Inspection on 05/08/09 for West Abbey House

This inspection was carried out on 5th August 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

West Abbey House 01/04/10

West Abbey House 21/01/10

West Abbey House 19/11/09

West Abbey House 30/01/08

West Abbey House 04/07/07

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

Key inspection report Care homes for older people Name: Address: West Abbey House Stourton Way Yeovil Somerset BA21 3UA     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: Justine Button     Date: 0 6 0 8 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 39 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 39 Information about the care home Name of care home: Address: West Abbey House Stourton Way Yeovil Somerset BA21 3UA 01935411136 01935420829 westabbey@barchester.net www.barchester.com Barchester Healthcare Homes Ltd care home 97 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is 97. The registered person may provide the following category of service: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia (Code DE) maximum of 32 places Physical disability (Code PD) maximum of 10 places Old age, not falling within any other category ( Code OP ) maximum of 55 places Date of last inspection Brief description of the care home West Abbey is located in a residential area on the outskirts of Yeovil. It was purpose built as a nursing home in 1994. In the main building is a 66-bedded unit for service users requiring general nursing care and this is located on two floors. There is one 13-person lift to the first floor. The Care Homes for Older People Page 4 of 39 Over 65 0 55 0 32 0 10 Brief description of the care home corridors are wide and can accommodate people who mobilise using a wheelchair. The home has accessible and pleasant garden areas. The majority of the service users in the main wing are older people. The home is also registered to take up to 10 younger people (18-65). In a separate wing there is a single storey 28 bedded unit (Lyde) for older people with mental health needs. The Lyde unit has its own central courtyard garden. The homes current fees are £550 per week plus free nursing care,and for younger people fees are in line with their individual care needs assessment. Care Homes for Older People Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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: This Key unannounced inspection was carried out over two days by two inspectors. The Manager was available on the day of the inspection. The inspector would like to thank the manager and the duty staff for their time and hospitality shown to the inspector during their visit. The home last had a Key inspection in 2008 and an Annual Service Review was completed January 2009. At this time the home was assessed a two stars good. This inspection was conducted in response to a number of concerns that have been raised to us and to Somerset County Council. As a result of these concerns we have bought forward the key inspection. Due to the timescales of this inspection, surveys were not sent out to people living at the home, relatives, staff or healthcare professionals. The home last completed an annual quality assurance assessment Care Homes for Older People Page 6 of 39 (AQAA) in January 2009. Surveys were received at this time from staff who work at the home. The concerns raised with us will be investigated under the Somerset Safeguarding policy and procedures. We will share the findings of this inspection with Somerset County Council under the information sharing policy. The focus of this inspection visit was to inspect relevant key standards under the CQC Inspecting for Better Lives 2 framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: excellent, good, adequate and poor. These judgment descriptors for the seven chapter outcome groups are given in the report. Records examined during the inspection were care and support plans as part of the case tracking process, medication administration records, staffing rosters, menus, the homes complaints file, staff recruitment files, staff training records and staff supervision records. We also conducted a tour of the premises. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Care Homes for Older People Page 7 of 39 What the care home does well: What has improved since the last inspection? What they could do better: A number of issues were identified during this inspection. The care planning process needs to be developed to ensure that it adequately reflects the current care needs of the people living at the home. This should include ensuring that risk assessments are up to date. Consideration needs to be given to developing a risk assessment for ingestion of chemicals The management need to ensure that the health care needs of people living at the home are met in all areas. This includes a regular change of position to prevent pressure damage to skin, regular oral hygiene and access to fluids and a nurse call bell. Medication is not well managed. Meals and mealtimes need to more organized to ensure that these are a pleasant experience for all and that people living at the home receive adequate diet and fluids. The management need to consider increasing the social and recreational opportunities at the home particularly for those with dementia. The staff need to ensure that they engage and interact with people living at the home. A large number of people were nursed in bed. The majority of these people did not have access to music or television. Due to this the days must seem very long and unstimulated. The staff must consider the social stimulation of people in these circumstances. The privacy and dignity of people living at the home is not always maintained. through lack of screening on doors, double rooms and by the institutional practices of staff. During the tour of the building it was identified that some areas had a very strong malodour smell. The management need to review this as a matter of urgency Care Homes for Older People Page 8 of 39 The health and safety of people living at the