Inspection on 09/12/09 for Waverley House

This inspection was carried out on 9th December 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Waverley House 17/02/09

Waverley House 05/03/08

Waverley House 15/08/06

Waverley House 03/03/06

Waverley House 18/11/05

Waverley House 24/03/05

Waverley House 16/11/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 14/03/2010.

Key inspection report Care homes for older people Name: Address: Waverley House Etnam Street Leominster Herefordshire HR6 8AQ     The quality rating for this care home is:   one star adequate 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: Jean Littler     Date: 0 9 1 2 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 33 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 33 Information about the care home Name of care home: Address: Waverley House Etnam Street Leominster Herefordshire HR6 8AQ 01568612126 01568620445 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Shaw Healthcare Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 47 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 47. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 47 Dementia over 65 years of age (DE) 47 Date of last inspection Brief description of the care home Waverley House is registered to provide accommodation and personal care for a maximum of 47 people over the age of 65. The registered provider is Shaw Healthcare Ltd. The building was rebuilt in 2007 to conform with the National Minimum Standards for Care Homes for Older People. The home is located in Leominster within walking distance of the town centre. Accommodation is provided over three floors providing Care Homes for Older People Page 4 of 33 Over 65 47 47 47 0 1 7 0 2 2 0 0 9 Brief description of the care home specialist nursing care and long-stay care for older frail people and includes people with dementia. There is also a seven bed unit for respire care or rehabilitation after hospital treatment where the maximum stay is six weeks. People who use the service and their representatives are able to gain information about this service from the Statement of Purpose and Service User Guide. Inspection reports can be obtained direct from the provider or are available on our website at www.CQC.org.uk Care Homes for Older People Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We, the Commission, carried out this unannounced inspection on 9th December 2009 by two inspectors over 7 hours. We carried out this Key inspection sooner than we would have ordinarily done as we had become concerned about the quality of the service. A range of information was collected to inform our judgements about the service. These included discussions with people using the service, staff and management; surveys completed by service users, relatives, staff and visiting professionals; a tour of the home; sampling records such as those for care, medication and staffing; observing people receiving the service and having lunch. Prior to this inspection the Annual Quality Assurance Assessment (AQAA) document was returned to us. The AQAA is a self-assessment that is filled in once a year by all registered providers. It informs us about how each service is meeting outcomes for Care Homes for Older People Page 6 of 33 people using the service. It is an opportunity for them to share with us areas that they believe they are doing well and areas the plan to improve. The manager completed this and some comments have been included within this inspection report. The manager Mrs Bevan is currently being assisted with the management of the service by an area manager Ms Hadley. Ms Hadley came in to assist with the inspection to allow Mrs Bevan to continue with her normal duties. Care Homes for Older People Page 7 of 33 What the care home does well: What has improved since the last inspection? What they could do better: People should be given clear information about fees in the Service Users Guide before they move in, to help them make an informed choice. The manager should always obtain full assessment information before a person is admitted, to help protect them by ensuring their needs are known. Work on needs assessment and care planning needs to continue to help ensure each person has their needs fully understood and met. There needs to be enough staff on duty at all times to put these care plans into place. Staff need to be better trained and supported to meet individuals needs. Care staff need time to provided a personalised service including activities and involving people in the day to day life in their home. For some people with dementia this will need to be on a one to one basis or it will not be effective. The environment could be enhanced and adapted to provide a more enriching experience for people with dementia. Arrangements for the involvement of external health professionals and for having safe systems to manage medication in the home need to be further developed and maintained. Care Homes for Older People Page 8 of 33 The company needs to develop robust management and quality assurance arrangements that will ensure standards are improved and maintained over time without the need for outside agencies to bring shortfalls to their attention. Some requirements and recommendations have not been made because these actions have already been recognised and are being implemented through an action plan developed by the area manager. 