Inspection on 24/08/09 for Waterside Care Centre

This inspection was carried out on 24th August 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Waterside Care Centre 21/01/10

Waterside Care Centre 26/11/09

Waterside Care Centre 02/03/09

Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

Key inspection report Care homes for older people Name: Address: Waterside Care Centre Waterside Care Centre Leigh Sinton Malvern Worcestershire WR13 5EQ     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sally Seel     Date: 1 0 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 54 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 54 Information about the care home Name of care home: Address: Waterside Care Centre Waterside Care Centre Leigh Sinton Malvern Worcestershire WR13 5EQ 01886833706 01886832882 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Minster Care Management Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 46 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: The maximum number of service users to be accommodated is 46 The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 46 Date of last inspection Brief description of the care home This is a purpose built two storey home situated in the village of Leigh Sinton, near Malvern. It provides nursing care on a permanent and respite basis for up to 46 older adults who have dementia and may also have some physical disabilities. All bedrooms are single occupancy and have ensuite facilities. There is a choice of well furnished seating areas. Bathing facilities are available on each floor offering a choice of a bath or shower. Aids and adaptations are available so that people requiring assistance can Care Homes for Older People Page 4 of 54 Over 65 0 46 0 2 0 3 2 0 0 9 Brief description of the care home receive it safely. There is a passenger lift so that people can access all parts of the home and there is a secure garden to the rear of the premises that is accessible to people with limited mobility. At the front of the building is a car park providing off road parking for staff and visitors. The home has a no smoking policy. There is a bus route to Leigh Sinton and the home is within walking distance of the local shops. In the reception area there is a range of information for people living in the home and their visitors to access about the home . A copy of the inspection report should now be added to that information.The home has a range of fees and the manager should be contacted for up to date information about what these are. Care Homes for Older People Page 5 of 54 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. This is the second key inspection at the home for the year 2008 to 2009 and it is recommended that this report is read in conjunction with the previous report for the home. The first visit to the home was undertaken on the 24th August by one inspector over one full day and an Expert by Experience spent part of the day at Waterside. The inspector spent the day meeting relatives and staff members. Mrs. Pat Whelan, an Expert by Experience is a person who, because of their shared experience of using Care Homes for Older People Page 6 of 54 services, and or ways of communicating, visits a home with an inspector to help them get a picture of what it is like to live in or use the service. The acting manager and project manager assisted us throughout. The management team and staff did not know that we were visiting on that day, when there were thirty four people living in the home with two individuals spending a short time at the home, known as respite care. The second visit to the home took place on the 3rd September by two inspectors over one full day. Information was gathered from speaking to and observing people who live at the home. Three people were case tracked and this involves discovering their experiences of living at the home by meeting or observing them, looking at medication and care records and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. We partially looked at two other care records. Forty six surveys were forwarded to a randomly selected number of people which included relatives and health and social care professionals prior to the inspection. We also forwarded twenty surveys to the home for staff members to complete. Comments from the returned surveys have been incorporated into the report along with any comments from relatives and staff working at the home on the days we visited. We have also used the information received from relatives who contacted us directly. Staff files, training records, maintenance and complaints records were also reviewed. It is difficult to get peoples views about the home due to differing levels of dementia however two people who live at the home, three visitors and staff who were on duty at the time were spoken to. The third visit to the home was undertaken on the 10th September by one inspector over a shorter day period than our first and second visits. The inspector spent the time briefly looking at a some care plans of people who live in the home, reviewing medications with staff and checking other documents that were not at hand on our second visit to the home. These included the staff training matrix, checking nurses PIN numbers, reviewing staff supervision and two reports of visits completed by the provider. The inspector also spoke with some staff that were on shift at the time. Reports about accidents and incidents in the home were reviewed in the planning of this visit. Prior to the inspection the former manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This was detailed and told us how well the management team think they are performing and gave us some information about staff and people who live there, improvements and plans for further improvements, which we have taken into consideration. Following these visits we will request that the management team complete an improvement plan. Once completed this will tell us what the management team are going to do to improve the service so that it meets all the requirements that we have made which can be found at the end of this report. A further inspection will be carried out to monitor progress of this to safeguard the health and wellbeing of the people who live in the home. We would like this opportunity of thanking people who live in this home, their relatives, the acting manager and project manager and all staff for assisting us with this inspection and making us feel welcome. Care Homes for Older People Page 7 of 54 What the care home does well: What has improved since the last inspection? Care plans have been reviewed since we last visited the home and with further improvements these will make certain individuals needs are met appropriately. Arrangements are in place to ensure that all complaints and concerns are fully investigated so that people can be confident that their views are listened to. Some further improvements should be considered to ensure that the acting manager promotes an open door policy which would be welcomed by relatives. One relative said, Home manager currently not present and have not managed to see and or speak with a acting manager when visiting. Where people are assessed as needing bed rails to keep them safe these are fitted with bumpers to eliminate the risk of individuals getting trapped. Care Homes for Older People Page 8 of 54 Staff are now beginning to receive supervision and a planner has been devised to help with the planning of supervision. Supervision provides staff have the opportunity of looking at their areas of practice and support is provided to staff with training and dealing with the people they care for. What they could do better: All preadmission assessments, care plans and risk assessments should be consistently read by all staff. This is so that people living in this home can be confident that their health, personal, psychological, emotional and social needs will be met for each person by staff who know what assistance and support is required. This will also make certain people are safeguarded from staff practices that place them at risk. Either the person living at the home and or their representative should be consulted about the care provided and invited to attend reviews of care. This ensures that all parties are aware of the care being given, why and what this achieves. The medicine management must improve to ensure that all the medication is administered as prescribed at all times as the doctor requires. Meal times need to be managed and coordinated to make sure that these are pleasant experiences for people who live in this home. Social stimulation and the provision of activities need improvement to make certain that it is meeting individuals needs particularly as people who live in this home have varying levels of dementia. This should include more opportunities for people to access the community and one to one stimulation. One relatives comments were, They need more activities funding: dementia patients need mental stimulation. Staffing levels must be reviewed and take into account the individual needs of each person who lives at the home so that there is sufficient staff on duty to meet peoples needs to keep them well and safe. Training for all staff must improve so that it gives confidence to people living in the home that they are supported by knowledgeable and skilled staff who can meet their individual and collective needs at all times. Specific training in Dementia care must be available to all staff so that the outcomes for people living at Waterside Care Centre improve so that peoples sense of well being is promoted whilst keeping them safe. Specific training is needed for all staff in the protection of vulnerable people which should include safeguarding/protecting vulnerable adults, Mental Capacity Act and Deprivation of Liberty (DOLS). This will ensure all staff have the knowledge and skills to protect people from harm together with working in the best interests of individuals. There are further areas which needs improving in this home and these can be found at the end of this report in the requirements and good practice recommendations if people wish to read these. Care Homes for Older People Page 9 of 54 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 54 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 54 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. Information about the service needs to be valid and correct to enable people to make an informed decision about the suitability of the service for them. There is room for improvement to make sure peoples needs are met if they move into this home. Evidence: In the reception area of the home we found a copy of the statement of purpose which provides people who are interested living at the home information about what it would be like to live at Waterside. It would be helpful if this was now updated as there have been some changes in the home, such as, the management structure. This is important as relatives told us on the 24th