Inspection on 11/05/09 for Winstonian House

This inspection was carried out on 11th May 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Winstonian House 20/05/08

Winstonian House 29/05/07

Winstonian House 24/07/06

Winstonian House 19/10/05

Winstonian House 12/04/05

Winstonian House 22/11/04

Winstonian House 01/06/04

Winstonian House 04/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 07/08/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Winstonian House 42 All Saints Road Cheltenham Glos GL52 2EZ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ruth Wilcox     Date: 1 1 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 39 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 39 Information about the care home Name of care home: Address: Winstonian House 42 All Saints Road Cheltenham Glos GL52 2EZ 01242577927 01242577927 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) : CTCH Ltd care home 18 Number of places (if applicable): Under 65 Over 65 18 old age, not falling within any other category Additional conditions: 0 The maximum number of service users who can be accommodated is 18. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Winstonian House consists of three terraced houses, which includes an end of terrace; all have been modified to create one property. The home is in the All Saints residential area of Cheltenham, close to local shops and the parish church, and is part of the CTCH Ltd group of homes. The centre of Cheltenham and Pittville Park are close by. It is registered to provide personal care to eighteen older people, and can provide respite care if this is wanted. Any elements of nursing care that may be needed are sourced from the local community nursing service. Accommodation is on three floors all served by stair lifts. The lower ground floor has two bedrooms, a bathroom and a small lounge/diner. The remaining bedrooms are Care Homes for Older People Page 4 of 39 Brief description of the care home located on the ground and first floors, with communal bathrooms on each. The communal accommodation consists of two open plan lounges leading to the dining room. Patio doors from the lounge provide access to the small garden. There is a pond, flowerbeds and a paved area where residents can sit. The front of the house has a ramp for easy access and a few parking spaces. Information about the home is available to prospective residents and interested parties in the printed Service User Guide, and a copy of the most recent CSCI report is available in the home for anyone to read. The charges for Winstonian House range from 479.00 pounds (lower Local Authority rate), to 534.00 pounds per week. Hairdressing, Chiropody, Toiletries, Magazines and Newspapers are extra charges. Care Homes for Older People Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection peterchart Environment Staffing Management and administration Poor Adequate Good Excellent How we did our inspection: The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service, and takes into account the views and experiences of people using the service. One Regulatory Inspector carried out this inspection over one full day in May 2009. The home was last inspected on the 20th May 2008. Pre-admission processes and care records were inspected, with the care of five residents being closely looked at in particular. We also inspected the management of residents medications. Care Homes for Older People Page 6 of 39 A number of residents were spoken to directly in order to obtain their views and hear about their experiences of the services and care provided at Winstonian House. Some of the staff were interviewed. Survey forms were also issued to approximately one half of the residents and staff, with four sent to visiting health care professionals to complete and return to us if they wished. Some of their comments feature in this report. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service, and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, provision, training and supervision of staff were inspected, as was the overall management of the home. A tour of the premises took place with particular attention to health and safety issues, and the maintenance and the cleanliness of the premises. We required an Annual Quality Assurance Assessment (AQAA) from the home, which was provided, and the contents of this informed part of this inspection. What the care home does well: What has improved since the last inspection? Documented care planning to meet residents needs is much more person-centred and reflective of their wishes and choices. A new cook has been appointed to address the shortfalls that existed in the kitchen and catering service. The kitchen appeared cleaner on this occasion. The recording associated with the management of residents personal monies, for those who had chosen to place it with the home for safe-keeping, has been improved, although some additional recommendations have been made for some further improvements. There has been some redecoration and refurbishment of facilities in the home, however Care Homes for Older People Page 8 of 39 there are still certain areas requiring some attention. There has been some improvement with the cleanliness of the home overall, however the absence of a housekeeper at the time of this visit was having a negative impact on this. The laundry equipment has been upgraded so that infection control procedures can now be better observed. A key-worker system has been introduced so that closer links can be made between residents and staff, and a more formal method of supervising staff has been introduced. The new management has had a more stabilising effect on the staff team generally. There is an overall move towards improvement at this home on this occasion, however a continued focus is needed if this is to develop further and be sustained. What they could