Care Home: Alexandra House

What the care home does well This key inspection was conducted with full co-operation of the acting manager and operations manager and staff team. The considerable improvements made in a very short space of time, had been sustained and built on. There was a range of up to date written information about the home. There were also some alternative formats, such as use of pictures, for people unable to easily understand the written information. People living at the home were able to make choices about their daily routines and meals. They told us they liked the food, which looked appealing and appetising. The home had received a Three Star rating for food safety and healthy eating from Dudley Environmental Services. The management team had an "open door" policy to encourage relatives and people living at the home and staff to talk to them on an individual basis. People told us they felt they were listened to and action was taken for improvements. There was a warm and friendly rapport between staff and people living at the home. Staff were aware of individual people`s likes and dislikes and how to meet their needs. We saw staff talking to people at a pace and in a way they understood. We saw that visitors were warmly welcomed to the home and offered refreshments. A relative told us, "staff are always helpful and welcoming. They care for people well" The bedrooms we looked at were clean, and some were comfortable and contained personal possessions. There was commitment to staff training and development with a ratio of 58 per cent of care staff qualified to the NVQ level 2 or above. There were also more staff undertaking the NVQ care award. All staff were checked to make sure that they are suitable to work with vulnerable people. What has improved since the last inspection? The new acting manager had introduced considerable improvements to many areas in a short period of time. There was improved assessment and management of risks, care planning and care records. These provided better information and clearer guidance so that all staff knew about each person`s needs, preferences and wishes. The records we looked at were completed and kept up to date, though there were some further areas for improvement were identified at this visit. Improvements had also been put in place to make the home`s medication system safer, so that each person would receive their medicines as prescribed at the right time and all previous requirements and good practice recommendations relating to medication were met. A new activities organiser had been recruited and work had started to find out how people preferred to spend their time and to provide a wider range of stimulating things for people to do. Planning for short trips and outings had also started. There were improvements to the way concerns, complaints and matters requiring notification to outside agencies were managed; and the Local Authority and the CQC had received notifications of any events affecting people living at the home. The acting manager had recruited additional suitable nurses and staff and had made sure training was available so that everyone up to date with essential training for their role. This meant that staff were more knowledgeable and skilled to meet the needs of people living at the home. Maintenance work was continuing to various parts of the home to improve the safety and cleanliness, making it a better place for people to live. The garden areas were attractive with planters and summer flowers. Improvements had been made to health and safety with systems and records better organised and information readily available. What the care home could do better: There were a number of areas still requiring improvement at this inspection. The management must continue to monitor and audit the way people`s medication is administered and recorded, taking action to provide additional medication training where necessary to make sure errors do not pose risks to people`s health and well being. Care records should also be expanded in some areas, for example to include correct pressure settings for pressure relieving mattresses and to include fuller details for the management and monitoring of wounds. Improvements to provide more individual activities and more opportunities for outings into the community need to be continued and funded appropriately. The registered persons must make progress with a maintenance and refurbishment plan for parts of the home where there the environment is unacceptable, such as Briony unit, with speedier action, to improve the home to make it a pleasant place for people to live. There were two areas, which posed risks to people that need to be dealt with a priorities. These are to stop the practice of using wooden door wedges to prop open bedroom, other doors and provide an acceptable alternative; and to minimise the risks to people from exposed hot water pipes. Key inspection report Care homes for older people Name: Address: Alexandra House 143 High Street Pensnett Brierley Hill West Midlands DY5 4EA     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jean Edwards     Date: 0 7 0 7 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 34 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 34 Information about the care home Name of care home: Address: Alexandra House 143 High Street Pensnett Brierley Hill West Midlands DY5 4EA 01214343996 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): suebastable@alexhouse1.fslife.co.uk Mr Jayantilal James Bhikhabhai Patel Name of registered manager (if applicable) Type of registration: Number of places registered: care home 50 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 