home may be compromised by poor systems with regard to moving and handling and pushing people in wheelchairs without footplates. The care plans seen did not contain enough detail in this area. This now requires urgent attention. People at the home were at risk of the ingestion of chemicals such as toiletries. These were not securely stored for periods during the inspection. Staffing levels need to be reviewed in line with the dependency of people living at the home. The management need to ensure that they inform us of all incidents in line with Regulation 37 of the Care Home Regulations 2000 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 39 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Pre admission assessments are made to assess that care needs can be met at West Abbey before an admission to the home is accepted. Evidence: The standards under this outcome area were not assessed on this ocassion. At the last key inspection which was conducted in January 2008 it was reported that Care plans were sampled including one recent admission to the home. The homes manager had undertaken a pre admission assessment. Details were taken from the hospital about the persons health and well being and risks to their health. The community single assessment document (SAP) had been received at the home to inform the pre admission assessment. Identified risks had been assessed and the care planning detailed measures to monitor and reduce these risks. Care Homes for Older People Page 11 of 39 Evidence: The commission had received a copy of the homes pack Residents terms and conditions, a Barchester company wide document that is very detailed. There is a Residents admission agreement in this which gives a clear indication of admission service detail, costs, method of payment and is signed as an agreement either by the resident or other person responsible for the payment of fees, when the place is accepted. One relative spoken with confirmed having visited the home to look around before making this their choice. Contracts were sampled, one identified a pre admission assessment, it was not clear that this person who was funded by a county council had received terms and conditions of residency. One other had the residents admission agreement with the breakdown of the funding and payment arrangements. Care Homes for Older People Page 12 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care planning process needs to be developed to ensure that they reflect the care needs of people living at the home and give clear guidance to staff. The staff need to ensure that all aspects of peoples health and hygiene needs are met. This should include regular access to fluids, oral hygiene and a regular change of position . Medication is not well managed Evidence: During the inspection we reviewed the care notes of four people who live in the area providing dementia care , the care notes for three people with general nursing needs and the care notes for two younger people. We case tracked a number of these people during the inspection. Case tracking involves identifying individuals at the beginning of the inspection and comparing the care and support they receive with the needs identified in the care plan. In addition we also viewed the bedrooms of a number of people living at the home. Care Homes for Older People Page 13 of 39 Evidence: It was very clear that in the majority of the assessments and associated care plans that had been completed did not contain adequate information to give clear guidance to the staff on the current needs of the people living at the home. A number of the assessments that had been completed had not been reviewed and no longer reflected the current care needs of the individual. For example one person living at the home had been in hospital resulting in a significant change to his mobility requirements. A falls risk assessment had been completed by staff in November 2008. This assessment stated that the individual was fully mobile and was able to walk. When we reviewed this individual it was very clear that this was no longer the case. A moving and handling assessment had been completed in July 2009. This assessment did not clearly demonstrate the individuals change in condition nor the changes to the equipment required to safely help the individual transfer or change position. This lack of information may have placed both the individual and staff at risk. It is particularly important for new staff and those who come to work at the home from an agency that they have relevant and up to date information in the care plans. A waterlow assessment (to assess the risk of pressure damage caused by staying in one place for too long) had been completed in July 2009. This stated that the individual was at high risk of sustaining pressure damage. The associated care plan (that had been reviewed by staff in July 2009) however contradicted this information stating that the waterlow score was only 8. The care plan stated that equipment was in use to help in the prevention of pressure ulcers. On observation however the individual was on a different pressure relieving mattress for that stated in the care records. As a result of becoming frailer the individual had lost some weight (9 kg in three months). Advise had been given by the dietitian with regard to this weight loss and staff had developed a care plan for this aspect of the the individuals care needs. The care plan however was ambiguous and did not give clear guidance to staff. The care plan stated record fluid and food intake and give snacks between meals. In addition the plan stated weight to be completed weekly. On viewing the care records it was clear that weights had not been completed on a weekly basis. The care records should also state the amounts of fluids the individual should be consuming on a daily basis. The individual had received some surgery during their stay in hospital and as such had a wound. In order to aid healing a high protein diet would be required. A diet high in calories would also be required to help prevent additional