September that they were unaware of the management changes and therefore did not always know who to direct their queries and or concerns to. We were given a copy of the service user guide which says that the home provides care to older people who have a diagnosis of dementia. The guide also confirms how Care Homes for Older People Page 12 of 54 Evidence: much it would cost people if they chose to live at Waterside together with what the environment of the home is like, services and facilities, such as, hairdresser and chiropody visits. The information in the service user guide may also need updating as we were told by family members that a hairdresser had not been to the home for a number of months. It was confirmed to us that the statement of purpose and service user guide can be made available in larger print. It would also be good practice to consider offering information in pictorial or audio visual formats so that people with different needs are able to understand information about the home before they move in. The Annual Quality Assurance Assessment tells us, Relatives are actively encouraged to visit and view Waterside on an unannounced basis and gain whatever information they want to form an opinion about the home, the service it provides and its suitability. During our visit we followed the experience of one person who had recently moved to the home. This persons relative had not been to visit the home prior to the person moving into Waterside and there was no indication that told us the reason why. However, we were assured by staff that people do come to visit the home. These visits are very often undertaken by family members and sometimes the administrator shows visitors around. We were told that preadmission assessments are completed before any person moves into Waterside so that the person is certain their needs can be met. In the AQAA it tells us, We undertake comprehensive and detailed pre-admission assessments whenever we are approached by an individual or organisation to consider providing a service for a person. Further care and consideration is now required when completing preadmission assessments as we found that one person was a diabetic but no full explanation for staff to clearly follow in relation to meals. This is to make sure there is sufficient information to meet a persons needs from day one and that all staff are reading peoples care records so that they know how to meet an individuals needs and keep them safe. Further examples are provided throughout this report. One person said that they wanted to return home. We discussed with the acting manager as to whether all of this individuals needs were being met. The acting manager told us that this persons needs had changed since initially assessing them and agreed that their needs required reviewing to make sure this home is the most appropriate one for them. This person is younger in age than other people living in the home, physically able and we wondered how their needs in respect of social stimulation were being met particularly from the examples we have given in the Daily life section of this report. The AQAA says, We assess and consider how well the Care Homes for Older People Page 13 of 54 Evidence: prospective client will interact with people who are currently using our service to facilitate effective social integration and companionship. We observed some positive practices but were also concerned about shortfalls in the service, examples being; management and administration of medications, staffing levels and there are only seven staff that have completed training sessions in relation to dementia care. Our observations during our time at the home confirmed that not all individual needs are being met and that they could potentially be placed at risk. Therefore we cannot be certain that new people moving into the home will have their individual needs met to ensure good outcomes for all people who choose to live at Waterside. Since we inspected this home we have been advised that the provider has agreed with the local authority to a voluntary suspension of any new placements. The home does not provide intermediate care so we did not assess this standard but does accept people for respite care. Relatives told us: Good friendly atmosphere. Provide a bright modern environment. Cheerful welcoming staff. Care Homes for Older People Page 14 of 54 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for meeting peoples health and personal care needs including medication are not always being adequately, consistently and appropriately met which puts them at risk of harm. Dignity and respect is not always fully practiced in this home which impacts upon peoples mental health. Evidence: We case tracked three people and part of this process involved looking at their care plans and risk assessments. Each person has a range of care plans which inform staff of individual needs together with what care and assistance is required from staff to meet these. We saw a range of care plans that covered washing, dressing, physical abilities, mental health, diabetes, eating and drinking and sleeping. Whilst it was positive that we saw care plans had been reviewed following the last inspection some of the needs of people that had been reported in care assessments were not fully drawn up into care plans. Examples of where some information was missing in care plans were in relation to paranoia, bed rails, possible fortified foods and dressing. In one persons care records it said that the person experiences Care Homes for Older People Page 15 of 54 Evidence: agitation. We were informed that there was a new care plan but we could not find this so were uncertain as to whether staff practices were meeting this persons needs appropriately. In some cases it was difficult to easily follow each persons care plan due to old care plans being replaced by new ones. It is recommended that care plans no longer in use should be filed to prevent possible confusion. In the main we observed people to be clean and dressed appropriately. We received mixed comments from relatives in relation to staff meeting individuals personal hygiene needs. Relatives commented: We are not unhappy or dissatisfied with his daily care he is always clean, well dressed, helped with his toilet needs etc. Attention to the personal care plan could be better, whether it is the lack of staff at times, things like hair washing and nail cutting. Care plans need to be better known by all carers they are so busy they havent time to study them. Ensure residents have own clothing. I like the care my husband and the other residents get from the staff they seem to be very caring and always on hand. The individual care workers are excellent and we have no complaints about my fathers personal care. We looked at separate records for people living on the ground floor of the home which were filled in by staff to highlight when people were assisted to bathe and or shower. It said on these records, Residents are bathed at least once a week. It was documented that five residents bathed on the 01.09.09 and three on the 02.09.09. There was no record of one person being bathed for three weeks. A member of staff said that they did not know about these records. This does not show good practice and we cannot be certain that staff are delivering consistent and appropriate care to meet peoples needs at all times. It was positive to see some care plans reflecting individuals choices and maintaining their independence whilst assisting people to meet their daily needs. This is generally known as person centred care. For example, in one care plan it informed staff that the person was able to wash their own hands and face and in another one it said to help the person to choose their own clothes. There is some room for improvements when writing care plans in relation to gaining good consistent information so that individuals receive the type of care they need in a manner which upholds an individuals way of life. This is particularly important when people experience varying levels of dementia and are unable to always express their needs fully. Therefore we recommend that care plans are drawn up with the involvement of relatives and or the persons representative as through the practice we have observed together with the comments we have received from relatives, this is not happening. Although the AQAA says,To continue improving user involvement and the involvement of relatives within Care Homes for Older People Page 16 of 54 Evidence: the care process. If this was put into practice it should make certain that individuals needs are met in a preferred way which has the potential to lessen some of the anxiety, distress and agitation that we observed through staff practices with people. In the main care is reviewed monthly or more often if needed and this is generally documented in an evaluation. The reviews examined whether the care given had the desired outcome or if changes were required. Some care plans were seen to reflect any changes. However, in one care plan we did find that some medication had been stopped but could not find any details of the staff member having discussed this within a multidisciplinary forum, such as, with a doctor. We also found that the information was not made clear in any of the daily records so that we can be sure that staff practices are consistent. Care should also be taken to ensure practices in relation to reviewing individuals care needs are done proactively as soon as this is recognised. This should make sure that all people are receiving the right type of care that they require and are not left in a situation whereby their needs are not being met adequately which can affect peoples health and wellbeing. Whilst case tracking we also saw some risk assessments that covered falls, mobility, the risk of skin breaking down and developing sores, moving and handling and nutrition. We observed staff practices to see if their actions and knowledge promoted the safety of people whilst completing daily tasks. We saw one member of staff lifting a person from a chair to a wheelchair using an underarm lifting maneuver which is not a safe moving procedure. We looked at this persons care records and this told us that this persons standing and walking was variable. It stated that two staff should assist this person and on occasions equipment should be used to ensure the person is safely lifted. This concerned us as we were already aware through comments received from some relatives where issues had been raised in relation to staff members using lifting procedures that were unsafe. We discussed this practice with a member of staff who acknowledged that two staff should have been assisting this person to maintain their safety. We looked at the staff training matrix which indicated that the majority of staff have received training in manual handling. In another persons care records we saw no risk assessments for a person who managed to leave the home unescorted and no daily