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 9 of 33 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 33 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 is available to interested parties. There are assessment procedures in place to help ensure the staff are able to meet each persons needs but these are not always followed. Evidence: The home has a Statement of Purpose and Service User Guide in place. The Guide does not include information about the fees and any extras people will have to pay for while using the service. This information is important to help people make an informed choice before moving in. The manager reported in the AQAA that a comprehensive pre-admission assessment is completed, and families are encouraged to share knowledge about their family members, so that we can build the best picture possible of their activities of daily living and their preferred life style choices. Feedback from surveys indicated that most people felt they received helpful information about the service in a timely manner. A Care Homes for Older People Page 11 of 33 Evidence: person on the nursing unit was spoken with. He had moved in four days ago. He said he was very happy with the service so far, saying the food and staff are lovely and everybody is very friendly. He just has to ask staff and they are there. He was not able to recall how he chose Waverley House or how the assessment process was carried out. The records of someone who had recently started to live in the home were looked at. These showed that a team leader had assessed the mans needs while in hospital before they had offered him a place. The Company pre-admission form had been completed but the information was brief. For example under likes and dislikes it just stated, dislikes marmalade; under personal care needs, independent was noted and under social needs it just said C of E. This information was supported by an assessment completed by a social worker with the mans son and a friend. This had detailed background information, explaining problems with daily living skills. A file had been set up with other forms to be completed within 24 hours of the admission. A care worker explained that if necessary the Occupational Therapist and Physiotherapist would assess the mans needs within the next day or two to set up a rehabilitation programme. She felt that staff on the unit always receive good information about new people. There was no hospital discharge information but she felt this may be elsewhere. The service has a contractual arrangement with Herefordshire County Council whereby the seven beds on the reablement unit and ten beds on the nursing unit are reserved for their use to place people who are funded by the local authority. They also fund the 20 places in day care centre. Ms Hadley said there is a contractual agreement that an assessment will be carried out by the home within 48hrs of a referral being made for these places. The home has the right to decline to admit a person if they can evidence that they cannot meet their needs. The internal investigation into a complaint found that the assessment information had not been completed before or shortly after the admission of a person from hospital to the reablement unit. The person had been visited in hospital by the manager but this was impromptu so assessment forms were not completed. These were then not completed after the lady was admitted two days later. Some hospital discharge information was not obtained prior to admission. There was no contractual reason for the admission to be agreed by the manager before this information was in place. Fortunately no negative outcomes occurred, but admission procedures should be followed to help protect people. As explained in the next section the needs of some people with dementia have not Care Homes for Older People Page 12 of 33 Evidence: been fully met. People need to be confident that when a place is offered it is because the service can meet their assessed needs. Care Homes for Older People Page 13 of 33 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Shortfalls in these areas have now been acknowledged by the owners and they are taking action to raise standards. On the large nursing unit staffing levels have not been kept at sufficient levels to ensure individuals heath and personal care needs are met in a timely manner and their dignity upheld. Evidence: Eight relatives gave feedback, all but one were very positive. Comments included, I have been very pleased with the level of care and nursing given to my mother. I have always popped in to see her on different days and times. Mum has always been clean and well cared for. The bedroom has an en-suite and the day rooms are light and open. The staff are always friendly and welcoming; The home gives a friendly caring environment, without losing the nursing care; The outside door entrance should always be open so visitors can be under cover while waiting for the door to be answered; The service covers all aspects of my mothers needs, the staff are caring and seem well trained; my husband has advanced dementia and he is well looked after. Care Homes for Older People Page 14 of 33 Evidence: A sample of care records held on behalf of people in the nursing and reablement units were examined as part of assessing if their needs are being met. The manager explained that a new care plan design has recently been introduced to make the information clearer for care staff. Access to information has been addressed as care plans were being locked away with only nurses having access. The sample seen showed that work is progressing well. The plans and risk assessments covered relevant areas giving staff appropriate guidance. They do not show well how the person is being involved in any individualised activities or their daily living skills promoted. Care staff on the nursing unit said they hardly