weight loss. The care plan should have therefore stated what snacks the staff should have being giving between meals and also should make reference to ensuring that any main meals eaten should have been fortified with such things as cream and butter. A nutritional risk Care Homes for Older People Page 14 of 39 Evidence: assessment had not been completed for this individual despite the recent weight loss. The completion of the risk assessment would help staff to ascertain if the actions that they completed were being effective and/or if they should review the care and support that they are giving. Pressure ulcers develop when a person spends too long sitting or lying in one position. People who are frail or who have underlying health issues are more at risk of developing these ulcers. The care plan stated that this individual had developed a pressure ulcer. staff had developed a care plan for this however again this needs to be completed in more detail. The plan stated the frequency and type of wound dressing to be used. The plan however did not give details of when the staff were going to review the effectiveness of the treatment and consider changing the dressing used. The care plan for another person living in the dementia care unit also showed failures in the care planning process. A range of assessments had been completed but had not been reviewed on a monthly basis. For example a Waterlow assessment had last been reviewed in June 2009 (despite being assessed as high risk), the moving and handling assessment in March 2009 and the falls risk assessment in November 2008. It was therefore difficult to assess if the information contained in these assessments was still valid or relevant. A range of care plans had been developed for this individual. The person has dementia and as such requires help and support with aspect of personal hygiene. The care plan made no references to the individuals needs in this area. It was not clear how staff would know how to assist or promote independence. The plan made little reference to the persons likes and dislikes for example how do they like their hair to e done, do they like to wear makeup or a particular perfume. The plan only stated likes to wear a dress. Again this plan had not been reviewed since June 2009 and we were unable to ascertain if their individual care needs had changed. A tissue viability care plan had been developed which stated that the individuals skin was intact. Although it was then clear in the plan that dressings were being applied to a skin tear on her leg. The care plan stated that the person was at high risk of developing pressure ulcers. Again th plan was not specific in this area. The plan stated check skin regularly and report any broken areas The plan did not state how often staff should check the skin and what should they be looking for. (There are usually signs a sore is going develop prior to the skin being broken) Other similar shortfalls were noted in the other care plans viewed. Care Homes for Older People Page 15 of 39 Evidence: During the inspection we observed the care and support afforded to some people living at the home. One person was case tracked who was nursed in bed. As previously stated people who spend long periods in one position are at risk of developing Pressure ulcers (sometimes called bed sores). For the individual observed a positional change chart had been commenced by staff. This showed that staff had not supported to change position regularly. To prevent the development of pressure ulcers a person should be supported to change position two to three hourly. The positional change chart was viewed for a three day period. This demonstrated that staff supported the individual to change position about every five hours. In one case the individual had been supported to change position at 02:15 Hrs. The next change of position was at 12:00 (a period of 12 hours). This could significantly increase the risk of developing pressure ulcers. On observation the individual was seen sat up in bed however had slid down slightly so the his feet were pressing on the end of the bed with his heels pressing onto the mattress. Again pressure to the heels of this type for a sustained period could increase the risk of the development of pressure ulcers. The individual did not have a change of position for 5 hours on this occasion. The care plan for this individual was viewed. This demonstrated that a waterlow assessment had been completed and the had been assessed as high risk. Staff should therefore have been more proactive in ensuring a regular change of position. The care records for some people with dementia were viewed. Again these lacked detail particularly with regard to their dementia care needs. On person was identified who could at times become aggressive to wards staff and other people living at the home. The care plan did not state clearly the actions that staff should take in these circumstances. Aids such as diversion are commonly used in caring for people with dementia or those showing aggressive behaviours. These were not discussed in detail in the plan. During a tour of the building it was noted that a number of people had no toothbrush or toothpaste in their rooms or that the toothpaste and brush were hard and dry. This leads us to believe that staff had not supported people to maintain their oral hygiene. Dentist recommend that the most effective way of maintaining oral hygiene in frail people is to use a small amount toothpaste and a toothbrush (even if this is a childs soft brush). It was also observed that the majority of individuals did not have access to fluids or a nurse call bell during the inspection. During the first day of the inspection it was noted that one lady had not eaten her lunch. The care records for this individual were viewed on the second day of the Care Homes for Older People Page 16 of 39 Evidence: inspection. The records showed no evidence that staff had recorded this. The care records also showed that the individual had some recent weight loss and so staff should have been more vigilant