do better: Information about the home should be given to interested parties and prospective residents much sooner in the pre-admission process so that they can have access to sufficient information on which to base their choice about moving here. Despite auditing arrangements, there were a number of areas where the systems for managing medications required improvement so as to remove any risk of residents not receiving their medication safely or in accordance with prescribed instructions. The home is trying to improve the opportunities for social activity for the residents because these are currently quite limited. There needs to be more effort made by staff towards more quality social interaction with the residents. Aspects of the catering are better, however there were some maintenance issues ongoing in the kitchen. The home appeared to have an adequately robust complaints policy, however this had not been consistently applied, with isolated incidents of dissatisfaction in this area. Improvements are required to some damaged furniture and decoration in certain rooms. The hot water supply was not consistent in some of the rooms and this too required attention. Carer numbers have been at the bare minimum during a period of low resident occupancy, however this now requires reviewing as resident occupancy has increased. Also carers are regularly removed from direct care because they are expected to carry out a significant amount of non-care duties which is having a further impact on their ability to spend any quality time with the residents. The home had failed to fully meet a previously issued statutory requirement in relation to the safe recruitment of staff, and an additional requirement for improvement has been issued in this area further to this visit so that the risk to residents from any unsuitable workers can be reduced. Care Homes for Older People Page 9 of 39 The home is now required to provide us with evidence of the Legionella controls that are adopted, and must now also address the risk posed to certain residents from an unguarded radiator in one of the bathrooms. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 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 11 of 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A pre-admission assessment provides prospective residents with an asssurance that their needs can be met at the home, but the failure to provide an information brochure in advance may hinder some people in making an informed choice about the home. Evidence: The homes information brochure had been reviewed and had been issued to residents. One resident told us that they had not received any such information when they came to the home. When we looked at certain arrangements the acceptance letters issued by the home after a successful pre-admission assessment indicated that the brochure was issued just a day before the admission had taken place. We considered this to be far too late in the process. Any prospective residents or interested parties must be given an information brochure at the point of enquiry, well in advance of admission, in order that they can use the information to assist them in making their minds up about the home, and whether they would want to move in here. Care Homes for Older People Page 12 of 39 Evidence: We inspected two examples of pre-admission assessments, each of which was for residents more recently admitted to the home. Each assessment had been carried out prior to admission being agreed, and had been recorded on the homes designated tool for the purpose. The assessments took account of the residents personal details and their past medical history, their health and care needs, their medications, and health and safety aspects. One of these assessments was recorded in fuller detail than the other and consequently was more informative. The AQAA told us that prospective residents were encouraged to come into the home for the day, enjoy a meal, and view the facilities and services when making decisions about coming here. We were told that residents were encouraged to come to the home as part of their pre-admission assessment where practicable, as this was viewed as an ideal opportunity for them to see the home and we saw examples where this had taken place. The AQAA stated that information on financial matters was always available and that prospective residents were encouraged to view the homes latest inspection report. When we checked on the availability of the latest inspection report produced in 2008 it was nowhere to be found, reportedly having been removed by a member of staff to read, and had not been replaced. Winstonian House does not provide intermediate care. Care Homes for Older People Page 13 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home can expect to have their care needs met in a way that is mindful of their privacy and dignity, however failures within the medication systems are posing a degree of risk towards their health and safety. Evidence: The homes AQAA stated that full and comprehensive care plans are devised with consultation with the resident and their relatives, and that they are updated and reviewed at regular periods. It also told us that carers practice person-centred care at all times. Each resident had their own plan of care, which had been based on an overall assessment of their needs, including risk assessments to address mobility, falls, pressure sore vulnerability and nutrition. In cases where acute illness had developed there was care planning to address the persons needs and treatments during their illness. Care Homes for Older People Page 14 of 39 Evidence: In one case the pressure sore risk assessment did not correspond with the circumstances that we encountered. This assessment needed much closer review given that the resident was under the care of the community nurse for a pressure sore. In