recordings that would inform staff that this person left the home by themselves. We were told that this incident happened on the 8th August but we were unaware of it until it was mentioned to us on the 24th September. This will be discussed further in the complaints and protection section of this report. The last inspection reported, It was of concern that we did not see that there were Care Homes for Older People Page 17 of 54 Evidence: any bumpers fitted and we were told by a senior member of staff that there were none available in the home. We saw that people had profile beds, these are beds that have specialised mattress to minimise the risk of skin breakdown, and attached bed rails that reduce the risk of entrapment or injury. We were shown some beds where bumpers were used. A member of staff also said to us that perhaps some confusion had arisen at the last inspection as bumpers are available in the home. Some staff told us that they do not have time to read peoples care plans and we were told new members of staff generally get to know how to meet peoples needs by watching their colleagues. Also through our observations there were times when it would have been very difficult for two staff to assist individuals without leaving other people without appropriate supervision. Indeed we observed times where staff needed some understanding of how to assess and manage aggressive and challenging behaviour, which can be experienced with people who have dementia. This would mean staff having received appropriate dementia awareness training together with reading care plans and risk assessments. In one persons care plan it stated that they would require some reassurance at times and that they should be supervised due to risk of falls. The Expert by Experience made an observation about this person, was wandering in a distressed manner in the corridor. She was trying to grab her (staff member) arm and asking to go home. In fact no one responded to this lady. She wandered up and down the corridors repeating the same request and one would have thought she was invisible. I was surprised to find that someone caring for residents with short term memory problems and dementia wasnt able to react in a more positive and supportive manner. One relative said, The care staff are always helpful welcoming and friendly but some lack the expertise to care for residents special needs required by their physical and mental disabilities and another relative told us, We are concerned about the lack of staff on duty at any one time. Recently there are only 2 staff covering the whole of the ground floor complex. I feel this is not sufficient for the residents disabilities. Therefore we cannot be sure that all staff had studied individuals care records and knew the needs of each person. Also we observed other instances, which are documented throughout this report where staffing levels have impacted negatively when trying to manage individuals frustrations and distress appropriately ensuring good outcomes for all people who live at Waterside. It was positive that staff are recording what individuals are eating and drinking to make sure that people are gaining their required nutritional needs on a daily basis. We saw a mixture of good and poor recordings. We observed some people to be very thin and found care plans in relation to diabetes that did not always provide staff with all of Care Homes for Older People Page 18 of 54 Evidence: the information so that individuals nutritional intake could be monitored in line with their medical condition. We did however look at weight records and in the main these were recorded regularly to make sure any losses and or gains were identified in a timely manner. Although we did observe staff trying their best to make sure individuals were eating their meals but this did not always reflect good practice and will be examined further in the daily life section of this report. We have raised our concerns throughout this report that staff are not always reading care plans and one staff member had not realized that they were supposed to record peoples daily food and drink. We also found that staff training is lacking in nutrition and staffing levels do not always result in helping staff to promote good outcomes for all people who live at Waterside at meal times. Therefore it could not be guaranteed that peoples nutritional needs are being met appropriately. Mealtimes were observed and found to be problematic and this impacts on the nutrition and hydration of people living in the home. This will be discussed fully in the next section of the report. In some care records we found recordings that told us that health care professionals visit the home when required to advice staff and assess individuals medical needs. On the 3rd September we saw a doctor visiting the home and prescribing some medication to one person. All people in the home have access to other professionals such as the GP, tissue viability nurse, community mental health nurses, social workers, and consultants. They also have access to opticians, dentists and chiropodists but with regards to the chiropodist visits we have been informed by relatives that these have not been happening regularly. We shared this with the acting and project manager who assured us that this has now been addressed. We were also told by some relatives that there was often a lack of communication in relation to some medication practices within the home. One relative said, As a family we are frustrated that there seem to be no clear channels of communication. We constantly seem to be reminding different members of staff about chasing up hospital appointments, regular injections etc. Often these need repeating because messages arent passed on. X (persons name) who has Alzheimers will not take their tablets and the staff were not proactive in solving this, it was left to me to show them proof (in a drugs book they hold) that liquid alternatives were available. A health care professional responded to what the home could do better Medication management. This has improved with nagging. We were also informed by a relative that staff were not applying some foot cream to their loved ones foot as prescribed. Care Homes for Older People Page 19 of 54 Evidence: We discussed this with the acting manager and project manager who said this was due to the relative applying tea tree oil. We asked if this had been documented in the persons care records as discussed with the relative. We were shown a care plan evaluation on the 3rd September 2009 where a member of staff had noted in August, no specific date, Tea tree oil preparations being used by X (persons name) appear to be helping Xs feet. There was no reference to this in the individuals daily records and or confirmation of discussion with the persons relative in any decision making process. The acting manager and project manager acknowledged that this was the case. The medication ordering, storage, administration and disposal was examined on the 3rd and 10th September to ensure that this is safe and meets the needs of the people living there. As with other examples of practice highlighted throughout this report we saw examples of good and poor staff medication practices. On the 3rd September medicine records, in the main, on the ground floor were seen to be appropriately documented with staff signatures to record that medication had been administered to people living in this home. A code was recorded to explain why medication had not been administered. Random checks were done to see that medication had been given as the doctor had prescribed. For example, one check showed that the number of staff signatures on the Medication Administration Record (MAR) was the same as the number of tablets that had been removed from the medication container. This shows that medication was being recorded accurately to ensure the well being of people who live on the ground floor of the home. We also looked at the storage and administration of controlled drugs on the 10th September. On the ground floor we looked at the controlled drugs register and counted the drugs in the cabinet with the nurse. We found that records of Temazepan 20mg and Phenobarbitone 30mg tablets did not tally with the drugs register and the numbers found in the containers were different. The nurse at the time and the acting manager could not provide us with an explanation. There was no information that would inform us that this medication had been previously audited, shown the discrepancy and been investigated. Therefore we cannot be certain that people are being given their controlled drugs as prescribed by their doctor. On the 10th September we looked at how medications are managed on the first floor of the home with a member of staff who was a nurse. The treatment room where medications are stored looked clean and generally well organized. We found there was a mixture of some recordings on the MARS which informed us that people had received their medications as prescribed and there were other examples which showed Care Homes for Older People Page 20 of 54 Evidence: us that this is not happening in practice. For example, we found some gaps on the MAR where staff had not signed and or used a code to inform us that individuals are receiving their prescribed medications as directed by their doctors. This was also found at the last inspection where a requirement was made which said Arrangements must be in place so that people receive their medication as prescribed. This was acknowledged by the nurse. It became difficult to determine the quantity of medication available due to the way this was recorded. There was no written information to tell us that all medications are audited to ensure that there is a correlation between medications dispensed and given. We were informed that only nursing staff administer medications to people. We did not see any records that confirmed that staff competency is assessed on a regular basis. Therefore we looked at the training matrix which is used to document training that staff have received and helps to plan any training gaps together with refresher courses. The training matrix indicated that one nurse had received training and one member of the care staff. No quality assurance system was used to assess individual staff practices in the safe handling of medicines. The manager was keen to implement this to improve practice to a safe level. We also looked through care records on the 10th September of people who received when required medications on the first floor with the nurse. We could not find any care plans for staff to follow to make sure people are receiving this type of medication within written protocols. This means that due to a lack of detailed records it was difficult to understand why the medication had been administered and therefore to know whether the medication had been administered correctly according to the doctors instructions. The management and administration of controlled drugs on the first