in supporting and monitoring this individual. Medication was viewed during the inspection. Lorazepam is used for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety. During the review of the medication it was noted that one person was prescribed this medication on a as required basis (this is called PRN). It would be given therefore by staff when the individual was anxious. It was noted that on the Medication Administration Record that this was being given regularly by staff. The care records including the daily reports were viewed for the period when the medication had been given. The running records showed or record no incidence of the person appearing anxious or concerned. We could not therefore ascertain why the medication had been given. Giving medication in this manner contraindicates the Nursing and Midwifery guidelines. In addition the over use of sedation can be seen as abusive practice. All Nursing staff must be reminded of their responsibilities and accountabilities. The most common side effects associated with lorazepam are sedation , dizziness weakness and unsteadiness. On observation the individual in question looked extremely tired. He told us that he was shattered. On viewing the care records that this person had had a fall on two occasion while taking the drug regularly. These falls may have been caused by the over use of the medication when it was not required. Creams and lotions are prescribed by the GP and therefore should be treated as any other medication. The creams and lotions seen in the majority of peoples bedrooms had not been prescribed for that individual. In some cases the prescription label had been torn off and in other a new name had been written by hand. As creams and lotions are prescribed a signature is required on the Medication Administration record (MAR) to confirm that they have been applied as per the prescription. This not seen on th day of the inspection visits. On viewing the MARs it was evident that the prescription for one person had been changed. It could not be confirmed who had changed this record. The change related to the frequency of lactulose. In order to be effective lactulose needs to be given at regular intervals. The lactulose dose had been changed to as required thus making in ineffective. During the inspection it was noted that on the Lyde unit some people were supported to have a bath in the afternoon. It could not be confirmed if people had chosen to Care Homes for Older People Page 17 of 39 Evidence: have a bath at this time. Following their baths all people were supported to dress in their night clothes. This was between the hours of 15:30 and 16:45. Staff need to consider how this impacts on peoples dignity and self esteem. This situation caused at least one person distress. The individual was crying to staff I want to get dressed, I will get a cold dressed like this staff told the individual that her clothes were in the wash so she could not get dressed. This does not respect the rights of people living at the home as an individual. People with dementia sometimes have difficulty in orientating themselves to the time of day. Getting dressed in night clothes in the afternoon may exacerbate this for some people. during the inspection it was noted that some of the rooms are shared. In two of the double rooms seen screening between the beds was inadequate. In one room no screening was available. In the other both occupants were being nursed in bed. For one person in this room the bed clothes had fallen revealing the bottom part of her body. Screening in the form of a mobile curtain was available but this had not been put in place by the staff. In the Lyde unit the doors to all the bedrooms have a glass viewing panel. In a number of the bedrooms the screening to the doors were broken or were not in place. These aspects do not maintain the dignity and privacy of people at the home. The home employs a physiotherapist who develops a plan for the care staff to then follow. It was aslo reported that the physiotherapist also completes some life skills with some people at the home. It was reported to us by staff that the physio spends the majoity of thier time with the younger people living at the home. Care Homes for Older People Page 18 of 39 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor 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 do not have opportunities for their social and recreational interests to be met. People living at the home are able to meet friends and family. The opportunity to make choices is limited with regard to social and recreational opportunities and with regard to some aspects of personal care. Meals and mealtimes are on the whole a pleasant experience for all except those on the Lyde Unit. Evidence: West Abbey provides care and support for a wide range of people with differing needs and therefore the range of activities available needs to reflect this. During the inspection visit we observed the social and recreational opportunities of people living on the Lyde unit. It was noted that although the area had an activities organiser doing some activities with a small minority of people, the majority of people had limited opportunities to engage in leisure opportunities. This was in part due to Care Homes for Older People Page 19 of 39 Evidence: the lack of availability of staff. There were periods of time when the lounge area was unsupervised with no staff available. In addition no television or radio was on for people to listen to. When a member of staff was available in the lounge we did not observe any meaningful interaction from some staff other than to assist with tasks and prevent accidents (two staff were observed to have excellent interactions with people). One person living in this area is receiving 1:1 support from staff. It was observed that one staff member did not interact with the individual for a period of nearly an hour. This was despite the individual trying to initiate conversation with the staff member. One person was observed being transferred in the lounge from wheelchair to