Care Home: Amberley

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What the care home does well The acting manager had a proactive approach in that she had started to audit records and the environment taking action where necessary and where she had the authority to make improvements. We received some positive comments from people living at the home which included, "the staff are friendly and always make you a cup of tea " and "staff are cheerful and helpful." The staff on duty were genuinely caring and friendly and made conversation with people living at the home. We saw staff talking to people and offering choices and assistance at a level and pace that they needed. We saw and heard lots of laughter and banter with people at the home. People looked well cared for, with clothing appropriate to the weather and according to their preference. What has improved since the last inspection? The management arrangements were more consistent and any events affecting people living at the home were notified to us. Medication practices were considerably improved. Care records were improved to be more detailed with clearer guidance for to staff meet people`s need more effectively, though further improvements were needed. There were some improvements to the cleanliness of the premises. There was a documented audit of the environment with an action though this was mainly reactive and because timescales were dependant on decisions by the company director. Some parts of the home had been redecorated, though people at the home had not been consulted on the colour scheme. Following requirements to improve staffing arrangements and complaints about staffing levels, there were improvements employment checks, numbers, skills and knowledge of staff to meet the needs of the people living at the home. The quality assurance audits had improved so that failings could be recognised and actions taken to improve the service. What the care home could do better: Care plans need further development, so that they are person centred, include all assessed needs and show that each person and where appropriate their representative is involved and in agreement. Some aspects of medication practices needed further improvement to make medication administration as safe as possible. The persons responsible for decision making in the organisation must make sure swift action is taken to progress the maintenance of the whole premises to acceptable standards. The views and choices of people living at the home must be sought and acted upon. All equipment, such as hoists and lifts must be serviced and maintained to demonstrate compliance with legislation to safeguard the health and safety of all persons at the home. Key inspection report Care homes for older people Name: Address: Amberley 481-483 Stourbridge Rd Brierley Hill West Midlands DY5 1LB     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: 1 2 1 1 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 37 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 37 Information about the care home Name of care home: Address: Amberley 481-483 Stourbridge Rd Brierley Hill West Midlands DY5 1LB 01384482365 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): paul.hughes@blueyonder.co.uk Merron Care Ltd Name of registered manager (if applicable) Yvonne Kathryn Hughes Ms Tracey Jane Williams Type of registration: Number of places registered: care home 25 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 25 The registered person may provide the following category of service only: Care Home Only (Code PC); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 6, Old age, not falling within any other category (OP) 25, Physical disability (PD) 5 Date of last inspection Brief description of the care home Amberley is a purpose built private residential care home, registered to provide care for 25 older people, this may include six older people with dementia and five older Care Homes for Older People Page 4 of 37 Over 65 0 25 0 6 0 5 1 8 0 6 2 0 0 9 Brief description of the care home people with physical disabilities. The home is situated on the main Stourbridge Road between Dudley and Brierley Hill. It is on the main bus route to local towns and there are many local amenities close by. There is off road car parking to the front and rear of the premises. Access to the home is through a small garden and patio area to the rear of the property. There are three storeys, with accommodation for people on all floors. A passenger lift services all floors. The accommodation comprises; communal lounge and dining rooms and 21 single and 2 double bedrooms. Toilet and bathing facilities are located on each floor and the main kitchen and laundry area are located on the ground floor. The fees are available on application to the home. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We, the Care Quality Commission (CQC), undertook an unannounced key inspection visit one long day. This meant that the home had not been given prior notice of the inspection visit. We monitored the compliance with all Key National Minimum Standards and requirements for improvements made at the random inspection visit in June 2009. The range of inspection methods to obtain evidence and make judgements included, assessments of records, and discussions with the acting manager and staff on duty during the visit. We also talked to visitors and people living at the home, and we 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 Commission. We looked at a number of records and documents. The acting manager submitted the homes Annual Quality Assurance Assessment (AQAA) as requested prior to this inspection visit. We looked around the premises, looking at communal areas of the home, the Care Homes for Older People Page 6 of 37 bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: Care plans need further development, so that they are person centred, include all assessed needs and show that each person and where appropriate their representative is involved and in agreement. Some aspects of medication practices needed further improvement to make medication administration as safe as possible. The persons responsible for decision making in the organisation must make sure swift Care Homes for Older People Page 8 of 37 action is taken to progress the maintenance of the whole premises to acceptable standards. The views and choices of people living at the home must be sought and acted upon. All equipment, such as hoists and lifts must be serviced and maintained to demonstrate compliance with legislation to safeguard the health and safety of all persons at the home. 