have time to look at these plans, which means the plans will not help ensure better care is provided. One said senior staff were supposed to be setting up a keyworker system but this has not happened. Ms Hadley said that in house care plan training was arranged and that two health care professionals were also providing training for nurses and care staff about appropriate record keeping. Ms Hadley reported that when she became involved in the service in September she found that staff were trying to cope with extremely difficult and changing behaviours in some people living on the specialist dementia care nursing unit. They had not been requesting support from mental health specialist nurses and other professionals therefore these people had not had their mental health needs fully met. She explained what action has now been taken to address these, including reviews by social workers and regular consultations surgeries in the home by mental health nurses and a psychiatrist to support care planning. Care staff are completing half hour behaviour observations to provide the specialists with information. Staff survey feedback and complaints received during the last year gave serious concerns about the staffing levels in the nursing units. Examples have been given of people being got up until midday or being incontinent because they are not taken to the toilet often enough or found very wet in beds because they have not been attended to regularly. Staff have reported that they have told the manager about their concerns but they were not taken seriously. Many incidents have taken place between people living on the nursing unit that may have been prevented if more staff had been available to supervise communal areas. Our observations of the care in the large nursing unit and discussions with staff supported the view that staffing levels of three or four carers and two nurses is not sufficient. We asked the manager and Ms Hadley to carry out an urgent review and Ms Hadley confirmed that there will now be five carers on this unit during the waking day. Care Homes for Older People Page 15 of 33 Evidence: A GP gave reasonably positive survey feedback but felt communication with the surgery could be improved about who is calling, how urgent a home visit request is etc. Responsibility for GP call outs had been identified by Ms Hadley and was seen on a management action plan. If people move into the home from another area they have to change GP due to doctors locality arrangements. This also impacts on people who stay for a few weeks in the reablement unit. It is not ideal for someone coming out of hospital to have to register as a temporary patient in Leominster. Physiotherapy is not provided directly by the home. The arrangement with the local authority is for the community physiotherapists to come and assess individuals needs when they have been admitted into the reablement unit. Permanent residents would need a referral from their GP before being assessed. Ms Hadley explained that a full medication audit on the nursing floor had been carried out at the beginning of December by a member of the quality support team which is currently helping to raise standards. This had highlighted shortfalls in practices for recording, ordering and returning medicines, stock monitoring, storage arrangements, temperature checks, staffs knowledge of and access to the homes medication policy. An action plan had been put in place. The arrangements were inspected and improvements had been made. Doses had been given correctly and one mans changes to his medication had been managed correctly. Some action points are still to be put in place such as additional storage. Some recommendations were made to further improve arrangements. The AQAA states the medication policy had been reviewed in the last year and that all staff who administer medication have had certified training. Ms Hadley reported that an audit of the other units had shown good arrangements were in place. Care Homes for Older People Page 16 of 33 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. A range of activities are provided to people. The lifestyle experienced by people with dementia is not equal to other residents due to staffing and resource arrangements. Visitors are made welcome and people enjoy their meals and are offered a choice. Evidence: AQAA states they hold regular meetings with residents as a group with minutes circulated to all. As a result of listening to people we have identified special treasured or items of interest for each person to enable staff to talk with them about these. We are promoting reminiscence sessions through these aids. We provide escorted holidays. In last year we have introduced an activity planning and assessment tool. The activity co-ordinate operates a full and flexible activity programme. An act planner is on show to inform people. On the day a three piece band performed in the ground floor communal lounge. The room was full and people were enjoying it. Televisions and music equipment are provided in each unit and in the reablement unit books and DVDs were accessible in the lounge. One carer said this worker does her best and organises group activities downstairs but it is a big home and care staff have very little time to spend socially with residents. Observations on the large nursing unit indicated that staff are too busy with care tasks to provide quality time with people, many of who are not able to occupy themselves in a constructive way without one to Care Homes for Older People Page 17 of 33 Evidence: one support. Records of two people with these special needs The environment on this unit had