to be accommodated is 50. The registered person may provide personal care with nursing, and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: - Old age not falling within any other category (OP 30) - Dementia over the age of 65 (DE (E) 20) - Physical Disability over the age of 50 (PD 10) Date of last inspection 0 7 0 4 2 0 0 9 0 0 10 Over 65 20 30 0 Care Homes for Older People Page 4 of 34 Brief description of the care home Alexandra House is an extended and converted house, which is registered to provide nursing care for 30 older people of which up to 10 beds may accommodate people requiring terminal illness care and 20 older people with dementia. The home is divided into two units: Rose accommodates persons requiring nursing care, including palliative care and Briony which provides dementia care. The home also provides Accident and Emergency Diversion beds, Intermediate care and GP Respite beds when required. The home is situated on an easily accessible public transport route, is close to Merry Hill and Dudley shopping centres and other local shops and amenities. There is a car-parking facility to the side of the building and a garden, which is mainly laid with grass and secluded areas. The home also has a memory garden. Care Homes for Older People Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection took place on 20 and 21 January 2009 and a random inspection took place on 7 April 2009. We, the Care Quality Commission (CQC), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. The inspection took place over a weekday and the CQC pharmacy inspector visited the home for part of the day to assess the homes medication systems. We monitored the compliance with all Key National Minimum Standards during the visit. The range of inspection methods we used to gather evidence and make judgements included, discussions with the acting manager, the deputy manager, company representative and staff on duty during the visit. We also talked to people living at the home, and made observations of people without verbal communication skills. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the previous Commission for Social Care Inspection. We also Care Homes for Older People Page 6 of 34 looked at number of records and documents during the inspection visit. We looked around the premises, including communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. This service was previously rated as adequate but had a Zero Star, poor, quality rating since January 2009. A random inspection visit in April 2009 told us that there were some improvements. The process of this inspection was to show where the service was doing well, where improvements were still needed, and to consider the management ability to sustain these changes. From all of the information we made a judgment on the outcomes for people using the service for all the different sections as shown in this report and a final quality rating, which will decide what further regulation action we might take. A statement of purpose and service user guide was available. The home had published the weekly range of fees in the service user guide. The weekly fees range from £460 to £560 per week, with additional individual £30 third party top up fees. There are additional charges for hairdressing and private chiropody. People are advised to contact the home for up to date information about the fees charged. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? The new acting manager had introduced considerable improvements to many areas in a short period of time. There was improved assessment and management of risks, care planning and care records. These provided better information and clearer guidance so that all staff knew about each persons needs, preferences and wishes. The records we looked at were completed and kept up to date, though there were some further areas for improvement were identified at this visit. Improvements had also been put in place to make the homes medication system safer, so that each person would receive their medicines as prescribed at the right time and all previous requirements and good practice recommendations relating to medication were met. A new activities organiser had been recruited and work had started to find out how Care Homes for Older People Page 8 of 34 people preferred to spend their time and to provide a wider range of stimulating things for people to do. Planning for short trips and outings had also started. There were improvements to the way concerns, complaints and matters requiring notification to outside agencies were managed; and the Local Authority and the CQC had received notifications of any events affecting people living at the home. The acting manager had recruited additional suitable nurses and staff and had made sure training was available so that everyone up to date with essential training for their role. This meant that staff were more knowledgeable and skilled to meet the needs of people living at the home. Maintenance work was continuing to various parts of the home to improve the safety and cleanliness, making it a better place for people to live. The garden areas were attractive with planters and summer flowers. Improvements had been made to health and safety with systems and records better organised and information readily available. What they could do better: 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 34 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 34 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. The home has an up to date statement of purpose and service user guide in the and easy to understand format, which means that people have good information