floor was looked at with the nurse on the 10th September. We saw that the controlled medications tallied with the amounts documented in the drugs register and two staff signatures were detailed alongside each time medication is given to people. This reflects good practice and informs us that individuals are receiving their medications as prescribed by their doctors. It was positive to observe some staff try their best to maintain peoples respect and dignity, such as, referring to people by their preferred name, knocking on bedroom doors before entering, making sure a person had their handbag and recognising that perfume can help people to express their sexuality. However, we also saw some negative practices such as, one member of staff trying to look at the back of a females trousers to see why they appeared too big for the person. This was done in a Care Homes for Older People Page 21 of 54 Evidence: communal area of the home in full view of other people and by a male member of staff. Clothes are important possessions that not only tell people who we are but promote our self esteem. We also saw a member of staff standing reading a magazine whilst one of the people who lived in the home was trying to talk to them. We are concerned about these practices which do not make people feel good about themselves. Therefore it is now recommended that all staff have training in promoting dignity and respect for all people who live in the home. The care plans demonstrated that people and or their representatives were not discussing their wishes in relation to end of life care. This means that people living at the home and or their representatives have no feeling of control and input into the way the end of their life is dealt with. In the AQAA it says, Possible access to and implementation of the Gold Standards Framework for End of Life Care. Care Homes for Older People Page 22 of 54 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. People living at the home are not always offered activities on a regular basis that would meet their individual needs so they are enabled to lead a more stimulating and fulfilling life. Meal times do not promote peoples enjoyment and well-being. Arrangements for visiting the home were flexible, so people are able to maintain important relationships. Evidence: The AQAA told us, We employ two activities co-coordinators who work a total of 40 hours each week. All activities are planned and arranged around the needs of people using our service, and we devise group and individual activities around the life experiences and interests of people, respecting individuality. We attempt to reflect the diversity within our client group. On the 24th August and 3rd September we were told that the activity co-ordinators were both on holiday. There was a varied picture of activities in this home. The home was visited on two separate days and there was no organised activity occurring. On the first floor at one stage a large dice was being thrown back and forth to people for awhile. It was noticed that there were no newspapers but we did see one Care Homes for Older People Page 23 of 54 Evidence: magazine on the ground floor. There were no other items available for people to use such as activity boxes and or other objects that people could pick up and use. This was also the case at the last inspection. However, on the 3rd September we did see some attempts to bring in items for rummage boxes which indicates the management team want to improve the quality of individuals daily lives. We were told that individuals are able to choose to attend the church services that happen at the home which means people are able to continue to practice their religious beliefs. We were told that an entertainer visits the home on a regular basis and we found a poster by the nurses station that advertises this event. Some relatives commented that it is difficult to see any notices on these boards due to where they are positioned. One relative suggests Put a notice board in the foyer/hall where one can read it. At present behind the nurses desk and very difficult to read. On the 24th August and 3rd September most of the people on both the ground and first floor were either walking around or sitting in various rooms. Staff did not appear to have time to sit and talk or do any form of activities. One member of staff said that some people enjoyed having their nails painted but they did not always have time to do this. We observed one person who had recently moved into the home becoming agitated and trying other peoples room doors. There were no activities taking place which may have helped this person and been a positive form of distraction. Staff tried their best to reassure this person but it would have been good practice if staff had been provided with a list of everyday phrases in this persons first language. Although the person did speak English we noticed that at times of agitation and confusion they did speak in their first language as well. This is another example of where preadmission assessments and care plans need to hold sufficient information for staff to refer to when trying to reassure people who experience dementia. We noticed in peoples care records that there was a lack of social histories which give staff information about peoples lives and interests. This gives staff information about people and gives them something to talk with people about which is meaningful to them, and pictures would help with this as well. The Expert provided us with their observations in relation to what is provided to people to make sure that they are offered the opportunities to take part in social stimulation and activities. The extracts from the Experts report on the 24th August Care Homes for Older People Page 24 of 54 Evidence: told us: On the ground floor. The lounge held a count of 10 seated residents and 2 other ladies wandering about banging and shouting, one of whom was X (persons name). Two further residents sat just outside in easy chairs in the corridor. The lounge was otherwise silent and sterile. There were no magazines or newspapers or items to pick up and put down. None of the normal rummage boxes, I have so frequently seen in use. They commonly contain such items as unused scarves, handbags, hats and dusters etc. These boxes are found to be stimulating and help to occupy a busy or restless mind. Even the TV was switched off. There was no music or radio on. I sat outside in the corridor for 30 minutes and not one carer other than X (name of staff member) was present or appeared. She was left to struggle to try to get to know the ladies and gents she was to care for and ascertain how best to support them. She looked near to tears. I asked X (name of staff member) why two ladies were walking about without anything on their feet, she didnt know, I also asked if she thought it was a good idea to put some TV on. She went to find the cleaning lady as she didnt know how the TV worked. When they returned the cleaning lady told me that X (name of person) in particular, wont keep her shoes on. I suggested that they found another way then to protect her feet. On the first floor. For a good 45 minutes none of the staff appeared to be doing very much at all apart from walking round and engaging in banter with one or two of the more vocal and aggressive gentlemen in an attempt to stop them hand fighting with each other. There was an atmosphere of tension on this floor which is borne out of boredom due to a lack of stimulating activity and diversional therapies being provided. On the 10th September we observed the activity co-ordinators assist some people to go into the garden as it was quite a nice sunny day. We also spoke with the two activity co-ordinators who told us that one of them worked 14 hours and the other 23 hours per week. They sometimes come into the home at weekends if there are prearranged activities, such as a fete. We were shown an activity planner which showed a sample of activities such as making cards (arts and crafts), hair dresser, board games, trip to pub, skittles, darts, sing- a- long, glass painting, shopping trip, flower arranging, pamper day (nails painted), crosswords, memory cards, snooker, film, parachute game, cake making, colouring and gardening. We looked at the training matrix to see if the activity co-ordinators had received any training in dementia awareness and found that they had not. Therefore we cannot be certain that there is adequate attention being paid to dementia care needs in terms of stimulation. Care Homes for Older People Page 25 of 54 Evidence: In the AQAA it confirms We operate the homes catering facility like a restaurant with catering staff being responsible for the delivery and serving of meals, while care staff provide people with sensitive support and guidance. From our observations we did not find this to always be the case. We observed the experiences of people who live on the ground floor of the home at meal times. The meal times were noisy, poorly organized and demanding on staff. There is a high dependency, over half of the people living there were seen to require either assistance and or supervision with verbal reassurance in relation to eating. We saw people becoming restless and agitated, the level of noise increased. Behaviour of some people meant that there was disruption and some individuals were not able to enjoy their meals. Some of this behaviour was due to lack of management in relation to making sure people who sat together were able to get along as we saw arguments and some aggressive verbal interaction between people. As discussed earlier in this report we cannot be certain that all individuals are receiving the assistance and supervision they require meeting their nutritional needs. One new person was given their roast lunch and a knife and fork made available. This person became restless and placed their lunch on their chair. This was removed by staff. We looked at this persons care records and it was documented that this individual liked to eat with a spoon and enjoyed finger food. This person walked away from the table and other people became agitated due to this persons restlessness. Another example that was observed was when a person became restless and followed staff from one dining area to the lounge whilst meals were being eaten. Staff were busy and could not manage to reassure this person in eating their meal. At one point we saw a member of staff standing in the middle of the lounge trying to feed this person. The member of staff thought they were doing this with the best intentions but shows lack of training and experience in caring for people who experience dementia. We also noticed that on the 24th August some people who live in the home were wearing blue plastic aprons which shows a lack of knowledge around protecting peoples dignity. However, on the 3rd September we did see some people wearing tabards to protect their clothes whilst eating, which was a positive improvement. The Expert observed meal times