cases where there was a nutritional risk and recorded weight loss there was evidence of regular consultation with the doctor and monitoring of the persons dietary intake. Where a risk of falls had been identified there were associated care plans which addressed this. We saw examples whereby health care support and treatments had been sourced from external health and social care services for the benefit of the residents and meeting their needs. Residents we spoke to said they felt they were looked after well. One person said in particular that they were very happy with the home, the staff, and the care. This person also said that their doctor was fetched when they wanted, and they got quick help when ringing their bell. Another resident told us that they had taken a while to settle but they were alright now. This person also commented that they were enabled to keep their independence and were glad of it. The resident discussed certain aspects of their healthcare with us with which they managed to maintain control and independence, which they said was so important to them. Residents also confirmed to us that staff were respectful. We observed an unwell resident being nursed in bed. Staff were monitoring and recording the residents fluid and food intake, and ensuring that regular changes of position were carried out for their comfort and safety. We were told that the community nursing service was looking into providing a hoist for this persons needs. A variable height bed had already been provided. We were told that a visiting health care professional had reported to the home that they were experiencing a more professional approach from the care staff than they previously did. Residents could manage their own medications if they expressed a wish to do so, which would be done within a risk management framework. We checked on the arrangements for one such person, and their lockable drawer for storing their medication items had been left unlocked, despite this being part of the risk assessment. Staff need to remain mindful of this and discuss its possible safety implications with the resident concerned. Weekly medication audits had been carried out and the home reported that there were Care Homes for Older People Page 15 of 39 Evidence: now less errors occurring, although we discovered a number during this inspection. There was improved stock control overall. Medication administration charts were printed by the supplying pharmacist. The printed dates on the charts did not correspond with the days identified, which although understood by staff, could be confusing and give rise to error. There were isolated handwritten entries on the printed charts, which had been double signed and verified, but the handwriting was not always absolutely clear; we recommended that handwritten additions be made in capital letters. Medications received into the home were recorded on the charts, with a separate register of items returned to the pharmacy maintained. In one case analgesia was not being regularly given as prescribed. This was due to the resident not requiring such regular pain relief, so we advised that staff record the reasons for omission on the chart using the recognised coding system, or the medications instructions should be reviewed by a doctor so that the medication can be given only when required. Written protocols were in place in most cases to address the indications and use for certain medications prescribed as necessary. Some had associated plans of care as well, which we consider good practice. There was no clear and consistent record of administration of a topical cream that had been prescribed in another case. Directions for its usage were not recorded on the medication chart, but an associated care plan provided very clear instruction, which indicated when to cease applying the cream. The treatment had now been discontinued, but this had not been reviewed and reflected in the medication records. We saw some signature gaps in the administration of eye drops in one case, and in another we found four administration gaps for an oral tablet. We audited this medication and found that they had in fact been administered as prescribed, but had not been signed for. We were able to identify the carer responsible for this failure from the rota and reported it to the manager to address. Other audits showed that a record of a resident refusing certain medications corresponded with the tablets remaining in their supply. A liquid controlled drug (CD) preparation was stored in the designated storage area. The CD register had been recorded when the bottle was received into the home, but recording did not actually include the name of the preparation; this had been an oversight at the time and had not had any effect on management and treatment. The records showed that the bottle had been opened in December 2008, with the first and only dose given at that time. Staff had failed to date the bottle on opening as would be good practice. This medication should have been discarded within ninety days of being Care Homes for Older People Page 16 of 39 Evidence: opened and had not, despite the home declaring they employed regular auditing of the medications. Staff who administer medication were trained by an accredited training provider and all staff were currently undergoing a refresher course with the same provider. The manager should ensure that the training delivered is actually meeting the needs of the staff given the issues that we have reported. Staff were observed carrying out their work efficiently, with circumstances in the home appearing to be calm, organised and tidy, with residents needs being met in full. We witnessed staff knocking on residents doors before entering, and heard some positive and respectful exchanges between staff and residents. Care Homes for Older People Page 17 of 39 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home