armchair. This transfer involved the use of a hoist. This can be a frightening experience for some people particularly those with short term memory loss who may not remember instructions previously given to them by staff. Staff were observed to give the individual no reassurance nor did they explain what they were going to do. The Lyde unit has access to a safe garden area however despite the weather being nice on the day of the inspection visit the doors to the garden were closed. The garden is maintained to a very high standard and staff should try to use this area with people living at the home as much as possible. Comments made in the outcome area for health and personal care with regard to choices around bathing should be noted. Over the two day inspection some physically disabled younger adults had no access to sensory stimulation beyond personal care tasks. When sitting out of bed in adapted seating some younger adults were positioned in the foyer of the home with seats tilted, making their eye line focus on the ceiling. This is concerning as there needs to be an improvement in the activity and sensory input for younger adults in order to satisfy their social care needs. As previously stated the physiotherapist does spend sometime developing the life skills of two of the younger people who live at the home. In addition music therapy is available. The younger adult area has its own kitchen and living area. On reviewing the care records for this group of people it would appear however that social and recreational opportunities outside of the home with peers are limited. No activities were observed for people with general nursing needs. The home has offered some trips out which one relative told us was enjoyed. Trips out have included to West bay, weymouth and stourhead. A hairdresser visits the home regularly and was visiting the home on the day of the inspection. Care Homes for Older People Page 20 of 39 Evidence: Visitors were seen at the home throughout the inspection. The majority of people stated that they were made to feel welcome by staff. (see outcome group for complaints and protection) The home has regular visits from visiting clergy and communion is held regularly Lunch was observed on both days of the inspection. The daily menu is displayed in the foyer of the home. A choice of main meal is routinely available to people living at the home. The dining areas in the general nursing part of the home were set to a high standard with tablecloths, glasses and napkins. The meal in this area was nicely served in a calm and peaceful environment. People with the highest needs appeared to have their meal in the upper floor dining area. This area appeared to be less calm than the lower ground floor but was still conducted to an adequate standard. The lunch time meal on the lyde unit was observed. This appeared to be chaotic and less organised. The tables were set by a member of the hotel staff at 12:00. As previously stated people with dementia may need help and support to orientate themselves to the activities of daily living and time. It is advised therefore that the tables are not set until the meal is due to be served. The meal arrived from the kitchen in a hot trolley at 12:10. However the meal was not served until 12:35. As the tables had been set at 12:00 a number of people had been sat at the tables for over half an hour and so had lost interest and had left. At the inspection in 2008 it was reported that Also noted was that the process of offering the choices, getting the meal served, and then cutting up the food left a number of residents sitting with no food whilst some people had already finished and were leaving the tables. It was felt that this may have been due to some of the staff being busy elsewhere at lunchtime. These comments appeared to remain on this inspection. Staff did not appear to be available to serve the meals. We were told that staff were still supporting people with personal care. One staff member started to serve the meals at 12:35. At 12:45 there was no supervision in the dining area. Six people had been served leaving nine people with no meal. When staff were again availer the people who had been served first had nearly finished with people who were sat at the same table yet to be served. By 13:00hrs some people had still not being served. It was observed that due to lack of staff supervision at least two people were struggling to eat their meals. For one person this resulted in little of the meal being eaten. For another the meal went cold prior to the individual receiving a prompt to eat her meal. Due to the timescales involved in the serving of the meal one person had eaten and left the room when staff were not in attendance. When the individual re entered the room staff offered another Care Homes for Older People Page 21 of 39 Evidence: meal. This was evidence that staff were unaware who had eaten and who had not. One person required support to eat his food. This person remained in the lounge area to eat. A staff member was observed sitting on a coffee table to support this person. Interactions from this staff member was limited. The staff member did not tell the person what was on the plate and did not get involved in any conversation. Drink was not offered to this individual until the end of the meal. By 13:20 the puddings had yet to be served. As previously stated by this time a number of people living at the home had become impatient and left the table. It is advised that food is not plated up until staff are available to support all people even if this means that some people do not get their meal until a later time. This allows staff time to ensure that they have the time to spend with people during meals and ensures that meal times are a pleasant experience for all. This time also allows staff to monitor dietary intake more effectively which will promote the general health of people living at the home. Menus were on display in the lyde unit on one table only.This menu did not relate to the day of the inspection but several days earlier. The menu