to help them make decisions about their choice of home. There are comprehensive assessment tools and regular reviews so that people living at the home can feel assured that their care needs are known about and can be met. Each person has a contract and terms and conditions of residence, which tells them about their rights and responsibilities. Evidence: The homes statement of purpose and service user guide had been revised and updated to contain clear and accurate information. These documents were readily available in the home. It was positive to see that the service user guide was in an easy read format, with pictures and contained information about the range of fees Care Homes for Older People Page 11 of 34 Evidence: charged by the home. This meant that people had good information to enable them to make informed decisions about the choice of home. We were told that there had been limited new admissions to the home since the random inspection on 7 April 2009. The recently appointed acting manager told us that there were 23 people accommodated. We saw evidence from a sample of care records looked at that everyone living at the home had received or been offered ongoing reviews of their care needs and placements at Alexandra House Nursing Home. We saw that each persons contract and terms and conditions of residence had been revised and updated and included comprehensive information. There were six people who had been admitted for intermediate care. This meant they were at the home for a limited fixed period of time. There were also terms and conditions issued to these people, which demonstrated positive practice. At the previous key inspection we had discussed concerns about staffing levels and the continuity of care from carers who had to work between the two different units. The acting manager had taken action to allocate carers to work on designated units at the random inspection in April 2009. At this inspection it was positive to see that the acting manager had taken account of the dependency levels of people living at the home and additional nurses, carers, kitchen staff had been employed. A named nurse and key worker system had also been introduced with positive results for continuity of care for people at the home, especially those who were admitted for short stays. Staff morale had also improved. Care Homes for Older People Page 12 of 34 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. There are care plans and risk assessments, which are adequate to identify peoples needs and provide staff with guidance. There are better assurances that individual needs will be met for each person. The arrangements for administration of medication do not entirely ensure people receive their medicines as prescribed by their doctor, which may pose risks to their health and well being at times. People are generally treated with respect and their privacy and dignity is maintained. Evidence: We looked at of care records of a sample of people living at the home. The acting manager had continued with improvements in the way the information was used to assess and plan to meet each persons needs. The care plans were person centred and demonstrated people or their representatives had been involved in developing the plans for their care and support. There was a more consistent approach to the way the healthcare screening tools, risk assessments and care plans were implemented, Care Homes for Older People Page 13 of 34 Evidence: monitored and maintained. This meant that persons living at the home could feel more assured that their care needs were known about, understood and would be met. People had good access to health care services to meet their assessed needs. The home uses the services of a contracted GP, though we were told that people could choose their own GP within the limits of geographical borders. We saw that people had access to dentists, opticians, chiropodists and other community services such as speech and language therapists and occupational therapists. There were improved instructions for the care of people with complex needs. For example the instructions for maintaining a PEG, an artificial feeding tube in to the stomach, were very detailed and clear and there were daily records to show that the instructions had been followed. There were some areas, which needed further improvements such as care plans and wound charts for pressure ulcers. The care instructions needed to be more specific in care plans and reflect information contained on wound charts, for example dressings to be changed PRN may be interpreted differently by individual nurses. Additionally the wound charts did not include measurements and periodic photographs of the pressure ulcers to show healing or deterioration, which would be good practice. A nurse on Briony unit updated one persons photograph and care records during this inspection. Pressure relieving equipment was recorded on risk assessments and care plans but there were no records of the correct pressure settings for pressure reliving mattresses. This meant that people might be left in discomfort and at risk of further damage or the mattress might be ineffective. We saw one mattress where the pressure setting appeared to be too high for the persons body weight. The acting manager agreed to take remedial action. We also noted that a person admitted for a short respite stay had been taken to the lounge and their glasses, recorded as needed for long distance were left in their bedroom. This might have hampered their visual awareness of their surroundings. The same person had a tray for oral care in their bedroom but no written care plan to show how and when this was