not been set up to enrich the lives of those with dementia and staff did not have time to engage them in daily life tasks. For example one man had his coat on, was clearly restless and was talking about birds. No one was available to occupy him constructively, for example, to take him to the garden to feed the birds. People were not seen to be engaged by staff in daily tasks such as laying tables. The people in the home who were able to give feedback felt their rights were respected and that they have a choice about meals and how to spend their time. Staff feedback and information we have had during the year indicate that low staffing levels in some areas have led to some people not having their right to dignity and good care upheld and choices available to them must have also be limited. Visitors reported that they were made to feel welcome. There was information on display around the home, however, the holder for advocacy services leaflets was empty. Lockable storage is available and bedrooms can be locked. Personal spending money is looked after by the management if this is requested. Only senior staff have access to this in office hours and records are checked regularly. In response to feedback Ms Hadley has arranged for a £50 float to be available out of hours when staff do not have access to individuals personal monies. People using the service gave positive feedback about the meals. A few staff felt the variety could be improved. The cook explained that a new menu has just been introduced as a result of feedback. Feedback books have just been set up in each unit to help improve the service. The sample menu seen appeared balanced and nutritional. Choices are offered and the cook had information about people on special diets. She had information about a mans needs who had moved in the previous day. She had recently had discussions with a diabetes nurse and said if people need soft diets meal components are not liquidised together. Staff were observed to sit with people at mealtimes and were heard to talk to them respectfully and trying to engage them in conversation. Breakfast and drinks are served on the units from the kitchenettes. Hot and cold drinks were seen to be offered between meals. Care Homes for Older People Page 18 of 33 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. People who use the service and their representatives are able to express their concerns and have access to a complaints procedure. When people have expressed concerns this has not always led to positive outcomes for people using the home. Procedures in place to safeguard people using the service have not been consistently followed. The way the care in the large nursing unit has been managed has increased the risks to vulnerable people. Improvements in both areas are now being made. Evidence: The home has a complaints procedure and this is made available to people who use the service. The manager had reported in the AQAA that six complaints have been received in the last year and that all had been resolved. None of the complaint records had been completed by the manager so it was not possible to judge how she had dealt with issues. Some were from earlier in the year before she took up post and recent ones had been dealt with by Ms Hadley. Ms Hadley had kept a record of the complaints she managed, letters showing the complainants had been invited to a meeting to discuss the findings of her investigations and information closing the matter. One was from a GP regarding there not being any nurses trained to set up a syringe driver for the administration of pain relief. Nurses had not been trained and Ms Hadley was advised to discuss the local arrangements and expectations with the Primary Care Trust. Another was from a relative regarding the arrangements for providing an escort for hospital visits. Care Homes for Older People Page 19 of 33 Evidence: A relative of someone who had received a short term service had informed us that his complaint about the assessment of his mothers needs had not yet been resolved to his satisfaction. Ms Hadley said agreement had been reached at a meeting, however, following this new issues had then been raised. She said the Chief Executive had been informed in line with their procedure and another meeting had been offered. As mentioned in the Health and Personal Care section we have received complaints from staff in the last year about staffing levels on the large nursing unit and how this has resulted in poor care outcomes for people living there. We alerted the owners about this in May 09. The Company Area Manager at the time wrote to reassure us that the correct staffing levels were in place to meet residents needs. The complaints we received indicated that the concerns had been raised with the home but that they had not been taken seriously. Ms Hadley showed in an action plan that the need for management to recognise concerns and to improve communication systems with staff were being addressed, for example by holding regular staff meetings. Despite this the staffing levels on the nursing unit had not been increased and Ms Hadley said staff had not been reporting concerns to her about staffing levels. This is surprising as staff had been forthright in their feedback to us in surveys and in personal discussions. Several staff said in their surveys that they would not know what to do if someone had concerns about the home. This is an area that the manager needs to address. There have been referrals made to the local authority under local vulnerable adult safeguarding procedures since the last key inspection. Some of these have been referred by the management