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 37 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 37 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. The statement of purpose and service user guide did not provide entirely accurate and up to date information about the home. People living at the home had contracts terms and conditions of occupancy, which contained some ambiguous terms. This has the effect that people and their representatives do not have accurate information regarding their rights and entitlements, and how care will be provided. Evidence: We looked at a copy of the homes statement of purpose, which had been updated since the random inspection in June 2009. The service user guide had also been updated and contained details of the range of fees charged. We were told there were no Third Party Top Up fees charged. The documents were not provided in alternative formats for people unable to read or understand written information. All documents should provide accurate, easy to understand information about the home. There had been no new admissions to the home since June 2009. The sample of case Care Homes for Older People Page 11 of 37 Evidence: files of two people living at the home showed that each person had been provided with a contract and statement of terms and conditions. However the contracts contained ambiguous terms, which might be considered unfair, such as an expectation that relatives should escort people to appointments outside the home with health professionals or pay an additional, unspecified amount for a staff escort. These documents should be easy to read and understand. There should be details about what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the person living at the home. We saw evidence that the acting manager kept each persons health and care needs under review and made referrals for reassessments to appropriate healthcare professionals. There were examples of medication reviews and additional support from the Speech and Language Therapist for someone with speech and swallowing difficulties, recovering from a stroke. The examination of a sample of care records showed that there was assessment information, which recorded individual preferences such as rising, retiring, preferred activities, likes and dislikes. This meant that staff had good information about each persons needs and preferences about how they wished their care to be provided. Care Homes for Older People Page 12 of 37 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 generally 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 a sample of care records of people living at the home. The acting manager had continued with improvements, which were at an early stage of implementation at the random inspection in June 2009. Information was being reviewed and used to formulate more person centred plans to meet each persons needs. More development was required, for example choices regarding personal hygiene should be specific as to whether the person preferred to be bathed or Care Homes for Older People Page 13 of 37 Evidence: showered, how often, at what time of day and what type of toiletries should be used. The approach to healthcare screening tools, risk assessments and care plans was variable and not consistent. For example the monthly reviews of peoples dependency levels, Waterlow scores and nutritional assessments showed considerable fluctuations, which were not an accurate reflection of their health needs. The acting manager had already identified some inaccuracies with staff and we saw evidence of discussions, which had recently taken place in staff meetings to improve staff skills. We noted that the home was not using a recognised nutritional assessment tool such as the Malnutrition Universal Screening Tool (MUST), which would provide clear guidance for staff to take action where people were identified to be at risk. The acting manager agreed to seek advice from healthcare professionals to put in place a more effective nutritional assessment. The moving and handling risk assessments gave a score but did not record what assistance was required for each transfer and did not give staff guidance about what equipment should be used, such as walking aids, hoists and slings. The acting manager had introduced a key worker system to improve individualised care and support. Each person had a record called this is my life, which were generally well completed with life history information, and preferred names. There were also social profiles, giving additional information about personal preferences such as bedtime routines and preferences. People had generally good access to health care services to meet their assessed needs. The home used the services of a contracted GP, though we were told that people could choose their own GP within the limits of geographical borders. There were records to show there was good support from the district nursing service. We saw that some people had access to community services such as opticians and speech and language therapists. One person had received assessments and support from the speech and language therapists to speech and swallowing reflex following a stroke. We discussed with the acting manager the lack of dental and chiropody appointments for a person with assessed needs for these services. She assured us that she would take action to make sure these services were accessed and offered. There were risk assessments and care plans relating to challenging behaviours. We saw that staff used appropriate techniques to diffuse situations when people became anxious or agitated. There