required. Immediate action was taken to rectify these issues. The pharmacist inspector visited the home on 7th July 2009 as part of the key inspection to check the management and control of medicines within the service. Care Homes for Older People Page 14 of 34 Evidence: We saw that improvements had been made to the security and room temperature of the main treatment room on Rose Unit. We saw that metal bars had been fitted to the window to improve security of medication storage. We saw that a new air conditioning unit had been fitted into the room. The temperature of the room was recorded daily between 21 and 22 degrees centigrade which was within the correct storage temperature for medication. We also saw that a new refrigerator had been purchased. We saw the temperature records for the medication fridge, which was between 2 and 8 degrees centigrade and was within the correct storage temperature. Medication stored on Briony unit was secure and stored within the correct temperature range. We found that medication was locked and secured in a medicine trolley or locked cupboards to ensure safe keeping. Medication was stored neatly and tidily. It was easy to locate peoples medication. This meant that peoples medication was stored securely and within the recommended temperature ranges. We found up to date information relating to medication. The manager had developed a new form called PRN medication guidelines plan which was used for people who were prescribed when required medication. Care staff would complete the form and explain how and when the medication was to be given. For example, one person was prescribed a cream to be applied when required. We saw written guidelines dated 12/5/09 which stated that the cream should be applied all over the body dry areas morning and afternoon. This meant that there were clear written directions for care staff to follow to ensure the health and wellbeing of people living in the service. We saw a document for the administration of covert medication. It would be used to assess and document the reasons why covert administration was required, how the medicine was to be given, the persons agreement, and included evidence of an assessment. A separate form was seen which would be used to document the medication and how it could be given covertly and in which food preparations. The manager informed us that nobody was currently being given medication covertly. The form would enable the home to ensure that the health and well being of people living at the home were safeguarded. The manager informed us that checks were made on medication records in order to ensure there were no errors. We were shown an audit dated 12th May 2009. The manager also showed us a document which demonstrated that random checks were made on the nurses medication knowledge. This showed that the service was assessing staff and ensuring that they are competent and also their practice was checked to ensure that people living at the home received their medication safely and correctly. Care Homes for Older People Page 15 of 34 Evidence: We found that some peoples prescribed medication was being reused and kept as a homely remedy and given to other people living in the service. We saw two boxes of soluble Paracetamol tablets with the original pharmacy label removed from both boxes. A homely remedy is a medication that has not been prescribed but can be given to people for minor health ailments such as a headache or a cough following an agreed procedure. We found evidence that at least one person who had been prescribed Paracetamol 500mg tablets was given some soluble Paracetamol tablets that had been prescribed for somebody else. A pharmacist had visited the home on 30th June 2009 to check medication and had informed the home that patients returns must not be used as homely remedies. However the home had continued to use the prescribed medication against the pharmacists advice. We informed the manager that the practice was not acceptable and issued an immediate requirement. It was acknowledged that the person received the painkiller to ensure that they were not in pain, however the practice of reusing other peoples medication is not safe and increases the risk of a medication error. The manager immediately took the necessary action and disposed of the medication and a new supply of medication was purchased from a local pharmacy for the homely remedy cupboard. We saw records for the receipt and disposal of medication, which ensured that it was possible to check records of medication for people who live in the service. We saw that some medication administration records (MAR) were handwritten, however the directions did not always match what was written on the pharmacy label attached to the medication. For example, we saw one person was prescribed a tablet to be given three times a day, however the written directions on the MAR chart stated TDS which is a Latin abbreviation for three times a day. There was a double checking system in place to ensure that the record was accurate so it was therefore disappointing that the directions were not written out in full. This meant that there was an increased risk of incorrect medicine records.The manager informed us that this was a known issue that was being dealt with. Medication administration records were not always clearly documented with current and up to date information. For example, we saw one MAR chart for a person recently admitted. The MAR chart included the name of the person but did not document their date of birth, GP name, or the month or year on the chart. Due to poor records there was an increased risk of a medication error. Also any future need to look at