was not readily accessible to the people living at the home. The area caters for people who have dementia and as such they may difficulty in making choices or remembering what choice of food they have made. Additionally some people living at the home cannot verbally express their choices. Staff could develop a system were they plate up the choices (one staff member only was observed to do this) and show these to people who can then make a choice. Alternatively staff could develop pictures and photographs of the food again enabling people to have a greater understanding on what is being offered. Drinks were available in the dining areas and communal rooms. Not all people in their rooms had access to a drink at all times during the day. One bedroom was observed in the afternoon. Three untouched drinks were observed to be on the window sill out of reach of the individual who was in bed. A tray with the lunch time meal was on the over bed table. The majority of this was untouched. This may have been in part due to the fact that the individual was not sitting in an upright position. A staff member was observed to enter the room and remove the plates. The staff member made no reference to the uneaten meal nor did they offer an alternative. In this report under the section heading Health and Person Care is reference to our concerns regarding some people who have sustained weight loss and low body weight. It is recommended that the provision of snacks between meals be provided in line with assessed nutritional care management needs. It should be noted that the food served was of a good standard and well prepared. On Care Homes for Older People Page 22 of 39 Evidence: one day of the inspection however only one vegetable carrots were served. It could not be ascertained what alternative would be offered if you did not like carrots. Care Homes for Older People Page 23 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems and procedures in the home may not protect people from abuse. People living in the home may not be confident that their concerns and complaints will be listened to. Evidence: During induction staff receive information about safeguarding adults and must sign to say that they understand this and the Whistle blowing policy. The home has copies of the local authority guidance Safeguarding Adults in Somerset and key staff are familiar with actions to be taken. The home has received five complaints since the last inspection. These have been investigated in line with the homes complaints procedure. In addition during the inspection other concerns were identified that had been raised by the manager that were not documented in the complaints log. We have also received some concerns with regard to the care and support afforded to a number of individuals living at the home. These concerns will be investigated under the Somerset Safeguarding policy and procedures. This may include restricted visiting for two people living at the home. A number of concerns were identified during the inspection that may impact on individuals rights. It was identified in the nursing area that for one person a table was being used to restrict the movements of this individual. A staff member explained that Care Homes for Older People Page 24 of 39 Evidence: the table was in place as the lady gets up and tries to walk. this is not in line with best practice guidelines. Staff should consider the use of such tools as pressure mats in this situation. Consideration should also be given to the comments made in the outcome group health and personal care with regard to the use of medication that is classed as sedation Care Homes for Older People Page 25 of 39 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to personalise their bedrooms. The home is fitted with a range of aids and adaptations. Orientation signage in the Lyde unit needs to be developed. Screening to protect the privacy and dignity of people is not available in all areas. The standard of cleanliness is overall good however some areas required attention on the day of the inspection. The home does not have systems in place to reduce the risk of the spread of infection in all areas. Evidence: The tour of the premises found the home in good condition. The premises were purpose built and have wide corridors and a 13 person passenger lift giving good wheelchair access around the building. The communal rooms are comfortable and have good natural light. The individual accommodation older and newly built is well appointed comfortably furnished and can be personalised. Care Homes for Older People Page 26 of 39 Evidence: There is a good level of equipment with adjustable beds and specialist equipment for pressure relief and nursing care. As previously stated in this report it was identified that a number of people were nursed in bed for various reasons nurse call bell leads were not in place in a number of these rooms. The dementia care unit is appropriately decorated in communal areas to aid peoples independence and interest around the unit. There is use of colour coordination for the toilets and there are objects of reminiscence around the corridors for people to view and handle. This however is not the case in individuals bedrooms. All of tr bedrooms have en-suite facilities and a built in cupboard. The doors to each of these are the same. This may add to the disorientation of people living in these rooms. Consideration should be given to signage on these doors to aid the accessibility of these area. As previously stated a number of the double rooms did not have adequate screening in place to protect the dignity of people occupying these rooms. In addition orientation signage was not available in on all the bedroom doors in the Lyde unit. Signage of this type would help people locate their personal space. There are infection control measures in place. All staff have access to personal protective clothing and there are sufficient hand washing facilities for them around the home. It was noted that some significant malodorous were noted on the first day of the inspection