following incidents. Others have been raised following concerns raised by staff and external professionals. The local authority contracts manager wrote to the owners in December 09 regarding a wide range of concerns they had become aware of through safeguarding investigations. These were being addressed by Ms Hadley through the action planning process and a team of company professionals spending time in the home supporting improvements. Ms Hadley said concerns raised by three night staff at exit interviews had been investigated and had resulted in the recent dismissal of a night nurse. Some of the actions of this nurse had put people at potential risk of harm. A referral for the barred list has been made to the Independent Safeguarding Authority. The training matrix showed that not all staff have had training on the Protection of Vulnerable Adults. This has been identified and is being addressed through the training action plan. Care Homes for Older People Page 20 of 33 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is new and purpose built. It provides good quality, comfortable and safe accommodation that meets residents needs. There is some scope for further improvement. Evidence: This home is in the centre of the Herefordshire town of Leominster. The home was rebuilt in 2007 replacing the original home on the same site. The work was completed over two years. The home is now fully operational and there were only six vacancies on the day of the inspection. There is a large, secure rear garden. This is divided into two with the ground floor residential area having exclusive use of one half and the rest of the home having the use of the other half. There is also a small car parking area to the rear of the home as well as public parking nearby. There are three floors with the ground floor being taken up with a residential unit as well as the service block. This contains the main kitchen as well as a fully equipped laundry. There is a large lounge on the ground floor that can be used by people from anywhere in the home. This is also used as part of a 20 place day service that is offered. Care Homes for Older People Page 21 of 33 Evidence: On the first floor the home provides nursing care in two units, one for 10 people and the other for 20. The top floor has seven beds and is the reablement and respite care unit. The other three units felt more homely than the main nursing unit. Although the 20 beds in this unit are split into two sections there is only one main lounge and dining room. Many of the people in this unit have dementia and have very special support needs. There is an area for people to walk around between the two communal areas, however this was not set out in a way to provide any interest to the residents. People cannot access the secure garden without staff taking them downstairs. This means that people cannot benefit from this facility without being limited to how long a worker can be away from the unit and in many cases without staff suggesting it. Each area has its own kitchenette, dining and lounge area and a small quiet room that can be used for visitors. All bedrooms are for single use and have en-suite toilet and wet room shower facilities. The bedrooms seen had been personalised to various degrees and were light and airy. An empty room smelt so the carpet needed treating before anyone moves in. No other unpleasant odours were noticed on the tour. There is a pay phone in a fairly private area under stairs in the main entrance, although this is not very accessible to people living on other floors. There is an equipped physiotherapy room, but this is not currently being used. There is a very small room that contained some sensory equipment, however, this is not used as a therapy room and had no seating in it. The manager reported in the AQAA that the required specialist equipment and adaptations needed to meet individual needs are in place. For example there are two mobile hoists, a standing hoist and disabled access bathrooms with bath chair hoists. Each bedroom has been equipped with an electric height adjustable profile bed. During the inspection domestic and kitchen staff were seen working to keep the home clean and infection control systems are in place. The cook said the kitchen is due its 18 monthly Deep Clean and she was assuming the manager would be arranging this. Staff are provided with training in infection control procedures and there is storage for products hazardous to health. Care Homes for Older People Page 22 of 33 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. Not all the people who use the service are being supported by staff who have enough time, knowledge and support to meet their needs. Evidence: Throughout the inspection staff were seen to be polite and helpful when supporting people. Feedback from residents and relatives was positive about the staff referring to them as friendly and welcoming. A learning disability nurse gave the following feedback, The staff team in the respite care unit where one of my clients stayed, communicated well with the client and family. They liaised well with the professionals in our team and implemented the advice given. They coped well with my clients complex health and anxiety needs. The client was also happy with the service. A Senior Practitioner from Herefordshire Adult Social Care reported, The philosophy is person centred and the care provided in a relaxed and homely environment. The reablement unit needs to have higher staffing levels in order to afford more holistic support to enable people to regain their independence. Staffing levels make it difficult to arrange for assessments