medication records for that person meant that it would not be possible to determine which month or year the medication had been administered. We found that prescribed medication was not always given according to the directions Care Homes for Older People Page 16 of 34 Evidence: of a medical practitioner. For example, we found that one person had not been given their prescribed medication on one occasion although the medication records had been signed for administration. It was not possible to determine which day or time this had occurred. We spoke to a member of staff who agreed that it looked like somebody had signed for administration but had not given it. This was poor practice and increased the risk of harm to people living in the service. We found that staff did not always document the amount of medicine that had been given to a person. For example we saw that when medication was prescribed as a variable dose such as, one or two tablets to be given, there was not always a clear record of how many were given. This meant that due to poor medicine records it was not always possible to determine whether medication had been given to a person as prescribed. We saw that all staff were aware of how to treat each person with respect and to consider their dignity when they were providing personal care. They spoke to people using terms and a pace they could understand. People looked cared for and well groomed, wearing clothing appropriate for the weather and of their choice. Care Homes for Older People Page 17 of 34 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at this home have opportunities to take part in activities. People are able to maintain contact with their friends and families who are welcomed. Meals are appetising, and generally people receive a nutritious diet. Evidence: We saw that care records had been improved to include rising, retiring, bathing or showering preferences. There were less people accommodated and the routines of the home were able to be more geared around each persons needs and preferences. From observations and discussions staff deployment and availability was managed better and staff felt they could give each person the time they needed. The acting manager acknowledged the improvements must be maintained when the vacant beds are filled. A new activities organiser had been employed and activities preferences and participation were recorded in a more meaningful and person centred way. The activities organiser had started work to put in place an activities programme for planned and spontaneous group and individual activities. There was now better evidence of activities suited to the needs of people with dementia, physical and Care Homes for Older People Page 18 of 34 Evidence: sensory disabilities. Examples were picture boards with scenes to prompt reminiscence, music, and large board games. We also saw staff spending time talking to people. We were told that the majority of materials for activities were acquired as donations and there was no budgetary provision for activities or access to the wider community. There was some evidence of people visiting the home to provide activity sessions such as musical sessions and the acting manager had audited peoples preferences to meet their spiritual needs for church services and visits from the clergy. Visiting times were clearly displayed and there was a visitors book for people to record their details for security and fire safety. We discretely observed meal times throughout the day, spoke to staff and examined records and found that generally food and fluid records had improved with better evidence that people received a wholesome, appealing, balanced diet. We saw the cook ask people for their preferred options for lunch and at other times we heard staff ask each person what they wanted at tea time. The meals appeared appetising and inviting. There were lots of fresh vegetables and fruit available. The home had been inspected by Dudley Environment Health Service and had achieved a three Star award for food safety and healthy eating. Efforts were made with table settings to make them attractive with tablecloths, all required cutlery and condiments, though most people ate their meals at small tables near their armchairs. Most people told us they enjoyed the food. Care Homes for Older People Page 19 of 34 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can have confidence their concerns or complaints will be listened to and investigated and the management practices generally protect people living at the home from risks of harm or abuse. Evidence: We saw that the home had an up to date complaints procedure, which was displayed in bedrooms, the reception area and contained in the service user guide. Information supplied at the inspection showed that the home had received two formal complaints since the random inspection visit on 7 April 2009. These had been upheld by the manager. We saw records to show the complaints had been investigated within 28 days, with satisfactory resolutions implemented. The responses during the inspection indicated that people were aware of how to raise concerns or use the homes complaints procedure. This demonstrated positive practice and the homes more proactive response to peoples experiences and perceptions of the service. A persons care records showed that they lacked capacity and it was recorded that staff were making decisions about daily personal care in best interests. We emphasised to the acting manager the importance of involving multi agency professionals and as necessary an Independent Mental Capacity Advocate (IMCA) for decisions to be made in the persons best interests. Care Homes