on the first floor on the 24th August and told us: The tables in the dining area were set with cutlery, linen and glasses. All appeared pleasantly presented. The dining area overlooks a garden area to the rear. I did however notice that the orange juice had already been put into the glasses and was sitting for a good thirty minutes plus and was uncovered. This poses a risk in terms of Care Homes for Older People Page 26 of 54 Evidence: food and hygiene practices. I also noticed that no one was taken to or invited to go to the toilet. Lunch was delivered on a heated trolley at around 12.45. X (staff members name) joked that this was because the inspectors were here. The ladies and gents had been sitting at the dining table for over 30 minutes and were frustrated and kept getting up and walking off or shouting. There was no menu on display but each person was asked what they would like to eat and each was served individually. There was a choice of macaroni cheese or meat and veg and mash. I opted for the former which came with peas. The lady next to me had the meat. It all smelled lovely and was well presented and served. We had napkins and copious drinks which were topped up frequently. It was pleasing to see that the ladies and gents were encouraged to have more than one drink with their meal. My meal was warm and tasty. It was nicely presented as opposed to being slapped on a plate in a messy manner. This dining room was made quite noisy by the carers chatter and checking back on who was having what for lunch, banging of spoons and the clatter of metal against the trolley along with the clanking of plates. One member of staff was not serving and was available to assist residents with their meals but only one person appeared to need one to one assistance. X (staff members name) and X (staff members name) walked around and generally encouraged or offered meat cutting assistance. There were two soft flan choices for dessert and I noticed that most plates were cleared. Apart from the long wait, lunch was a fairly pleasant if not a bit of a functional affair. It would be nice to have some background music that is maybe stimulating or nostalgic and for maybe the carers to sit alongside a table occasionally to offer support rather than walk round like warden. Some good practices were seen during the course of the inspection such as staff talking to people at lunchtime whilst assisting them with their meal. However, the routine of the home is task orientated which does not enable a person centered approach to meeting peoples individual needs. Responses from relatives told us: Meals are also very good. Always a cup of tea or coffee when we visit. Food is of a high standard and presented well by kitchen staff. Meal times, appropriate cutlery, placement at tables to put suitable people together. Meal times should be a peaceful enjoyable time but is usually noisy disruptive and chaotic. In the main staff told us that meals were good and healthy but perhaps more meal Care Homes for Older People Page 27 of 54 Evidence: varieties could be introduced. There is a flexible visiting policy enabling people to maintain contact with friends and relatives at a time that suits them. This helps people to maintain relationships that are important to them. Relatives and friends were observed around the home during the inspection and staff were seen to be warm and friendly to them. As already highlighted in the previous section of this report practices varied in relation to maintaining and promoting dignity. Choice however was not always being promoted, for example people were not being asked whether they wanted to eat at a particular table, or where and when they had a bath. In one persons care records it said that the person liked to have their handbag with them. However, we observed this person without their handbag on the three separate occasions of visiting the home. Indeed we only saw one person with their handbag on the 3rd September. The lack of females having handbags was reported We also saw that the ladies did not have handbags with them so they could keep things that they like and are important near to them. Lack of choice does not empower people and impacts on their self esteem and dignity. Care Homes for Older People Page 28 of 54 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems and arrangements in place at the home should ensure that people can be confident that their views are heard and responded to. Systems and practices that are in place, which should protect people from harm, are not being applied consistently which may leave people at risk. Evidence: There is a clear complaints policy and procedure which is available in the statement of purpose, service user guide and in the reception area of the home. The AQAA confirms that the manager has received two complaints which were upheld. We have received some complaints and concerns which have been raised in the surveys that we sent to relatives and health professionals. These were mainly around staff not recognising individuals needs, lack of communication, activities, staffing levels, training and management within the home. We were told by relatives on the 24th August 2009 that a meeting had now been arranged with the proprietor so that their complaints and concerns could be focused upon together with action taken where appropriate. We have received one letter of concern on the 21st September 2009 in which a relative has raised their concerns with their doctor. The concerns raised were in mainly in relation to lack of communication, appropriate stimulation, staffing levels, respect should be shown to people at meal times and the individual smelling of urine Care Homes for Older People Page 29 of 54 Evidence: together with their clothes can look dirty. We have also had telephone contact with one relative about their concerns which were mainly that the homes standards have gone down hill since the registered manager left, the home is visibly dirty and there is a distinct smell of urine. A relative was concerned that builders working on the home are using residents bathrooms to wash their hands. This relative has now had the opportunity of discussing his concerns with the provider. Two safeguarding referrals have been made to Worcestershire local authority. Meetings where all professionals involved in safeguarding people from harm were held where the former manager of Waterside Care Centre confirmed at one of the meetings that the member of staff had been dismissed. Staff spoken with told us what abuse means to them and this is in line with local and national information. They also told us what they would do if they witnessed or were informed of abuse. It was difficult to establish from the training matrix how many staff have received training in the Protection Of Vulnerable Adults, (POVA). However, on the training planner it stated that on the 30th September 2009 there was training for staff in safeguarding and POVA. This training should make sure that staff have the knowledge and skills to protect people living in this home from any potential harm. We were concerned that two people have left the home unescorted on two separate occasions and we could not find clear recordings of these incidents within care records. One incident occurred on the 8th August as confirmed earlier in this report and another one happened on the 10th August and a Regulation 37 was completed on the 7th September. The service is required to legally send us a Regulation 37. This is a notification that tells us about these incidents so that we can make sure that people living in the home are safeguarded by the actions of staff when incidents do occur that place people in unsafe situations. We confirmed with the acting manager and project manager that we have not received any notifications of these incidents. The acting manager and project manager said it could have been a human error on the part of staff as they were probably concerned for the individuals welfare at the time. We have now received the notifications but were further concerned that the member of staff completing one of the notifications did not tick the box which would indicate, Event that adversely affects the persons safety and welfare. Instead the member of staff made a comment, None of these. This is concerning as it shows a lack of understanding by the member of staff in reporting any incidents where peoples health and safety may be placed at risk. At the last inspection it was reported, we have received some information from the home where people have been hurt by others living in the home. These incidents have not been recognized by the service as things Care Homes for Older People Page 30 of 54 Evidence: where other agencies should be informed under safeguarding procedures. Therefore we cannot be certain that all staff on a consistent basis have the appropriate level of knowledge to fully understand when people are at risk and how to report incidents of this nature. This is so we can be assured that all people living at Waterside are in safe hands at all times. Four staff have had Mental Capacity Act training so that they are aware of their responsibility in supporting people who lack mental capacity to make decisions. We could not find any documentation that would confirm staff have received training in Deprivation of Liberty Safeguarding (DOLS). This examines how risk assessments and decisions to restrict someones liberty such as movement, leaving the home or making decisions for themselves should be done to ensure that their liberty is not denied. This training is important as a significant number of people living in the home have some form of cognitive impairment. We were told that the home does not manage peoples personal finances but does hold some money on behalf of some of the people using the service. This money is kept safely and records kept of the balance of money held and expenditure. Staff files were sampled and in the main recruitment practices appeared to be robust in the files we looked at so that people are safeguarded from harm. Care Homes for Older People Page 31 of 54 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. There is room for improvement within the environment of this home to make certain that it meets the needs of people who experience dementia. Evidence: The service has two floors, the physical layout on each is almost identical with choices of combined lounges and dining areas, toilets and bathrooms. It has spacious corridors which provide people with sufficient space to walk about. Some people we saw were able to move around the home freely. Walking aids, such as frames or walking sticks were available to help people to walk around the home safely. The home has been described by relatives as being hotel like which is also confirmed in the AQAA. We certainly found this description to be the case. The environment is lacking as theres nothing for people to see, touch, smell, do and listen to that would meet the needs of someone with