in the Lyde unit. The management need to consider these comments and ensure that the malodours are kept to a minimum at all times. This may include the replacement of some floor coverings if necessary. The home has sluice facilities and sufficient toilets and bathrooms. One bathroom was seen that was being used as a storage space for equipment and was very cluttered. This may reduce the use of this bathroom. Care Homes for Older People Page 27 of 39 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff recruitment is not robust in all areas. Staff have recieved all necessary training Staffing numbers appaer to be sufficant although these need to be reviewed in line with the dependancy levels of the people living at th home Evidence: The staff duty rotas were obtained during the inspection. These were viewed following the visit to the home. These showed that the home appears to have sufficient numbers of staff on duty at all times. These however were not compared to the dependency of people living at the home. Some areas identified in this report such as staff still supporting people with personal care and hygiene when the lunch had arrived suggest that the staffing levels need to be reviewed. A range of other staff including cleaners, cooks and maintenance staff are available. The duty rotas showed that some staff are working a relatively high numbers of hours. Some in around 58 hours per week. Staff have however opted out of the working time directive and it was evident that the manager ensures that all staff have two full days off a week. Comments received by staff were very positive about working Care Homes for Older People Page 28 of 39 Evidence: at the home. Staff training records were viewed. The home was unable to produce a training matrix. Training is recorded for each staff member separately. It could not be confirmed therefore how the training needs of each individual staff are identified easily and subsequent training arranged. It was noted however on reviewing a random sample of individual staff training records that all staff appear to the received all necessary training. This included updates for the registered nurses in line with NMC guidelines. A number of staff have completed or are completing an NVQ. Five staff recruitment files were viewed during the inspection visit. These showed that recruitment procedure may not be robust in all cases. In three of the files it was noted that two written references were not obtained before the individual staff member commenced work at the home. For one person it was evident that there had been gaps in the employment history which had not been discussed with the staff member. For additional person it was evident that there had been issues with the persons last employer. There was no written evidence that the manager had discussed this with the staff member or previous employer. We raised this issue with the manager who stated that she had discussed and reviewed this issue prior to offering employment and was satisfied enough to employ the individual. It is advised that the manager documents issues such as these at the interview stage. It was confirmed in the recruitment files seen that staff had completed an induction in line with good practice guidelines. Care Homes for Older People Page 29 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home manager has the experiance to run the home. Staff do not recieve adequate supervision. The Care quailty Commission may not recieve all notifications about events at the home People living at the home cannot be assured of a safe environment and that systems are in place to rectify problems. Evidence: The Registered Manager, Mrs Bev Davies, has managed the home for a significant period of time . The Statement of Purpose confirms that she is a Registered Nurse with qualifications and experience in management. The manager and the company as a whole need to consider the comments,requirements and recommendations made in this report as a number of the requirements made at this inspection remain Care Homes for Older People Page 30 of 39 Evidence: outstanding from previuos inspection visits. Staff spoken with felt able to approach the manager and felt well supported. Various staff meetings are held regularly. Records seen confirmed that these are usually well attended by most staff. Staff are issued with a copy of the General and Social Care Council code of conduct, as seen on staff files. It could not be confirmed if staff receive formal supervision. The nurses supervise a group of care staff each and the manager supervises nurses and senior staff. We requested copies of recent supervision for staff. These could not be found. The manager could not confirm when staff had received supervision nor if this was up to date. The manager appeared unclear what was meant by supervision as described in Standard 36 of the National minimum standards. All records seen were stored securely. A current Employers Liability Insurance certificate is displayed. During this inspection some concerns were raised with regard to the health and safety arrangements at the home. The care planning process could not confirm what arrangements were in place for all individuals living at the home with regard to the equipment used for moving and handling. In addition during the inspection it was observed that staff were pushing people in wheelchairs with no foot plates. This increases the risk of injury to the person in the chair as their feet and legs may be dragged and caught under the wheelchair. During the inspection the care planning process did not identify if any person living at the home was at risk of ingestion. Toiletries were insecure and freely available to people living at the home. This may pose a risk particularly to people who have dementia. Under Regulation 37 of the Care Home Regulations homes are required to inform us of any adverse incident at the home. We have received numerous of these notifications with regard to deaths at the home. As previously stated we have received some concerns with regard to the care and support afforded to people living at the home. Some of these concerns relate to incidents of pressure ulcers at the home and subsequent admissions to hospital and to concerns raised by member of the public and relatives. We have not received information with regard to these issues. Care Homes for Older People Page 31 of 39 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 8 16(2)(i)(4)12 Fluids must be available to (4)(a)(b)17(1 those who can manage )(a)Sch.3 (l) independently at all times when sitting in their rooms or when in bed. Call bells must be accessible at all times and must be placed within reach after care interventions / changes of position. A recorded system of appropriate supervision is required to be implemented to support people to summon assistance when needed. 