to be carried out for potential new clients. Ms Hadley acknowledged that there has been staffing shortages in the past particularly at weekends. As stated earlier our evidence indicated that staffing levels need to be increased, particularly on the nursing floor. She reported that it had been a difficult year but the use of agency staff was now reducing as posts are filled. Care Homes for Older People Page 23 of 33 Evidence: Recruitment is continuing and a pool of bank staff is being built up. There is also a problem with high sick levels that personnel staff are now addressing. As reported earlier, following the inspection, on behalf of the owners Ms Hadley committed to ensuring that there would be five carers and two nurses on the large nursing unit during the waking day. In addition to care staff the home employs an activities organiser, cooks, domestic and laundry staff. These areas of the service seemed to be running smoothly. A new cook has recently started. Some staff surveys said staff are hard working and positive. A few were less positive about some colleagues motivation levels. The majority said there are never enough staff to meet the needs of the people in the home. As reported some expressed strong views about residents being aggressive towards each other and there not being enough staff on the nursing units to supervise everyone and provide the care needed. Some staff said they could be better supported by the manager, nurses and senior staff through more regular supervision and appraisal, better communication and by being listened to and praised for their hard work. They did not feel well valued and some said they are isolated by working alone on units and team leaders being too busy to support them or listen to their concerns. One spoken with said the staffing levels have always been awful and she only stays for the residents sake. One carer had only had two supervision sessions in two years and one of these she had arranged. Two recruitment files were examined and the required information was available to show checks on their background had been carried out. One worker had started before the Criminal Records check had been returned however the file contained no date for the PoVA first check and no risk assessment or explanation about why the worker was started early. Ms Hadley contacted the head office who confirmed the PoVA First check had been in place when the worker started. She said there is now a company policy that staff do not start until the CRB has been returned. Both staff records showed that supervision sessions were not being provided. Induction and training records were also incomplete. During 2009 several mandatory and refresher courses have been held but the information is not held on staff personal files. Ms Hadley said the training manager had realised there were difficulties at the home when staff booked for training often did not attend. Neither worker had a personal development plan in place. The care worker had completed a four day induction but it was not clear if she had completed the six month foundation programme. One carer on the nursing unit had moving and handling training but no dementia training. She said she had not had an induction programme and had just Care Homes for Older People Page 24 of 33 Evidence: shadowed a colleague for two days. Other feedback indicated that inductions and shadowing arrangements feel rushed and therefore to not cover all the information new staff need. Ms Hadley showed that a training matrix is now in place, which identifies gaps in areas such as moving and handling, common induction standards, safeguarding adults and fire drill practice. A training plan was seen for the coming year. She reported that staff supervision sessions had been started and would now be held regularly. She had been running dementia awareness courses and all staff including domestic staff would be attending these. Community mental health nurses were also providing training in this area and around working with individuals complex behaviours. The AQAA indicated that only nine care staff have an NVQ award, so this area also needs to be focused on. Care Homes for Older People Page 25 of 33 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has not been managed by the owners in the best interest of the people using the service. Action is now being taken to raise standards and better protect these vulnerable people. Evidence: There has not been stable management arrangements since the home reopened in 2007. Mrs Bevan was new at the time of the last inspection in February 2009. She is a qualified mental health nurse and she has previously been a deputy manager of a service for older people. She was registered by the Commission in June 2009. She has not had the support of a deputy until one was recently recruited. Evidence indicated that she was not properly supported by the Company, for example she had not been provided with a formal induction including information about corporate management and business policies and procedures. Due to the concerns raised by external agencies the providers have now taken steps to provide appropriate support to assist the manager to learn her role and improve Care Homes for Older People Page 26 of 33 Evidence: standards in the home. The areas of concern included supplies of health care equipment; procedures for calling the GP; management of periodic medical procedures; feedback about concerns raised including those from staff; effective communication between staff and across shifts; review and updating of care plans; staff rota management and the effect on staff morale; staff training, mentoring