dementia. Therefore the homes environment is not meeting the needs of people who live there and we have provided examples in this section of the report to highlight where improvements would benefit and meet the needs of people who live at Waterside. As mentioned earlier in this report improvements need to be made in relation to the experience of the meal times at the home. As for the environment there needs to be some consideration made to make sure there is sufficient dining space, such as, tables Care Homes for Older People Page 32 of 54 Evidence: and chairs so that individuals can choose to have their meals with other people. This was noted at the last inspection and the Expert by Experience also observed the lack of dining space. The general decoration of the homes environment is not meaningful to people who experience dementia. We saw pictures displayed on the walls which go some way to making the environment less institutionalised, but which have no meaning to people trying to make sense of where they are in the building. There needs to be improvement to ensure that people are given signage cues to where the toilets and bathrooms are together with individuals own rooms. For example, pictures on walls to confirm the area of the home and for these to be in different textures for people to touch and feel. Memory boxes by peoples bedroom doors with objects in them that hold meaning to them which they can recognise maybe from their past lives. This will help people to find their way around the home and recognise the different areas. The Expert provided us with their comments in relation to the homes environment:The door to each residents room held metal name plates with statements such as serenity, patience, endurance and so forth on them. I only saw one room with a small photocopied picture of a gentleman crudely stuck to the door. I cannot see the relevance of these name plates. They are totally inappropriate in a care setting for ladies and gents with dementia. Waterside Care Centre staff should, put the ladies and gents names and pictures on the doors to their rooms, as a visual prompt to signpost them. I consider the current practice to be irrelevant, offensive and undignified. The toilets and bathrooms also require easily visible, pictorial signage indicating their presence. I was asked by 5 people on the ground floor the way to their room or toilet within the first ten minutes. Clearly the ladies and gents are unable to find their way around their new home easily, which is yet another hurdle for them when they already have dementia. We observed one person who pulled down their trousers and undergarments to sit on a chair in the corridor area thinking it was the toilet. An observation was also made by the Expert, I looked back through the glass panel, into the apparent dining room and noticed an elderly gentleman standing by a table with his trousers round his ankles, relieving his bowels on to the floor. One relative told us that a person came into another individuals room and used their toilet in full view of visitors not realising it was not their room. This shows that the environment is not promoting individuals respect and or dignity which means that it is also lacking in meeting the needs of people who experience dementia. The bedrooms all have en-suite facilities but we were told by some relatives, and Care Homes for Older People Page 33 of 54 Evidence: observed for ourselves, that there is no signage of items in the bathrooms such as liquid soap and paper towel dispensers which are also not at eye level for most people who live in the home. We also saw that the ensuite bathrooms are not all wheelchair friendly as people are not able to fully access the hand washbasins and there is some distance for individuals to reach the toilet roll independently. This may impact on peoples ability to be and feel clean but also on their privacy and dignity as facilities would not be within easy reach for everyone. One person showed us that they had put signs on their relatives bedroom and bathroom door together with the soap dispenser and paper towels so they would be easier to recognise for the person. This person and their relative gave us permission to see their room. This had lots of personal items such as a table, chair, television, photographs and ornaments. Relatives said to make it feel more like home. We also saw some other bedrooms with individuals permission which also had items that were important and personal to them. This practice helps the person to settle into the home quicker and promote their comfort. Communal bathrooms were functional in appearance and we noticed items of equipment were being stored in some which is unlikely to promote a bath which feels like a homely, relaxing and enjoyable experience. The garden area can only be accessed by people living in the home when staff are able to accompany and supervise people. Free access to the garden is not possible as there is numerous obstacles preventing this, a key code plus alarm system and chairs in the lounge need to be moved before the door can be opened. There is also a raised lip at floor height to negotiate which would be a problem for those with wheelchairs, mobility difficulties and or sight impairments. From our observations it would be difficult for staff to always be on hand to supervise people in the garden due to the demands of their hands on caring roles. As reported in the previous section two people have managed to leave the garden area of the home unescorted but we have been assured that the garden access has now been made safe. One relative told us that their loved one enjoyed gardening but due to the lack of staff was not always able to go into the garden at Waterside. In the garden there is a large water course with Koi Carp and ducks which is railed off to keep people safe. It was positive to see that there is garden furniture for people to sit on as they choose. There is air conditioning in the home but we saw one free standing fan on the ground floor and one on the first floor which were plugged in the corridor area, both with trailing electrical cables. The fan on the first floor was working when we passed it. We observed these to be a hazard to people who wander up and down the corridor areas Care Homes for Older People Page 34 of 54 Evidence: of the home unsupervised. We discussed our concerns with a member of staff who said that the fans were in place due to staff being hot. They also said that normally the fan on the ground floor was placed behind the nurses station, however people living in the home also have unsupervised access to this space. Residents were complaining of being cold (several residents were observed to be very thin). We discussed our observations with the acting manager who said that she turns the air conditioning on and believed staff were unsure as to how to do this, hence the use of free standing fans. The Environmental Health office should be consulted to ensure people are safeguarded from avoidable risks. We observed that the door where the photocopier is stored did not have the appropriate fire door closure in place. This was mentioned to the acting manager and we noticed that this was rectified on the same day whilst we were at the home. In the AQAA it confirms that, We have achieved an excellent (5 star) food hygiene rating from Malvern Hills District Council. Care Homes for Older People Page 35 of 54 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are not always supported by suitably trained staff in the right numbers to meet their needs. Evidence: We noticed from our observations and looking at some staffing rotas that staffing levels within the home are variable. On the 24th August the acting manager confirmed that normally staffing levels consist of seven care staff and one nurse 07:00 until 14:00, six care staff and one nurse 14:00 until 21:00 and three or four care staff and one nurse 21:00 until 07:00. There are currently thirty-four residents and two respite placements. However the actual care and trained nurse numbers on duty were less than this, and this was also the case on the 3rd September. There have been some further changes in staffing levels in the home as the former manager had introduced two nurses to be on duty throughout the day. We sampled some staffing rotas and found that the provision of nurses on each shift was variable sometimes there were two nurses and at other times one. In addition to the nursing and care staff the home also have laundry, domestic, kitchen, maintenance and administrative staff to meet all the needs of the people who live in the home. Care Homes for Older People Page 36 of 54 Evidence: As was reported at the last inspection relatives and visitors to the home confirmed that, without exception, staff are caring. A large majority of relatives feel that the staffing levels and lack of dementia knowledge within the staff group is concerning. We have shown examples throughout this report which confirms this as being the case. Relatives told us:- Relatives are welcomed, service users have a lovely environment and personal rooms. Most individual carers and the nurses and activities ladies are outstanding in their attitudes towards my husband but when they are short staffed it can affect them because they are overstretched and tired. There are times, especially weekends when there are only two care staff on, one for upstairs and one for downstairs. This is totally unfair on staff and residents. When staff are on holiday or off sick, arrange replacements, rarely enough carers especially at weekends. I have the feeling that the home is under staffed, particularly at weekends. Observations during this inspection demonstrated that care practice is task orientated and that the staffing levels or deployment of staff does not meet the individual needs of people living in the home at all times. It was particularly noted that at times when staff are assisting and supervising people with their personal care, such as washing and dressing and at meal times, were very busy. Our observations together with speaking with relatives and staff informed us that there are insufficient staff to ensure that all people living at Waterside have good experiences. The management team were made aware of this during the inspection. However, the acting manager and project manager seemed to feel that staffing levels were appropriate and on occasions the home had more staff on shifts than were required to meet each persons needs. We confirmed with the acting manager and project manager that through our observations we saw staff to be very busy. We have provided examples throughout this report whereby staffing levels have not provided confidence that people are in safe hands at all times. The management should now consider how staffing can be better managed and revisit their assessment process to make sure the staffing ratios meet the dependency needs of each person who lives at Waterside. We examined a number of staff records and this