are able to make choices in their lives and with their meals, however opportunities for social engagement within the home are slightly limited for them. Evidence: The homes AQAA told us that social activities are now coordinated by nominated staff, with a monthly plan devised, and that the home is planning to widen the social opportunities for residents. A monthly diary of activity showed a number of organised group activities, such as bingo, film shows, games, arts and crafts, nail care, and musical movement. The April and May 2009 diaries were repetetive with similar activities on offer. The home had a system for keeping a record of activity participants but this was not being utilised. The manager agreed that the home definitely needed to do more socially with residents, and that staff were talking with residents to establish their ideas and interests for activity. When the manager reported to us that there was little interest amongst residents, we suggested that the prospects could be made more attractive for residents if staff made more effort to interact with them at all times in a more social Care Homes for Older People Page 18 of 39 Evidence: way. We also made the observation that it was not just about activity as such but also about quality time for conversation with residents. We said that staff must have time to do that and not be taken up with non-care tasks, such as two of them washing up in the kitchen or cleaning whilst the cleaner was away. Staff were making efforts to make the ground floor communal rooms more inclusive for the two residents living in the basement who could otherwise become isolated. One resident was pursuing their hobby of jigsaw puzzles, whilst another was going out regularly with their friends. One resident told us they had enjoyed making Easter cards with staff. The home welcomes visitors in, and enables residents families and friends to become involved in the home if they wish. The AQAA told us that they are actively encouraged to participate in meetings and activities, but to date the home reported that there had been very little interest from visitors. One resident told us that their family visited frequently and were invited to have a cup of tea with them. We did not meet with any visitors on the day of this inspection. Residents were able to have as many personal effects in their rooms as they wished, and the homes AQAA told us that the home encouraged residents to bring their own individuality to Winstonian House. Rooms contained personal belongings but some more so than others. One resident told us that they could choose what they did. Another told us that they preferred their own company and that staff were polite and respectful of their choice. We met two residents who were in bed until late morning, one of whom had not washed or dressed at that time. Each indicated to us that this was their preferred habit. The AQAA told us that the menus had been reviewed in consultation with residents, and that they had been well received. The service of meals was an area that the manager had decided was an area in which the home could improve. A new cook had been appointed since the last inspection in order to assist with this. The cook was absent on this day and a supernumerary carer had been brought in to prepare the meals. The lunch menu offered a fish or a meat dish with fresh vegetables, and at least two puddings. A resident with diabetes said she had a vegetarian and a diabetic diet, which was catered for well, according to her needs and choice. Residents told us that they enjoyed their food. Care Homes for Older People Page 19 of 39 Evidence: A list of residents choices had been compiled and given to the person cooking. The meal looked nutritious and was presented in a satisfactory way, with staff in attendance to give help to residents where needed. Some residents, who were unwell, were served in their bedrooms with staff helping to feed where necessary. The kitchen is sited in the basement and is of a more basic domestic provision. There were two control knobs missing off the well-used oven, and a number of wall tiles were lifting off the wall above the refrigerators. However, the kitchen did appear to be somewhat cleaner than seen on previous occasions, with closer attention having been paid within the limitations of the environment. Catering records were in place, and storage of refrigerated items was appropriate. The catering facilities were inspected by the Environmental Health (EHO) inspector some months ago. Following our inspection we liased with the EHO inspector to discuss their overall judgement of circumstances in the home since their last visit. Care Homes for Older People Page 20 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Despite the good policies in place to address complaints and protect the rights of the people living in this home, these have not been consistently robust, and this has resulted in their inability to have complete reassurance in them. Evidence: There was a written complaints policy displayed in the front hall, with a copy included in the residents guide book; this needed to be updated to reflect the contact details of the current regulatory body. Concerns had been raised by a residents relative and as a consequence of them appearing to remain dissatisfied with the homes actions was seeking a placement at another care home for their relative. One resident told us that they did not know the procedure for making complaints, whilst another told us that staff did not listen anyway. One resident told us that she felt quite happy to voice concerns if she had any, and that she had great confidence in the staff to assist her. A second resident said that she had previously raised a concern about cleanliness in her room, which she said had been fully addressed at the time. The AQAA stated that all staff