21/04/2008 2 22 23(2)(l) Designated storage must be used rather than communal bathrooms for equipment that is not in use. 21/04/2008 3 27 18 (1) It is required that the 21/04/2008 manager reviews the numbers of staff available to ensure that the needs of the people living at the home are met. Previously required by 19/9/07 Recruitment procedure must 21/04/2008 include that at interview any Page 32 of 39 4 29 18(1)(a) Care Homes for Older People 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 gaps in employment history be explored and the reasons for them be documented, to ensure the safety of people using the service. Care Homes for Older People Page 33 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 22 16 The management must ensure that appropriate orientation signage and screening is available throughout the home. To ensure that the home is accessible to all. 16/09/2009 2 26 16 The home must ensure that malodours are kept to a minimum. This may include the replacement of some carpets if required This will ensure that people live in a clean and pleasant environment 16/09/2009 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 The assessments and 16/09/2009 associated care plans should be up to date in order that they reflect the current needs of the people living at the home and give clear guidance to staff. This will ensure that staff meet the needs of the people living at the home. Care Homes for Older People Page 34 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 2 8 12 The health and personal care needs of people living at the home should be met at all times. This should include access to fluids, oral hygiene and a regular change of position. To ensure that the health needs of people living at the home are met. 16/09/2009 3 9 13 Staff should ensure that they record when medication is given or applied this should included creams and lotions. creams and lotions should have date of opening and only be applied for the person for whom they are prescribed This will ensure the safe administration of medication 16/09/2009 4 9 13 Staff should monitor the 16/09/2009 condition of people on medication and should only give PRN medication in line with the prescribers guidelines To ensure that people living at the home are given mediation in line with their assessed needs 5 10 12 The management need to ensure that the home is 16/09/2009 Care Homes for Older People Page 35 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action conducted in a manner which respects the privacy and dignity of people living at the home. This should include improvements to screening in the double rooms and to the glass panels in the doors on the Lyde unit This will ensure the dignity and self esteem of people is maintained 6 12 16 The home shall develop a 16/09/2009 range of social and recreational oppertunites for all people living at the home To ensure that people life full and active lives 7 14 12 The management must 16/09/2009 ensure that people living at the home are offered choices in all areas including meals, times of bathing and how to spend thier day. To ensure that people have an influence on thier lives 8 15 16 Staff must be available to support people with meals To ensure that meals are a pleasant experience and to ensure staff can robustly monitor the dietary needs of 16/09/2009 Care Homes for Older People Page 36 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action the people living at the home 9 18 13 The home must review any restrictive practises in place for people living at the home. To ensure that people at the home are protected from abusive practises 10 29 18 Two written references need 16/09/2009 to be obtained for all new staff prior to them commencing work at the home. To ensure that people living at the home are protected by robust recruitment procedures 11 37 37 The management must ensure that CQC are informed of all events in the care home which adversely affects the well being or safety of any service user. This will ensure that CQC can adequatly monitor the home. 12 38 12 Staff must not push people in wheelchairs with out footplates This will reduce the risk of injury. 16/09/2009 16/09/2009 16/09/2009 Care Homes for Older People Page 37 of 39 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 The care plans should demonstrate that due consideration to the mental capacity act has been given. The plans should detail if the individual has capacity to make decisions which may effect their lives. If people have been assessed as lacking capacity then the plan should clearly state who will make decisions on their behalf. The home must consider the use of advocates for any person who lacks capacity to make decisions and choices about their lives It is recommended that staffing levels are reviewed in line with the dependency levels of people living at the home. It is recommended that all staff receive regular supervision in line with Standard 36 of the National minimum standards. The staff must consider the risk of ingestion particularly in the lyde unit. Toiletries should be held securely for those people deemed at risk. 2 18 3 4 27 36 5 38 Care Homes for Older People Page 38 of 39 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). 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