confirmed that all checks are carried out to ensure that they are suitable to work with vulnerable people. The AQAA confirms that twenty four staff have left the home in the last twelve months with three of those being dismissed. We were advised by the acting manager that recruitment is ongoing. All nursing staff have had their PIN number checked with the Nursing and Midwifery Care Homes for Older People Page 37 of 54 Evidence: Council to ensure that they are registered to nurse. The AQAA states, All new appointments receive three days supernumerary time. If staff need more supernumerary time, this is accommodated. We did not find this to be the case in practice when we observed a new member of staff often left on their own in the ground floor lounge to assist and supervise people who live in the home. Therefore we cannot be confident that new staff are given the opportunity of not working as part of the shift so that they have the time to get to know the home and the people who live there so that they know how to meet their needs. In the service user guide it confirms, We offer a wide and varied range of training to our staff in order to ensure the homes policies and procedures are adhered to as directed by the National Care Standards Commission, as are the staffing levels set out by the commission. We have provided examples throughout this report which calls this into question. In the main we observed staff showing a willingness to provide care and assistance to individuals in a patient manner. However, as reported at the last inspection, interactions with people did not have a positive affect on them. Suggesting that staff need further training to be able to make people with dementia feel good about themselves. In the AQAA it confirms that there are forty one members of staff who work at the home and nine have completed National Vocational Qualification Level 2. It is recommended that at least 50 per cent of staff have this qualification so that a knowledgeable and skilled workforce can meet peoples needs individually and collectively. On the 3rd September we looked through staff files to see what training staff had received as we were informed there was no training matrix to hand at this time. Staff files looked at did not always have up to date clear training information so that we could be assured that staff have received ongoing training. However, on the 10th September we were shown a training matrix which had been completed since our visit on the 3rd September. A copy of the training matrix was provided, however this showed that there were some gaps in the training. The majority of staff had received training in moving and handling and fire. Some staff had received training in infection control, first aid, care planning and dementia. The deputy manager told us that two trained staff had completed a tissue viability course (sore skin) but this was not recorded on the training matrix. No care staff had received any training in this area and this is recommended so that staff have knowledge and skills to meet peoples needs. Care Homes for Older People Page 38 of 54 Evidence: The training matrix showed us that improvements need to be made to make sure all staff have received mandatory training in, manual handling, infection control, health and safety, first aid, COSHH, fire training and food hygiene. We were made aware that a kitchen assistant had no up to date food hygiene training. It is required that all staff who work in the kitchen complete food hygiene training to make sure people living in the home are protected against cross contamination of food and infections. Staff training should start to improve as we were shown a training planner and this showed that POVA and safeguarding training was planned for the 30th September, in October 2009 training is planned in relation to infection control, pressure ulcer assessment and treatment, moving and handling, nutrition and dementia. In November 2009, appointed persons first aid and dementia training is due to take place and in December 2009, dementia training. Staff told us, I strongly feel that the care team both trained and untrained have a positive relationship with the families of the residents we care for. Better training to cope with residents needs. More consistency in staffing levels. Care Homes for Older People Page 39 of 54 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is in need of a stable management team and a proactive approach needs to be sustained to ensure that it is run in the best interests of the people who live there. Evidence: Since Waterside opened in September 2008 there have been three managers, the third manager recently left their position within the home. A registered manager from another of the providers homes is now in the position of acting manager until a new manager is recruited. They are supported by the project manager. The acting manager is experienced and is a qualified nurse. They are also aware of the structure and actions required to ensure that the home is well run. There was a deputy manager in post on our first visit to the home but when we visited the home on the 3rd September we were informed that this arrangement had now changed. The previous deputy manager is now manager of the first floor and another member of staff has become manager of the ground floor. Both of these members of staff are qualified nurses and we were told that this is a trial arrangement to see how Care Homes for Older People Page 40 of 54 Evidence: it worked in practice. The change in management in the home has been a particularly worrying and unsettling time for relatives. Some relatives told us on the 24th August that they had not been formally introduced to the acting manager. Therefore as highlighted earlier in this report all information about the home needs to be updated so that people are made fully aware of the management structure within the home. This will show that this service is open and transparent in the best interests of the people who live there as individuals rely heavily on their relatives due to their levels of dementia. It was reported at the last inspection that, Greater priority should be given to ensuring staff receive supervision at regular intervals so that they can receive constructive feedback on their performance which will enable them develop their competence further. The supervision of staff has started to take place and we were shown a supervision planner and spoke with some staff who confirmed that this was the case. Staff spoken to generally felt they were not supported by the managers or the organisation. Comments included, Staffing levels are very poor and there is lack of communication and Staff morale is low right now and More information sometimes from senior management of their expectations of the qualified staff. This suggests a low staff morale which ultimately affects the standard of care delivered to people living in the home. We saw that relatives meetings are held and recently relatives had a meeting with the proprietor to share their concerns. Staff told us that they have meetings but some staff commented that these seemed to happen when there was a problem. These meetings are important so that people have the opportunity to raise concerns or ideas about the home and how it can be improved and have some input into decisions about home. There is a maintenance person who carried out basic repairs and ensures that the fire checks are carried out. There is up to date information which tells us that the gas, electric and fire systems are safe and appropriate for this service. We sampled the reports of monthly visits that by provider is by law required to carry out. The provider is expected to speak to a number of staff, relatives and people who use the service to see what the home is doing well and what they need to improve. On the 3rd September we could not find all of these reports but on the 10th September we were shown a further two reports that the provider had completed. No visits were undertaken in February, March, May, July and August 2009 which was acknowledged Care Homes for Older People Page 41 of 54 Evidence: by the acting manager and project manager. As at the last inspection we found that there is a quality assurance system in place to seek the views of people who use the service and their relatives. This provides people with the opportunity of stating their view points about what could be improved in the home to ensure that it is run in the best interests of people who live there. We found that some questionnaires were completed by relatives in April 2009. We have provided many examples in this report whereby some of the practices, services and facilities for people who live at Waterside were apparent at the last inspection. Therefore this shows that these systems have not been effective in identifying the shortfalls we saw in the home and ultimately does not promote peoples health and wellbeing leaving individuals in some practice instances at risk. A health care professional commented, Retain staff, huge turnover which is not a good sign of a well run organisation. Relatives told us some the things they thought could be improved upon:Communication from owner and management. When staff are on holiday or off sick, arrange replacements, rarely enough carers especially at weekends. I feel better staff relations with owner/management, so as the staff would be happy to stay employed. The residents need continuity with the same staff as confusion sets in very quickly. Provide insert name plate to indicate name of duty manager so when visiting home point of contact. Staff be allocated with name tags. Many other suggestions have been put forward as requested in questionnaires but perceive management have made limited inroads. Carers in particular have been left in the dark along with relatives. One volunteered to me that she did not know who was managing the home no information has been made available to relatives. Care Homes for Older People Page 42 of 54 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 43 of 54 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 Risk assessments must be in 09/10/2009 place for all identified areas of risks to a persons health and wellbeing which must inform staff practices. This will help to maintain peoples safety at all times. 2 7 15 All care plans must be 09/10/2009 accessible to staff delivering the care and be a reflection of the care given and when we reviewed and amended at the point where a persons needs change or routinely all staff must be aware of these changes. This will enable all staff to meet individuals needs at all times to make sure peoples health and safety is fully promoted and met at all times. Care Homes for Older People Page 44 of 54 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 3 7 12 Care plans must be in sufficient detail so that staff have the instructions and guidance to meet each persons needs. This will ensure to ensure risks to individuals health and wellbeing is minimised. 