had received training in Safeguarding Vulnerable Adults, and were made aware within that training of the whistle blowing policy. It also stated that staff had attended training in the Mental Capacity Act (2005) (MCA). We were Care Homes for Older People Page 21 of 39 Evidence: able to confirm this had taken place through interviews with staff and the training records. However in one case, although the records showed a particular carer had attended this training the carer told us that she had not in fact attended an update, and was due to undergo it in the near future. Deprivation of Liberty Safeguards (DoLS) training had also been delivered to staff by the local authority. There was a Staff Disciplinary policy, which aimed to protect residents and staff. In recent months some serious concerns had arisen around some allegedly abusive conduct by a member of staff, and appropriate measures were taken in response by the management, with the home sharing the information with the relevant authorities. Record keeping associated with safeguarding the monies and valuables of those residents choosing to place them in the homes main safe was clearer and more robust on this occasion than at a previous visit, and offered better protection for them. The interests of one particularly vulnerable resident were being protected and upheld through open communication and collaberative working between the home the resident concerned, and their legal representative forming a power of attorney arrangement. Care Homes for Older People Page 22 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 living in this home are provided with accommodation that is reasonably suitable to meet their needs, however the owners programme to slowly address less satisfactory aspects of it should make the environment more safe, accessible and pleasant for them over time. Evidence: The homes AQAA told us that some of the ensuite facilities in residents rooms needed refurbishing, and that many areas could do with upgrading, with further improvements needed to the fabric of the home. A visiting health care professional had told us that the home provided a nice atmosphere, but was not an ideal environment for mobility. The accommodation is provided within an older style extended house, not built for its purpose, and is spread on three different floors. There is no passenger lift, although two stair lifts are provided. Maintenance personnel were employed and were actually on site during this inspection, involved in upgrading one of the vacant bedrooms. Redecoration had taken place in other areas, with new carpets fitted and some ensuite facilities installed. A new walk-in shower in the communal bathroom on the ground floor had been fitted, which was a significant improvement in this room. Some new furniture had been Care Homes for Older People Page 23 of 39 Evidence: provided to the two basement bedrooms, but the doors to the vanity unit cupboard in one of them were broken, and in the other the storage chest drawers were broken. Also the emulsion paint on the walls was very discoloured dirty and patchy in here. Wall coverings and wood paintwork in the entrance hall particularly were scuffed, damaged and unsightly. We checked the hot water in one of the basement rooms later in the morning and there was only cool water available, despite leaving the hot tap running for some considerable time. In view of this we also checked another residents room on another floor, and the same situation arose. The resident said it was always like that, and had to leave it running ages before she needed it in order to get some warm water. One resident raised concerns in a survey form about the smoke that often pervaded from the smoking area, and about it affecting them. We spoke to this resident directly and they told us that it was staff who were smoking on the patio outside the lounge, but that this had now been stopped and was no longer a problem. One resident told us that their toilet did not get cleaned every day. One resident told us that they had previously raised concerns with the home regarding the inadequate cleaning in their bedroom. They went on to report that things had improved as a consequence. A first floor bedroom carpet was covered in debris and had not been vacuumed. There was no housekeeper on duty on the day of our visit, and although this had been due to a planned absence, no cover had been sourced to maintain the work. However, overall cleanliness had generally improved and the home was somewhat cleaner on this occasion, with little odour detected. New laundry equipment had been installed, which could provide sluicing and disinfection cycles for foul items. The laundry room was locked with more secure chemical storage now provided. Care Homes for Older People Page 24 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. Despite an improved focus towards staff development, some isolated shortfalls in staffing provision and recruitment procedures are posing a degree of risk to the health and safety of the people living in this home. Evidence: The previous unregistered manager who left the home immediately prior to this inspection had been endeavouring to stabilise the staff team, and had been managing peoples performance where necessary. Agency staff usage was minimal, and although the staff team was reasonably stable there have been issues with a lack of cohesiveness in certain areas that have required particular attention. None of the surveys that we issued to staff as part of this inspection were completed or returned to us. Staff rotas showed that the manager worked in a supernumerary capacity. The mornings provided three care staff, the afternoon and evenings two, and there was one waking and one sleep-in carer overnight. One of the two evening carers had to undertake a significant degree of catering duties with the supper time meal, which