and supervision; continence management; management of behaviours others may find challenging; incident and safeguarding reporting; standards of care practice; management of medication. It is positive that action is now being taken to address the management of the service. However, the companys quality assurance systems that include monthly monitoring visits failed to alert the Responsible Individual to falling standards resulting in a delay in action being taken by the company. The action plans prepared by Ms Hadley from September and November 09 showed the extent of the shortfalls. They included the following; stop the practice of running separate rotas for each unit and staff refusing to support colleagues by covering other areas of the home; the recruitment of another team leader and cook; to update staff training; to action the fire officers advice from July 09; to provide staff with dementia training; review residents continence needs; to carry out quarterly quality audits; establish staff communication systems; implementation of personalised activity plans, care plan and medication audits; reducing staff sickness; implement a staff supervision programme; fill vacant posts; provide the manager with a full induction; set up a training plan for the next year. Good progress has been made but the level of change needed is significant and will take time and strong leadership. The manager reported in the AQAA that feedback questionnaires are available and the results are published. Surveys were seen at the front desk and there are suggestion boxes available. Ms Hadley reported that a recent relatives meeting had been mainly positive and a few issues raised were being addressed. The manager reported in the AQAA, staff are given supervision and appraisals and have the opportunity to influence the service. This was not reflected by our findings, but improvements are being made. The manager acknowledged that she had not had the capacity to manage incident reporting in line with legal requirements. Examples were discussed where the information sent to us had been incomplete. Nurses and team leaders were having a briefing on the day about how to complete notifications to try to improve standards. Ms Hadley reported that an audit had shown that during November 15 incidents had occurred but none had been reported as notifications. Some health and safety issues have been referred to under other sections such as Protection and Staffing. The fire officer issued action points following a visit in July 09. Care Homes for Older People Page 27 of 33 Evidence: Ms Hadley reported that these have now been addressed. Many routine procedures appeared satisfactory at the time of the inspection such as kitchen temperature check. Care Homes for Older People Page 28 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 29 of 33 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 8 12 Effective arrangements must 15/01/2010 be in place to ensure all people using the service have their health and personal care need met in a timely manner. This is essential to ensure their dignity is upheld at all times. 2 18 13 Ensure suitable systems are 31/01/2010 in place to protect people using the service from the risk of neglect or abuse. Ensure safeguarding incidents are recognised and appropriately managed and reported to the Commission and relevant Local Authorities. This is essential to help protect the vulnerable people using the service. Care Homes for Older People Page 30 of 33 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 37 37 Incidents that fall under the requirements of Regulation 37 must be clearly reported to the Commission as soon as possible. This is important to help protect people using the service. 15/01/2010 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 Include clear information in the Service User Guide about the fees charged for the various services provided. Always obtain hospital discharge information and complete a comprehensive assessment before proceeding with an admission. Two staff should sign any hand written entries on medication administration charts. Administration charts and protocols should be kept in good order and stored under the section relating to that individual to help avoid errors in administration. The returns book should be signed by the pharmacist to complete the audit trail. 2 3 3 9 4 12 Further develop the opportunities for people with dementia to partake in meaningful activities to increase their sense of wellbeing and engagement. Retrain staff so they are all aware of how to deal with any concerns about the service that they have or that they are made aware of. Develop the environment so it is more beneficial for people with dementia. Page 31 of 33 5 18 6 19 Care Homes for Older People 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 7 8 22 27 Make better use of the sensory and physiotherapy equipment available. Staffing levels should be kept under close review to ensure they are linked to the support needs of the residents in the home at any time. Continue to implement the planned training and improvements to the staff management and support arrangements. Continue to implement the current action plan and ensure standards are improved in a timely manner. The company should review the way they monitor services to ensure they can identify falling standards quickly and take prompt action to safeguard people using the service. 9 30 10 11 33 33 Care Homes for Older People Page 32 of 33 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. 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. 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