were some areas, which needed further improvements such as care plans for people with dementia, which needed to be expanded to include all presenting symptoms. The care plans for people with diabetes needed to be expanded. For Care Homes for Older People Page 14 of 37 Evidence: example one persons plan stated, if unwell BM should be taken and abnormalities should be reported to GP. There was no information about what the normal parameters were for this person. This meant it would be difficult for staff to make an accurate assessment of when to inform the doctor. We saw that some people had been prescribed antibiotics for time limited infections but acting manager acknowledged that there were no short term care plans to give staff guidance to meet increased care needs. The information was difficult to find in some files, which were disordered. All care files should be reorganised to easily access information. The care plans and evaluations provided a space to show that the person or their representative had been involved but there were no signatures to demonstrate their active involvement. Relatives and a person living at the home told us they had not been shown information or asked to confirm their agreement. The acting manager acknowledged there were people living at the home who were capable of giving informed consent and this was an area, which needed to be improved. The daily records had generally improved to show how each persons care was being provided. However we discussed incidents recorded during the night, where the person was displaying disruptive behaviour. The acting manager acknowledged there were no night care plans in place for people who required supervision and assistance during the night. This meant that staff did not have information and guidance as to how to meet these needs and there was no review and evaluation as to how night time care needs were being met. The pharmacist inspector visited the home on 12th November 2009 to check the management and control of medicines within the service. We looked at medication storage, some care records and medication administration records. We were shown a report made by a pharmacist following a routine check of the services medication on 24th March 2009. There were no issues recorded in the report. We found a medication policy available in the office where medication was stored. It was located next to the medication storage trolley and was therefore readily available for staff to read. It had been reviewed on 24th November 2008. We saw a signature and initial list of staff who had been trained to administer medication. We were shown certificates for staff who had attended and completed medication training courses. For example, we were shown a certificate dated 22nd October 2009 for one member of staff who had completed a course in safe handling of medicines. This meant that a Care Homes for Older People Page 15 of 37 Evidence: working medication policy was in use and staff had received appropriate training in order to handle peoples medication within the service. We saw that medication was secure with good storage arrangements. For example, we saw that the medicine trolley was securely chained to a solid wall. We saw that medication was stored neatly and tidily which made it very easy to locate peoples medication. There was no overstocking of medication and only medication that was required was kept. This means that medication was stored securely and was well organised, which helped to ensure that people who use the service were protected from harm. We found that the storage temperatures of medicines were not being monitored each day and some records indicated that medicines were not always being stored at the correct temperature. For example, we saw records for November 2009 documenting the temperature of the room where medication was being stored; however there were some gaps and records were not available for every day. Medication should be stored below 25 degrees centigrade. The records showed that the room temperature was usually within 20 to 22 degrees C which is within the safe storage temperature range for medication. We looked at the November 2009 temperature records available for the medication refrigerator. Medication requiring refrigeration should be stored between 2 to 8 degrees centigrade. We saw readings recorded for the maximum and minimum temperatures. The minimum temperature recordings were within the safe temperature range, however some of the maximum temperature recordings were above 8 degrees C. One maximum recording was 14.1 degrees C. We checked the temperature of the refrigerator at the inspection, which was 6.6 degrees C and was therefore within the recommended storage temperature range. This means that the temperature records for medication storage were not always documented and sometimes indicated that medication was not being stored within the recommended safe storage range, which may increase the risk of deterioration of the medicine and possibly make it ineffective. We looked at the Medication Administration Records (MAR), which were printed by the pharmacy. We saw that the location of each medication was highlighted on the persons MAR chart. For example, side of trolleyor Blister was documented on one persons MAR chart, which helped to quickly and easily find the medication. We saw that any handwritten entries or changes made on the MAR charts were checked and signed by two trained members of staff. For example, one persons medication had been stopped by the General practitioner which had been documented and signed onto the MAR chart. This means that the MAR charts were clear and kept up to date, which helped to ensure that people receive their prescribed medication as directed by a Care Homes for Older People Page 16 of 37 Evidence: medical practitioner. We found that medication records were generally up to date. For example, we saw current records for the receipt, administration and disposal of medication. The date of opening of boxes and bottles of medicines were usually recorded and balances of medication were carried forward from old