takes them away from the care and company of the residents. We expressed our concerns about this arrangement with the manager and the Group Care Manager (GCM), saying that the level of staff in the evenings was not adequate given that there Care Homes for Older People Page 25 of 39 Evidence: were clearly times when there was only one member of staff out in the home and readily available to the residents. During the morning we witnessed two carers in the kitchen washing and drying up, which left only one carer upstairs with the residents. The GCM said that the carer numbers had been temporarily reduced whilst resident occupancy numbers had previously been very low, but that now they were nearly back at full occupancy the staffing level could be reviewed. One of the care staff told us that things were tight at times, with two residents needing more care and feeding, and suppers to do, as well as the caring. There was no housekeeper on duty during the week of our visit and it appeared that no attempt had been made to replace her, despite it being a planned absence. Because of this carers had to be responsible for keeping the place clean as well. The cook was also absent on this day and a supernumerary carer had been drafted into the kitchen to help. Residents who responded to our survey or who spoke to us directly spoke well of the staff. We received comments such as staff are helpful and kind. One person said they come and help me as soon as I ring, and get the doctor for me. Another person said they could not fault it and that the staff were very good. A key-worker system had been introduced, which was an improvement, with care staff taking more responsibility and accountability with caring for residents and with care planning. The homes AQAA told us that one of the visiting healthcare professionals to the home had reported observing a much more professional approach from the staff. There were six care staff who had acheived the National Vocational Qualification (NVQ) in Care, four of whom were on night duty, with only two on day duty. Another carer on days had just completed the course, which will make a total of seven. There were no other staff currently on a course although there is an expectation within the home that all care staff should progress to the NVQ training programme. We inspected the recruitment arrangements for two more recently recruited members of staff. Each contained application forms and an offer letter, but there was no actual start date of their employment identified anywhere within the files. In one case the application form did not include a full employment history, and although the worker had submitted a full resume of their work history separately it did not include their actual employment dates in the history. This made it impossible to see whether there had been any employment gaps that required exploring. The interview notes did not inlcude this information either. This was an unmet requirement from the previous inspection. A criminal convictions declaration had been signed and medical fitness confirmed. Proof of identity had been sought, but there was no photographic Care Homes for Older People Page 26 of 39 Evidence: identification of the person on file and no record had been kept of what identity proof had been checked. Two written references were on file in each case, including from a previous employer, having been received in advance of them starting work here. A Protection of Vulnerable Adults (POVA) First check had been done in each case, with a full Criminal Records Bureau disclosure on file in one case. However in the other case a full CRB had not yet been received despite the worker being employed for some time. Certain difficulties with the processing arrangements, which were not under the homes control, were reported and this was now being case tracked by the homes umbrella body for CRBs. We emphasised the importance that this person did not have any unsupervised access to residents until a full CRB had been received, and this was fully acknowledged by the GCM who said that the worker never worked alone. We inspected the induction training arrangements that had been in place for the two more recently recruited staff. Training had included the Common Induction Training Standards (CIS) for care workers. Each had been checked and signed off by the manager at the time, with an in-house training programme also. Fire Safety training had been delivered to them in-house. The AQAA told us that the manager had found that previously held training records had not been retained as they should have been and that a new programme had been set up as a consequence. A training matrix had been devised but this could not be completely relied upon. This was because one particular carer had been entered on it as having attended POVA training but when we spoke to her she said she had in fact failed to attend the training despite it being scheduled for her. A revised date had been arranged. Moving and handling training had been provided by an external training provider. Eleven staff had received infection control training through a local college. Food safety training had been provided for the cook through an accredited agency, and all staff had received instruction in basic food hygiene given their involvement in catering duties. COSHH (Control of Substances Hazardous to Health Regulations) training had been delivered last year. First aid training, MCA and DoLS training had been delivered, although there were still two more staff yet to do this in June of this year. Equality and Diversity training was being made mandatory for staff this year using a distance learning course. Two staff we spoke to directly confirmed they had an NVQ in care and had received training in MCA and DoLS, safe management of medications, first aid, food hygiene and infection control. Care Homes for Older People