for Older People Page 20 of 34 Evidence: We were given information that the acting manager had recently attended training regarding Mental Capacity Act and Deprivation of Liberty Regulations and she told us about her plans to cascade this training to the staff team, which demonstrated a positive and proactive approach. There had not been any allegations of abuse or safeguarding referrals since the random inspection in April 2009. We looked at a sample of safeguarding training certificates providing documentary evidence of good progress to equip all staff with relevant safeguarding training. We saw from the staff training matrix that the majority of staff had been provided with training, with future training dates planned. This meant that staff had appropriate awareness of safeguarding vulnerable adults and staff we spoke to were aware of what they needed to do should an incident occur. We recommended that all staff should be given time to read, be aware and understand, the homes and the multi agency procedures for the protection of vulnerable adults. Care Homes for Older People Page 21 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The changes needed to the decor and furnishings would contribute to create a pleasant environment for people to live in. The grounds are maintained to provide an interesting outdoor environment. Evidence: Alexandra House was a large converted, extended detached house situated in a residential area on a main high street near to shops. The home was registered to provide nursing care for 50 older people 30 frail older people requiring nursing care of which up to 6 beds may accommodate people requiring end of life, palliative care, and 20 older people with dementia. The home was divided into two units: Rose accommodated persons requiring permanent nursing care, including palliative care, now sited on the lower ground floor, and Briony providing dementia nursing care. The home also provided Accident and Emergency Diversion beds, intermediate care and GP respite beds when required. The acting manager acknowledged that Briony, the dementia care unit was not homely and lacked orientation and stimulation. This unit had combined one lounge and dining area, which had previously been decorated with new carpets but the acting manager told us that she planned to install more appropriate floor covering. The lounge area had comfortable seating, a television and there were painted murals on the walls. On the one wall there had been an image painted to resemble a pub that people in the Care Homes for Older People Page 22 of 34 Evidence: home would be able to recognise. The opposite wall resembled a shop with jars of sweets and other items. The acting manager told us this had caused confusion when people with dementia had tried to touch the objects. She told us about plans to create a more tactile and stimulating environment to help with orientation. She also had plans for a sensory room in this area. The home has a variety of aids and adaptations throughout which were suitable for dependent people and a nurse call system throughout the home. Toilets are situated throughout the home, are accessible and some had raised seats and grab rails. At previous inspections it had been identified that the toilets and bathrooms were very clinical and institutional, many requiring refurbishment. Examples were sliding doors which were difficult to open and close and locks which did not work properly. We looked at a large sample of bedrooms with peoples permission where possible. The bedrooms on Briony unit were generally stark, institutional, with altro flooring and very little personalisation. Bedrooms on Rose unit were generally more personalised and homely and the respite bedrooms were spacious, comfortable and well equipped. We saw a number of bedrails, which were fitted, regularly checked and maintained in a safe condition. Minor anomalies were rectified during this inspection visit. The laundry room, which was well organised with dedicated staff working 09:00 15:00, seven days per week. The area was divided into separate areas for dirty and clean laundry, demonstrating good management for infection control. There were two commercial washing machines and dryers and an iron press. There were pigeon holes with names of people accommodated at the home, where laundered clothes were stored to help with the organisation of personal clothing. There were infection control measures in place and evidence of colour coded mops in use. The kitchen was maintained in good order, clean and tidy and well organised. There was a good range of varied food stocks, including fresh vegetables and fruit. The cook in charge had revised the menus and told us she was involved in residents and staff meetings to discuss the food provided. We noted that appropriate food hygiene and safety measures were in place, with well kept records, monitored by the manager, and Environmental Services. The home had achieved the Dudley MBCs Environmental Health Three Star Food Award for healthy eating and food hygiene. The acting manager acknowledged that there were still a number of areas, including bedrooms, which needed refurbishment and she was developing a maintenance and refurbishment programme. Care Homes for Older People Page 23 of 34 Evidence: There were additional areas, which required attention at this inspection, such as: Provision of magnetic door closers linked to fire alarm system for doors which need to be kept open and to cease the use of wooden door wedges that compromise the integrity of fire doors. Compromised double glazed windows, at various locations throughout the home, needing replacement. Appropriate sluicing