records to new records. These records helped to ensure there was a clear audit trail of medication. The manager informed us that a monthly medication audit is done to check the medication administration records. We found that counts and checks made on medication were accurate. However we found one MAR chart that had not been clearly documented. A signature for administration had been crossed out with no written explanation available. A member of staff informed us that the error was a mistake and the medication had been administered but the MAR chart had not been signed. The next day another member of staff had signed the MAR for administration in the next blank box but then realised the wrong day had been signed so crossed the signature out. The acting manager informed us that this incident had not been documented or recorded as an error. We checked the medication and found that the tablets had been removed for that day, however the records did not document if the medication had been given. We discussed this issue with the manager; however we did agree that all other current medication records had been recorded. We found that the homely remedies list of medication had been reviewed by the General Practitioner. For example, we saw that one person had a review of their homely remedies on 24/11/08. This means that medication required for a minor ailment had been reviewed and agreed with the General Practitioner. We found that information for the use of medication prescribed to be given when required was available; however it was not easy to find in the care records. For example, we saw that one person was prescribed medicine to be given three times a day when required for agitation. We found a protocol for the administration of the medication but it was not easy to find in the care record folder. It was not dated or signed and was not person centred in order to ensure staff could give the medication according to a specific behaviour management plan. We found the information relating to the persons behaviour and treatment in different sections of the care plan. We found a section for behaviour in the care plan dated 8th April 2009, which documented that when the person becomes agitated staff should allow her time and space to calm down which is not always successful and her medication is needed, however it did not document the name of the medication to be given for agitation. We found a section for Health Needs dated 8th April 2009 which had been updated following a doctors visit on 4th November 2009, which stated that the medication was still when Care Homes for Older People Page 17 of 37 Evidence: required. We spoke to a member of staff who informed us exactly how the person became agitated and what triggered the behaviour and explained what calming measures worked. This information was not easily available in the care records. We saw that the MAR chart had been signed for the administration of the tablet on 7 occasions. We found dated records on the back of the MAR chart which gave reasons why the medication was given. We found this information had also been documented into the persons daily records. This means that although the information for giving this medication was documented the information was not specific and person centred and was not always easily and readily available to staff. We spoke to relatives who told us that staff were kind and treated people with respect. We also saw a letter from relatives, To all staff, we very much appreciate the kind and loving assistance you have provided to our mother. Care Homes for Older People Page 18 of 37 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. There are some activities for some people, though limited access to social stimulation in the local community. People are enabled and encouraged to maintain good contact with family and friends. People can choose from a balanced and varied selection of foods that meet their preferences and nutritional needs. Evidence: The routines of the home were generally flexible to meet each persons needs. There had been improvements to record each persons choice of rising, retiring, and food preferences. Discussions confirmed that people were generally assisted at the time of their choosing. There were four people who chose to stay in their bedrooms. The home does not have an activities organiser and staff at the home were using their knowledge of peoples preferences to plan activities, which people might like. There were no allocated hours for activities, though staff told us they made time to lead activities sessions each morning and afternoon. We were told that most people enjoyed games, bingo, quizzes and exercises to music. We were told that there was no budget for equipment for activities. There was little evidence of involvement with Care Homes for Older People Page 19 of 37 Evidence: the wider community, such as trips or outings. However the acting manager told us that some people wanted to go to the pantomime for Christmas and she was planning to organise this. We were told that there were arrangements for people to practice their faith. One person was visited at the home by people from Jehovahs Witnesses; two people attended the local churches near the home, where they had always worshipped. There were also regular church services at the home every two weeks for anyone wishing to attend. We saw that family and friends were welcomed and we spoke to some visitors who told us they knew they could visit the home at any time. They told us that the acting manager and staff team always made time to talk to them and offer them drinks. People were encouraged to bring in their personal possessions to make their room more familiar and homely. There were no inventories of personal possessions on the sample of files examined. Inventories of each persons possessions should be recorded and should be kept up to date, signed and dated by the person or their representative and witnessed by the member of staff. There were written menus for each meal, with at least two choices. There were no other formats for people unable to understand the written