11/09/2009 4 8 12 All staff who provide care to 09/10/2009 people who live at the home must have the knowledge, skills and competency required to meet individuals needs together with their planned care. This will make certain that individuals health and welfare is not placed at risk by staff practices. 5 9 13 A quality assurance system must be installed to assess staff competence in their handling of medicines. Appropriate action must be taken when these indicate that medicines are not administered as prescribe and records do not reflect practice. This is to ensure that all medicines are administered as prescribed and this can be demonstrated. 18/09/2009 Care Homes for Older People Page 45 of 54 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 6 9 13 Appropriate information relating to medication must be kept, for example, in risk assessments and care plans to ensure that staff know how to use and monitor all medication including when required, as directed and self administered medications. This will make certain that all medication is administered safely, correctly and as intended by the prescriber to meet individual health needs. 18/09/2009 7 9 13 Staff who administer 18/09/2009 medication must be competent and their practice must ensure that residents receive their medication safely and correctly. This will make sure individuals receive their medications as prescribed by their clinicians. 8 9 13 The quantity of any balances 11/09/2009 carried over from the previous cycles must be recorded. This will enable audits to take place to demonstrate the medicines are Care Homes for Older People Page 46 of 54 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 administered as prescribed. 9 9 13 The medicine chart must 11/09/2009 record the current drug regime as prescribed by the clinician. It must be referred to before the preparation of the residents medicines and be signed directly after the transaction and accurately record what has occurred as some gaps were found on the MARS. This is to ensure that the right medicine is administered to the right resident at the right time and at the right dose as prescribed and records reflect practice. 10 9 13 The receipt, administration 11/09/2009 and disposal of controlled drugs must be recorded in a controlled drugs register. This must be referred to before the preparation of the residents medicines and be signed directly after the transaction by two members of staff and accurately record what has occurred as some controlled drugs were unaccounted for. This will make sure that Care Homes for Older People Page 47 of 54 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 individuals are receiving their medications as prescribed by their clinicians to promote their health and wellbeing. 11 9 12 All changes in individuals 11/09/2009 medication regimes must be completed following a discussion with the appropriate professionals, such as, doctors and all staff must be aware of any changes together with the persons representative where the individuals lacks capacity. This should make sure peoples health and safety is promoted. 12 18 12 Training must be provided for all staff that work with people who have dementia some of whom may be assessed as having difficult to manage behaviour. This will make sure that individuals needs are met in a safe way that respects their dignity. 13 18 13 All staff must be trained in safeguarding procedures so that they have the knowledge and skills in recognising, reporting and 30/09/2009 30/09/2009 Care Homes for Older People Page 48 of 54 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 recording all safeguarding incidents. This will make certain all people are protected. 14 25 13 Following advice from the council Environmental Health office a risk assessment should be carried out in relation to the use of free standing electrical fans in the home. This is to ensure that people are safe from harm. 15 28 18 The homes staffing levels 18/09/2009 must be reviewed. This must be in line with individuals dependency levels and available for inspection. This will ensure that people living in the home receive care in an appropriate and timely manner that meets their needs. 16 33 37 Notifications to the Commission must be made in accordance with current guidance. This is to comply with the law so that health, safety and welfare are protected. The registered persons or a person who they instruct on their behalf must undertake 30/09/2009 11/09/2009 17 33 26 30/09/2009 Care Homes for Older People Page 49 of 54 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 monthly visits to the home as part of their quality assurance process. These reports need to available at times of inspection. This is to to make certain that it is run in the best interests of the people living there. 18 38 13 Staff who work in the kitchen area of the home must receive up to date training in food hygiene and at times of inspection certificates must demonstrate this is in the case. This will ensure individuals health and safety is maintained by all staff who are in the positions of preparing and cooking their meals. 19 38 13 Staff must receive training in manual handling. This is to make sure the safety and wellbeing of individuals is promoted and protected at all time. 30/09/2009 30/09/2009 Care Homes for Older People Page 50 of 54 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 registered person must ensure the statement of purpose and service users guide includes all relevant information in a format accessible to people, so that they can make an informed choice. Written information in the statement of purpose and service user guide should be reviewed and updated regularly. This will make sure that any changes in the service are reflected so that people can make an informed decision about the home. All staff should read pre admission assessments so that people can be confident that staff know how to meet their needs and keep them safe from day one of moving into the home. All management and staff who are responsible for pre admission assessments should ensure that they collect information in a comprehensive and individualised manner so that it provides a person centred approach to meeting that persons needs once living in the home. Care plans that are no longer used should be removed from the care files to avoid any confusion with the care currently required. Care plans should provide details about personal preferences so that people receive care in a way that they prefer. There should be some consideration made in relation to ensuring the privacy, respect and dignity of all people in relation to appropriateness of dress, movement around the home and interactions. Consideration should be made to all staff receiving end of life care training that is appropriate to their position to ensure peoples and relatives needs are met in an appropriate manner. Consideration should be given to enabling people to access a range of tactile items and objects so that they have things to explore and do. Activities must be reviewed and based on individuals needs. Following this review an action plan should be drawn up and findings implemented. 2 1 3 3 4 3 5 7 6 7 7 10 8 11 9 12 10 12 Care Homes for Older People Page 51 of 54 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 11 13 People should have opportunities to access the local community with staff on a regular basis so that they are supported to lead interesting and meaningful lives. It is recommended that the management team obtains a copy of the Department of Health guidance Mental Capacity Act 2005 core training set and staff are provided with training, so that staff are aware of their responsibility and peoples choices and rights are protected. The arrangements for mealtimes should be reviewed so that there is enough staff available to help people with their meal in a way that promotes their dignity and independence and enhances the social aspects of mealtimes. People should be offered a choice of meals daily so that their personal and dietary preferences are met and this is done in a manner that individuals understand to enable full participation. The homes environment must meet the specific needs of individuals who experience dementia so that peoples privacy, dignity, rights, choices and independence is fully promoted. This will make sure that the environment not only meets individuals specific needs but is in line with homes are for living in. Consideration must be given to make sure that there is sufficient dining space for all individuals to be able to choose to eat their meals at dining tables with others. Action should be taken so that there is unrestricted safe access to the garden area and that the garden environment is safe to use without continual staff supervision. The physical environment of Waterside Care Centre must be reviewed to make sure that individuals ensuite facilities meet all individuals needs including people who use wheelchairs. Particularly the washbasins as these appear to be quite low. Urgent cconsiderations should be given to providing additional visual clues and orientation aids so that people can find their bedroom easily. Some thought should be given to providing appropriate signage on the paper towel dispensers and soap dispensers 12 14 13 15 14 15 15 19 16 20 17 20 18 21 19 22 20 22 Care Homes for Older People Page 52 of 54 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 in each persons ensuite facilities. 21 22 The management team must review and audit the suitability of the premises against recognised national guidance such as Alzheimers 50 Point Action Plan and the needs of current residents. Staff should be shown how to effectively use the air conditioning system within the home so that people living at Waterside are living in an appropriate environment where the temperatures are regulated for their comfort at all times. Staff should not work long days so that they are not tired and are able to meet the demands of the people using the service. Staff should receive National Vocational Qualification Level 2 (NVQ) training in care to ensure they have the knowledge and skills to care for people. The management team must take a proactive approach in enabling staff to complete relevant mandatory courses together with some specialist courses, such as, dementia awareness, challenging behaviour and end of life care. Consideration should be given to identifying ways that communication within the home can be improved so that people living there will benefit Staff should be clear on their roles, be supervised at least six times a year, and have meaningful regular appraisals of their knowledge, performance, and development needs. We recommend audits of safe working practices and quality of care as well as observed practice is used to confirm competences. 22 25 23 27 24 28 25 30 26 32 27 36 Care Homes for Older People Page 53 of 54 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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