facilities to maintain effective infection control measures. Exposed hot water pipe work must be risk assessed with control measures implemented to safeguard people living at the home from risks of harm. Bathroom with walk in shower facility, some communal items removed during visit. Majority of bathing and toilet facilities required privacy blinds and attention to some sliding doors, difficult to close and with insecure locks. Care Homes for Older People Page 24 of 34 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skill mix of staff, generally meet the needs of people living at the home and people at the home receive care more consistently to meet their needs. The homes recruitment procedures provide safeguards to protect people living at the home from risk of harm. Evidence: There were a total of 23 people living at the home, 12 people with dementia accommodated on Briony Unit and 11 people with a variety of dependency levels and diverse needs on Rose Unit. The acting manager told us that she reviewed staffing levels on a regular basis, taking account of the occupancy and dependency levels of the people accommodated, which demonstrated good practice. There was evidence she was able to deploy staff flexibly to meet the occupancy and dependency levels, which can change very frequently at this home. Assessment of staffing rotas, information from the records and discussion with people demonstrated that the home was generally maintaining satisfactory staffing levels. There was a qualified nurse on duty on all shifts for each unit during the day, with the option of two nurses on Rose unit at busy periods, with appropriate numbers of care staff deployed on each unit. In addition there were catering, laundry and domestic staff. There was a qualified nurse in charge of the home at night and care staff allocated to each unit at night. A number of additional staff had been recruited since the last key inspection in Care Homes for Older People Page 25 of 34 Evidence: January 2009, including the acting manager, a deputy manager, three registered nurses, care assistants, a catering assistant, an activities organiser and an additional part time administration assistant. We noted at a random inspection in April 2009 that the home was much better organised with a calmer atmosphere and this improvement had been sustained. We looked at a random sample of staff personnel files, which were well organised with satisfactory information about each person. The organisation demonstrated robust recruitment practices, which provided essential safeguards for people living at the home. We noted that the organisation and acting manager demonstrated a good commitment to staff training and development and were generally providing all staff with appropriate training to raise awareness and skills to respond to peoples changing needs. It was positive that there was recognition and action to meet the need for registered nurses to keep up to date with clinical practices, such as end of life care and pain management. We saw evidence that 58 per cent of care staff had achieved an NVQ level 2 care award or above, with new candidates registered for training. During discussions staff told us they felt much more supported and could see how much the home had improved over the past few months. The comments received from staff included, people are cared for well, and feel listened to with action taken to improve things. Care Homes for Older People Page 26 of 34 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 are effective management arrangements in place and generally people who live at the home can feel reassured that their health, well being and safety will be safeguarded. Evidence: A new acting manager was appointed in February 2009, a Registered General Nurse (RGN) with considerable clinical and management experience in care settings. She was in the process of submitting an application to the Care Quality Commission be registered as manager at this home. A new deputy manager had also been employed in May 2009. There was a willingness to co-operate throughout this inspection and both the acting manager and deputy manager demonstrated a commitment to their own professional development. It was positive that they had a good awareness of the recently implemented Deprivation of Liberty Safeguarding Regulations and the implications for people living at the home. There were plans to cascade the information to all staff at the home. Care Homes for Older People Page 27 of 34 Evidence: During discussions there was evidence of a more open, approachable ethos, which encouraged good communication with people living at the home, their relatives and staff. We saw evidence that a nominated person on behalf of the registered proprietor visited the home regularly. We looked at the Regulation 26 Reports held at the home and noted that they were realistic and constructive. We were told that the quality assurance system was based on the National Minimum Standards. The acting manager had introduced useful quality audits for areas such as accidents, pressure ulcers and incidents and events affecting people at the home. This meant better outcomes for people receiving the service. The acting manager had quite rightly focussed attention on the quality of care provided for people using the service and on staffing arrangements. There were other areas, which she acknowledged needed improvement such as the environment of the home. Examples have been given at the environment section of this report. There were two concerns, which had implications for peoples safety. These were the use of wooden wedges to prop open a bedroom door, which must cease and there