information but the acting manager told us that she planned to devise and put in place pictorial menus to help people make realistic choices. We discussed nutrition with care staff and acting manager. They were generally knowledgeable about each persons nutritional needs and we were told that a choice was always offered, there were also diabetic and soft diets. We were told there was also added calorific value at mealtimes for people with poor appetite or at risk of weight loss, using cream, butter and cheese. The main meal looked appetising and people appeared to have enjoyed their food. Care staff on duty made the tea, supper and drinks and snacks at all other times. Staff were aware of the needs of people who found it difficult to eat at mealtimes and they offered sensitive assistance with feeding. They were aware of the importance of offering food at the persons pace, so that they were not hurried. Efforts had been made with the dining room to make it look inviting with attractive tablecloths, table decorations, crockery and condiments. Care Homes for Older People Page 20 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can generally feel assured that any concerns and complaints are listened to with action to investigate using systems to record findings and outcomes. There are arrangements in place to safeguard people living at the home. Evidence: We looked at the homes systems to deal with complaints. We saw that there was a complaints procedure displayed in the home and available in the Service Users Guide. Some of the information was out of date. There were no other alternative formats for people who may not be able to read or understand written information. There had been no complaints since the last random inspection in June 2009. However we were concerned to note at the random inspection visit that staffing levels had been decreased. We saw evidence that additional new staff had been recruited and staffing levels were improved. We looked at the homes complaints log. There were no recorded complaints about the home or people living there. We spoke to relatives and people living at the home, who told us they felt they could tell the staff or manager if they wanted to complain. The home had policies and procedures to inform staff about abuse and responsibilities Care Homes for Older People Page 21 of 37 Evidence: for reporting suspicions or incidents. Some of these needed to be reviewed and updated. We saw that there was a programme of safeguarding training and certificates for the majority of staff who had attended training. The acting manager told us that she had booked training places for staff who had not received safeguarding training. We spoke to three members of staff who told us that they knew where they must report allegations or suspicions of abuse. There was a copy of the multi-agency Safeguard and Protect procedure for the protection of vulnerable adults at the home. The acting manager acknowledged that she had not take action to make sure the previous good practice recommendation had been met. This was to make sure all staff had read and signed to demonstrate awareness of procedures to safeguard people at the home. The acting manager had displayed the details of contacts in the Local Authority so that they were available to staff, relatives and people at the home, which meant they could report directly any concerns, suspicion or witnessed incident of abuse. Care Homes for Older People Page 22 of 37 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 home provides a generally homely and comfortable environment for people living there. The systems in place for maintaining infection control are not sufficiently robust. Evidence: The home was a three storey detached property, which had been adapted and extended to provide accommodation for up to 25 older people, some with dementia or physical disabilities. There were gardens to the front and rear and some off road parking facilities. The gardens had been tided since the random in June 2009 but required further needed attention. The work needed to exterior paintwork had not been undertaken and it was worn and flaking. A number of double glazed windows throughout the home were compromised and misted, which obscured the view for people living at the home. These must be replaced. The interior was generally homely and comfortable, with a large lounge, separate dining room, and a small conservatory used as an office. At the random inspection in June 2009 the communal areas, kitchen and some bedrooms were not adequately cleaned and many carpets were faded and heavily stained. There were some improvements and the acting manager had devised a maintenance plan. There was handyperson, employed to undertake all decorating, maintenance and repairs for three homes in the Dudley area. However timescales to make more than superficial or Care Homes for Older People Page 23 of 37 Evidence: cosmetic improvements depended on decisions made by the director of the company. This meant that the management of the service could not demonstrate when actions identified at the random inspection would be completed. Though some redecoration had taken place, all walls and paintwork were painted in magnolia. We were told that there was no consultation with people living at the home about colours or new carpets. This meant people did not have a say in important aspects of where they lived. Staff told us they had requested blue as a colour for the decoration due to take place in the main lounge. We viewed a sample of bedrooms with peoples permission where possible. Some had been personalised with possessions such as photographs and ornaments. However some bedrooms had malodours, which the acting manager told us were difficult to eradicate because the floor coverings were not suitable. We also saw a stained bed base and mattress, and damaged headboard. The management must audit all beds and floor coverings and arrange renovation or replacements to acceptable standards for the comfort and safety of people at the home. We saw that action had been taken to meet an immediate requirement to provide