is running the home in the absence of the registered manager; she is new to the role and has found it challenging but is aware of areas she needs to improve to lead the team more effectively. There are some quality assurance systems in place but there is no evidence that surveys or meetings take place to enable residents, relatives and stakeholders to air their views and contribute to improvements. There are systems in the home for dealing with residents money and health and safety that aim to safeguard residents from harm. Evidence: The registered manager has been on sick leave since February 2009. A deputy manager was employed in October 2008 and she is responsible for the daily running of the home at the moment, with support from the general manager and one of the registered providers. The deputy manager is a Registered Mental Nurse who is presently undertaking the Leadership and Management for Care Services Award. She said she keeps up to date by reading and using the internet. She said she also
Care Homes for Older People Page 29 of 35 Evidence: networks with colleagues within the company. Recent training includes the prevention of pressure ulcers, Deprivation of Liberties, Mental Capacity Act and risk management. She did a great deal of research in a previous job when she introduced the tidal model of mental health, which is still being used. She said she is learning all of the time and running the home has been a big challenge for her. The lack of staff has meant she has had to spend time as a nurse on the floor and she works at weekends sometimes. Staff told us that the deputy manager has worked hard and she is popular with the staff team. Relatives told us they do not know who is managing the home. One said I have never met the manager I see the nurse on duty . We saw that the staff areas of the home, for example offices, nurses station and treatment room were untidy and disorganised. Some staff said that people do not tidy up after themselves. Nurses were frustrated that the new treatment room was already in a mess. We have already mentioned the disorganised care files and the lack of continuity of wound care earlier in this report. The management team need to have systems in place to ensure the home and the record keeping is more organised and ensure that all staff are consistent in the care they provide to residents. We were told that quality assurance surveys have not been undertaken recently. The surveys shown to us were not dated. The manager said she hopes to change the format of the survey form. The manager and staff told us that staff meetings have taken place but there were no minutes. The manager said there has been one nurses meeting and one care staff meeting since February 2009 but there was a meeting planned for next week. We were told there have been no resident or relatives meetings. The manager said she plans to increase the number of audits undertaken but has not been able to do this yet. We saw the recent medicines audit and the accident audit. The deputy manager has completed an Annual Quality Assurance Assessment (AQAA) for the Commission. One of the registered providers completes a monthly regulation 26 report that reports on the conduct of the home; these reports were seen in the home. We were shown a policy for the management of resident s money and a page about pocket money in the resident s guide, The information was vague and needs to be updated to state the procedures used in the home and at the administration office. The manager said there is money held for three people in the safe and other money held in a resident s account dealt with by the administration office staff. She said a consent form is going to be devised for residents / relatives to agree to money being held. We were told that one person is escorted to the bank and gets her own money that she deals with herself. There was a small amount of money held in the safe and we saw records of the transactions that were signed by two people, one being the resident when possible. We were told that petty cash is used to purchase items for some people and the receipts are sent to the administration office where an administrator deals with the resident s account and invoices relatives for
Care Homes for Older People Page 30 of 35 Evidence: purchases as necessary. The administrator explained the system to us and said that she would discuss the issue of some people having a negative balance with the registered providers as it means that money is borrowed between people within the resident s account. She said that electronic records are maintained of all transactions and the accounts are printed each month for the resident or their representative. Receipts are kept for purchases and for money received on behalf of residents. We were told that the home has a health and safety policy. We were also told that an external consultant deals with most of the health and safety issues in the home, for example the audits and the fire risk assessments. An action plan is in place and as previously stated in this report he provides some training for staff. We spoke to one of the maintenance staff and saw the other at work in the home. We were shown the service and equipment check certificates which were all up to date. Fire safety records were seen and include details of weekly fire drills. The maintenance records and small office were very tidy and organised. The maintenance man told us that he has recently purchased some window restrictors; we had noticed that one was missing on a window upstairs. He said the legionella, asbestos and health and safety audits had been completed and the recommendations were being addressed. He said that not all water outlets have thermostatically controlled hot water although baths and showers were regulated. He agreed to purchase signage for area where water is very hot. Risk assessments also need to be done for residents who have access to hot water. The most recent Environmental Health Officers report was seen and we were told that the issues are being addressed. Refurbishment of the kitchen was recommended. The seals on one freezer are worn and the freezer frosts up very quickly and needs to be addressed. The cook now has the Safer Food Better Business manual and staff are awaiting training on its use. The accident book was seen and accident reporting discussed with the manager. There were 16 accidents reported in May and 13 in June this year. Care Homes for Older People Page 31 of 35 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 9 13(2) The registered person shall 26/10/2009 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. For example: Any handwritten information on MAR charts must be witnessed with two signatures recorded. The medicines fridge temperature must be monitored and recorded regularly Medicines must be appropriately disposed of Care Homes for Older People Page 32 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 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No. Refer to Standard Good Practice Recommendations 1 1 The statement of purpose and residents guide should be updated. To enable people to make an informed choice about moving into the home The care files should be re-organised so that staff can access information they need effectively Care plans should include the use of medicines where appropriate to ensure staff have specialist guidance and direction. Care plans should be more detailed and contain religious, social and cultural needs. To inform and direct staff on the care to be provided Suitable activities and entertainment should be provided for all people using the service with suitable records maintained for each person. To evidence people are stimulated and have opportunities to socialise. The registered providers should ensure that suitable bathing facilities are provided in numbers that meet the National Minimum Standards The registered providers must review the way that the residents account is run so that money is not shared between people who use the account.
Page 33 of 35 2 3 7 7 4 7 5 12 6 20 7 35 Care Homes for Older People 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. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 35 of 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!