was some exposed hot water pipe work in a communal WC, which might pose risks of harm to people and must be risk assessed with control measures put in place as a priority. At the random inspection on 7 April 2009 we reported that considerable improvements had been made to the systems for managing and administering peoples medication. Not all improvements had been sustained and new requirements were issued at this inspection visit. The acting manager took action to meet the immediate requirement relating to use of prescribed medication as a homely remedy and gave us assurances she would increase vigilance of her medication audits. There were clearer lines of accountability within the home, and through the management structure. We saw that formal supervision sessions had been introduced to support and develop staff and the acting manager was undertaking appraisals with each member of staff. She had also introduced a key worker and named nurse system to improve individualised and more person centred care for people living at the home. We saw that staff meetings were also taking place, which improved communication and had benefits for people living at the home. The acting manager and staff team have continued with good efforts to involve people living at the home, their relatives, and representatives in the running of the home. We noted that there had been a meeting with people at the home and their relatives, with Care Homes for Older People Page 28 of 34 Evidence: minutes available. We saw evidence that the results of previous consultations had been acted upon areas where there were concerns, for example the meals were regularly discussed and reviewed. We looked at a random sample of heath and safety, fire safety and maintenance documentation, which was satisfactory and well organised. There were some gaps in the mandatory training, however there was evidence that there was a planned programme to make sure all staff would receive mandatory training commensurate with their roles, such as fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training. There had been 35 recorded accidents involving people living at the home since April 2009. The acting manager had introduced an effective system for auditing, analysing and evaluating accidents, with control measures implemented. Care Homes for Older People Page 29 of 34 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 30 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 12 Care plans and records of 01/09/2009 care for pressure ulcers must be more detailed to demonstrate how care is to be delivered and to show the progress or deterioration of the wounds. This is to promote and maintain the health and well being of persons living at the home. 2 9 13 To ensure that medication administration records are accurately maintained and that the person administering the medication completes the Medication Administration Record (MAR) in respect of each person at the time of administration to demonstrate that all medication is administered as prescribed. 01/09/2009 Care Homes for Older People Page 31 of 34 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 This is to promote and maintain the health and well being of persons living at the home. 3 38 13 To provide magnetic door closers linked to fire alarm system for doors, which need to be kept open and to cease the use of wooden door wedges that compromise the integrity of fire doors. This is to safeguard people living at the home from risks of harm. 4 38 13 Exposed hot water pipe work 01/09/2009 must be risk assessed with control measures implemented. This is to safeguard people living at the home from risks of harm. 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 01/09/2009 1 6 That there should be consideration and continued assessment of the provision of intermediate care on Rose unit and the impact on people living at the home on a permanent basis. Pressure settings for pressure relieving mattresses should be recorded in each persons care plan and should be 2 8 Care Homes for Older People Page 32 of 34 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 checked regularly. 3 4 12 18 Budgetary provision should be made for activities and social stimulation for people living in the home. All staff should be made aware of the homes safeguarding policies and Dudley MBC multi-agency Safeguard and Protect procedures for vulnerable adults, and that that staff signatures should be obtained to demonstrate they have read these documents. That the organisation increases the maintenance, renewal and redecoration programme throughout the home, with clearly identified priorities and timescales to provide a pleasant and comfortable environment for people living there. Action should be taken to undertake all repairs to bathrooms and WCs, and bedrooms, which could pose health and safety risks to people living in the home. That serious consideration be given to providing separate facilities for people admitted for short stays or intermediate care, so that they do not intrude on people who live permanently at the home, unless this is with their clear documented agreement and consent and is regularly reviewed. This was a previous good practice recommendation, which has not been met. That serious consideration should be given to the internal environments of Briony unit to provide more orientation and stimulation, especially for people with dementia and sensory disabilities. This was a previous good practice recommendation, which has not been met. 5 19 6 19 7 20 8 20 Care Homes for Older People Page 33 of 34 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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