covering for all unguarded hot water pipes in the home. We saw that all hot water pipes were covered with grey foam material, which was adequate in terms of safety but not very aesthetically pleasing to look at. Although the majority of high-risk areas were provided with liquid soap, paper towels, gloves and hand wash signs, there were no posters or infection control guidance in the sluice. The sluice needed redecorating, with appropriate flooring and racking to store commode pots, which were on the floor. There was general clutter in this area, including vases; and there was dust and grime. There was no risk assessment for manual sluicing, and there were no hand washing or infection control posters. This area must be prioritised on a cleaning schedule, with monitoring checks to ensure effective infection control measures. There were two laundry areas. The ground floor laundry was small, cramped and in need of redecoration to remedy the surfaces of the walls and floor as a priority. The laundry area on the first floor was not suitably arranged and needed to be reconfigured so that staff could access appliances and had washing facilities to maintain effective infection control and health and safety. There were no dedicated laundry staff. We were told care assistants did the laundry mainly at night and as and when they can during the day. At the random inspection in June 2009 we recommended that the management should revise the laundry procedures to reflect Care Homes for Older People Page 24 of 37 Evidence: good practice guidance in the Department of Health Essential Steps for Infection Control. The acting manager acknowledged that she did not have a copy of this guidance and had not undertaken an infection control audit or devised an action plan to ensure there were effective infection control measures throughout the home. We were told at the random inspection in June 2009 that the kitchen had been redecorated and some new work surfaces had been provided in response to an Environmental Health Report. We spoke to the cook who had recently completed food hygiene training and was knowledgeable about catering and food safety. However we noted that the general cleanliness was not satisfactory, with most areas needing a thorough cleaning, especially behind the freezer where there was food debris and inside cupboards. We were told the catering hours were not sufficient to provide for the dietary needs of people at the home and complete the cleaning schedules. The fly screens had been removed during the summer for redecoration and had not been replaced and there was insufficient ventilation without the windows and external door open. We saw dirty, cracked and broken bins, storing dried foods such as porridge and rice. Some equipment was not in a good state of repair, such as the chest freezer, with a broken lid and the microwave with scorch marks on the inner door. These items must be replaced as a priority. A relative told us that they felt cleanliness in communal areas had improved and there were no smells now - had previously raised the issue of unpleasant odours with the previous manager with no effect. They commented that storing wheelchairs in the corridor was not an ideal location. We discussed these observations with the acting manager, who was receptive. Care Homes for Older People Page 25 of 37 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. The numbers and skill mix of staff were adequate to meet peoples needs and recruitment is adequate to safeguard vulnerable people living at the home. There is a training programme in place to equip staff with skills to meet peoples needs. Evidence: There were 17 people accommodated at the home, with a range of diverse needs. We looked at copies of staff rotas and discussed the staffing levels with the acting manager in relation to occupancy and dependency levels, which she had assessed since the random inspection in June 2009. People were accommodated on three floors and some people chose to stay in their rooms, which was positive that they could make this choice. We saw that the staffing levels were four carers on the early shift, with a domestic and cook. The acting manager told us that her hours were usually supernumerary. At the random inspection we were told that one of the directors had reduced the number of carers on the late shift. At the random inspection we assessed that this was not sufficient to provide safe levels of cover at this home or to be able to meet each persons needs and we required that and that the former staffing levels must be reinstated immediately. We saw evidence that the staffing levels had been improved. However staffing levels should be kept under review to take account of peoples needs and the amount of time care staff spend undertaking ancillary duties such as laundry, Care Homes for Older People Page 26 of 37 Evidence: catering and cleaning on late shifts. As already highlighted there must be sufficient resources to improve the standards of cleanliness and infection control throughout the home. There must also be an appropriate amount of allocated time for activities and socialisation for people living at the home. We looked at a sample of two personnel files of staff recently employed. The files were generally well organised with a recruitment checklist. The acting manager had improved the recruitment process, which was now more robust and provided safeguards for people living at the home. We also saw evidence of in house inductions and the Skills for Care Common Induction Standards on the staff files. The homes AQAA gave us information about the number of care staff who had achieved a NVQ (National Vocational Qualification) level 2 care award. We confirmed that 11 of the 16 care staff had achieved an NVQ Award. The acting manager told us that additional care staff had been registered as candidates to undertake NVQ 2 and 3 training. We were also shown a training matrix and evidence that staff training in a number of additional areas had been booked. Care Homes for Older People Page 27 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management