Page 27 of 39 Care Homes for Older People Page 28 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There have been some improvements to the management systems in place here, however these need further development if the interests of the residents living in the home are to be safeguarded more consistently. Evidence: The AQAA was completed to a satisfactory standard, although the list of policies and procedures was incomplete with many showing they had not been reviewed for some considerable time. There has been significant instability with the management of this home in more recent years. The latest experienced manager never submitted an application to register with us, and having just recently left the home has now been replaced by another person. This latest person has a degree of previous experience of running a care home in a deputy manager capacity at another home in the care group. She has achieved an NVQ level 2 and 3 and is currently undergoing the level 4 award in Care Homes for Older People Page 29 of 39 Evidence: readiness to do the Registered Manager Award straight afterwards. Another more experienced home manager within the group is providing mentorship to her. An application to register the new manager must be submitted to us by the end of August 2009. Resident occupancy numbers have not previously been well sustained in this home and the manager had been trying to rectify this. This has been with some success given that there were just two vacancies at the time of this visit. A new deputy manager had been brought in and this had been viewed by other staff and stakeholders to have had a positive impact in the home for the residents. As previously reported the lack of consistency with strong management and leadership has made it difficult for improvements to be maintained at the home. However this had begun to improve under the most recent manager who has now left. Quality monitoring had incorporated internal audits as part of attempts to effect improvements where needed, and this had included care planning, medication management, accidents and complaints. A resident satisfaction survey had not been carried out this year so far, however questionnaires were issued to residents, visitors and other stakeholders in order to gain their views about the quality of the service that the home provided last year, but this had produced very few responses. A suggestion box had been placed at the front door for anyone to put their suggestions and comments into if they wished. Staff had tried to hold meetings for the residents and their relatives but there had been little response to this either. The newly appointed manager intended to keep trying with this. A notice was displayed inviting visitors to join a relatives forum but so far no-one had expressed any interest. Staff meetings had been held and records of minutes were seen. The homes AQAA told us that regular quality monitoring visits were conducted in the home by the Group Care Manager, and that there was an open door policy where anybody could request to see the manager if they wished. Some residents had chosen to place personal money in the homes main safe. Records were maintained, which contained evidence of money totals, running balances and transactions. We checked two arrangements, one of which was chosen randomly, the other on the basis of some concerns identified at the previous inspection. Clearer records were now being held in each case with receipts attached to account for any financial transaction carried out by staff on the residents behalf. We were able to audit payments made for chiropody treatments in a designated chiropody book. However Care Homes for Older People Page 30 of 39 Evidence: entries did not show the exact amount paid next to the name of the client in the book, and the chiropodist had not signed the book for having received the money. One of the carers and the manager had both signed financial records to remove money for expenditure on residents behalf, although it was not exactly clear which one of them had actually taken it to spend. The AQAA told us that staff received formal supervision and that records of this were held in staff files. The new manager told us that she had started to carry out supervisions with staff, and two carers confirmed that they had received it. They said their sessions had included discussion about any problems, their work performance, and training needs. Supervision records were not checked on this occasion. Records showed us that regular checks had been carried out on the fire safety systems, including the fire alarms, smoke detectors and emergency lights. A fire safety risk assessment had been carried out. Individual risk assessments were on file for staff, the outcome of which determined the frequency of their fire safety training. A fire safety evacuation plan had been formulated but this had not yet been displayed around the home; this was in hand however. Safety checks and maintenance of utilities and equipment had been undertaken, including checks on the fire alarm, fire doors, and smoke detectors. Records indicated that the gas boilers had last been serviced over a year ago and would now be overdue. Hot water outlet temperatures were being checked for safe temperatures each month. Some hot outlets were recorded as low as 30 degrees Centigrade on occasions, which posed a slight doubt about whether staff were carrying out this task properly. If they were it then posed a degree of doubt over the veracity of a previous statement given to us that hot water was stored above 60 degrees Centigrade and distributed at over 50 degrees Centigrade as a control for Legionella prevention. Staff had been trained in basic first aid and first aid facilities were available. Accident records were being maintained and any incidents were being regularly audited. The kitchen had been inspected some months ago by the Environmental Health Inspector (EHO), and this had raised a number of concerns at the time, with requirements for improvement made. We have contacted the EHO since our visit to confirm their current status with this home. There was an unguarded radiator in the basement bathroom, which felt very hot to the touch. The room is used by some of the residents, and consequently the hot surface was posing a risk to them, particularly to those who might be at risk of falling against Care Homes for Older People Page 31 of 39 Evidence: it. Care Homes for Older People Page 32 of 39 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 29 19(1.b) Schedule 2 (6) The Registered Person must 31/07/2009 ensure that a full employment history is obtained for new workers, which includes the dates of previous employment, in order to identify and explore any gaps within it. Care Homes for Older People Page 33 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 The registered person must ensure that there are clear directions for the usage of medications on medication administration charts. This is to ensure that residents can receive their medications as prescribed. 30/06/2009 2 9 13 The registered person must ensure that auditing arrangements for medications are carried out robustly to identify expired medications and dispose of them appropriately. This is to ensure that residents are not placed at risk of out of date medications being administered to them. 30/06/2009 3 9 13 The registered person must ensure that staff maintain a consistent record of administration of all medications, including topical creams. 30/06/2009 Care Homes for Older People Page 34 of 39 This is to ensure there is a clear record of the medications residents have received, and to reduce any risk of them not receiving their medications as prescribed. 4 29 19 The registered person must ensure that records are retained in the home to confirm that proof of identity, including a recent photograph, has been obtained when recruiting new staff. This is part of the required pre-employment checks so that only suitable people can be employed to care for the vulnerable residents in the home. 5 27 18 The registered person must ensure that staffing levels are reviewed. This is to ensure that there are sufficient numbers of staff to meet the care needs of the residents at all times of the day. 6 19 23 The registered person must redecorate the identified basement bedroom walls. This is to ensure that the resident has a clean and well maintained environment in which to live. 31/07/2009 31/07/2009 31/07/2009 Care Homes for Older People Page 35 of 39 7 19 23 The registered person must ensure that a consistent supply of hot water is available in all bedrooms. This is to ensure that residents have access to hot water in their rooms whenever they want or need it. 30/06/2009 8 19 23 The registered person must 30/06/2009 ensure that repairs or replacements are carried out in the two basement bedrooms to: The broken vanity unit doors; The broken drawer fronts on the storage chest. This is to ensure that residents are provided with suitably maintained and usable facilities in their room. 9 31 8 An application for the manager of the home must be submitted to CQC for consideration. This is to ensure that a suitable manager for the service can be considered for registration by CQC. 31/08/2009 10 38 13 The registered person must provide information to CQC to confirm the risk reducing measures adopted for the control of Legionella. 31/07/2009 Care Homes for Older People Page 36 of 39 This is to determine whether appropriate controls are in place for the health and safety of the residents. 11 38 13 The registered person must carry out a risk assessment on the radiator in the basement bathroom, and take any steps necessary to reduce the risks identified. This is to reduce the risk of any resident using the room sustaining a burn injury from the radiators hot surface. 30/06/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The home should ensure that a copy of the homes information brochure is provided at the enquiry stage in order that prospective residents can have access to information about the homes services and facilities on which to make an informed decision. The registered person should deploy staff in a way that enables them to give time towards more quality and meaningful social contact with the residents. The registered person should ensure that the record keeping system that is associated with social activities in the home is maintained by staff. The registered person should take steps to ensure that all residents are aware of the system for making complaints, raising and discussing issues that affect them, and that all staff adopt a more consistently receptive approach towards any such issues that they do raise. The registered person should ensure that there are more staff on day duty who have the NVQ level 2 qualification. The registered person should ensure that the damaged 2 12 3 12 4 16 5 6 28 19 Care Homes for Older People Page 37 of 39 woodwork, particularly in the hallway, is prioritised for redecoration. 7 26 The registered person should ensure that a replacement housekeeper is found for when the permanent housekeeper is temporarily absent. The registered person should ensure that the following additional safeguards are adopted when managing residents personal monies: The amount of chiropody money paid to the chiropodist is recorded in the designated chiropody book as well as on the individuals financial record, and ensure that the chiropodist signs the book to acknowledge its receipt; The member of staff taking the money to spend on the residents behalf is made clearer on the record. 8 35 Care Homes for Older People Page 38 of 39 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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