arrangements do not always provide sufficient safeguards for people living at this home. There are informal systems for consultation with people living at the home. Evidence: The acting manager was appointed in June 2009 and had submitted an application to be registered as manager for this home. She had previously worked with older people over a number of years and had achieved a National Vocation Qualification (NVQ) level 3 Care Award. She had commenced the Leadership and Management skills training. At the random inspection we were told the company director and previous Responsible Individual had not provided supervision sessions for the manager. The acting manager and the acting Responsible Individual (RI) acknowledged there were no recorded supervision sessions or Regulation 26 visits and reports. At this visit we saw that that the acting (RI) had visited the home and had undertaken unannounced Regulation 26 visits and had provided reports. However the acting manager had only received one formal supervision session since June 2009. It was important for the acting managers Care Homes for Older People Page 28 of 37 Evidence: support and development that regular supervision meetings take place. We noted at the random inspection in June 2009 that the acting manager had started to carry out some quality assurance checks; these included some care files and some staff files, where she had already noted omissions and accidents. She had also put in place maintenance and development plan and action plan, though the timescales were mainly reactive. There were areas needing attention identified during this inspection visit, which were not recorded on the maintenance programme, for example relating to the premises. There were records of recent staff meetings and staff told us they were useful and that they could share their views openly. People told us they were not aware of residents meetings. These are important for people to give their views about their home. We were told that people were offered the opportunity to manage their own money if they wished, and there were facilities to help keep it safe. We looked at a random sample of balances and records of monies held in temporary safekeeping on behalf of people living at the home, which were accurate, with records of all transactions. We saw supervision records, which showed us that staff had been receiving regular supervision since June 2009. We saw evidence that the acting manager was arranging mandatory training to ensure each person received training appropriate to their roles, such as fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training. We looked at a sample of heath and safety, fire safety and maintenance documentation, which were generally well organised. We noted that there was no report of the bacteriological water test in conducted in October 2009. The acting manager told us that the company director did not keep all of the service documents at the home; some may be at the company office. She confirmed that there was no record of a Legionella or Asbestos risk assessments at the home and was not aware of whether these risk assessments had been undertaken. We viewed the hoists and lifts service work sheets available. The servicing company had identified work to be carried out on the passenger lift but there was no satisfactory service certificate available. We expressed our concerns and informed the acting manager that we would refer this matter to Dudley MBC Environmental Care Homes for Older People Page 29 of 37 Evidence: Services. At the random inspection we saw a person with bedrails in place, used with an overlay pro pad pressure relieving mattress. The height of bedrails was less than 30mm, instead of the permitted height dimension of 200mm from uncompressed mattress to the top of the bedrails. Although the acting manager had put a risk assessment in place, it did not include all of the high risk areas. She explained that the person did not required bedrails but liked to have them in place to feel secure. The bedrails had been removed temporarily but the person had become distressed. Extra height bedrails must be purchased and used to alleviate the potential risks posed by the extra mattress. Care Homes for Older People Page 30 of 37 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 31 of 37 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 To ensure that there are care plans, which include all of each persons assessed needs that are appropriately evaluated and updated to accurately reflect all changes to health and needs. This is to ensure care for each persons health and well being is properly provided at all times. 31/01/2010 2 9 13 The care plans for the administration of when and as needed medication must be expanded to ensure the information for giving this medication is specific and person centred and must always easily and readily available to staff. This is to ensure staff have robust guidance to administer medication appropriately to promote each persons health and 31/01/2010 Care Homes for Older People Page 32 of 37 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 well being. 3 9 13 The service needs to make 31/01/2010 arrangements to ensure that medication is stored at the correct temperature recommended by the manufacturer. This is to ensure that medication does not deteriorate which can make the medication ineffective and possible harmful to people living in the home. 4 19 23 To audit equipment such as beds, floor coverings, ensuring each person is provided with suitable furniture and fittings for their comfort and safety. This is to promote the health, well being and comfort of people living at the home. 5 26 13 To ensure that all areas of the home are clean and meet the infection control criteria. This is to ensure the health and well being of people living in the home is safeguarded. 31/01/2010 31/01/2010 Care Homes for Older People Page 33 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 6 26 13 OP26 To audit and replace any damaged or defective equipment to maintain effective standards of food safety. This is to ensure the health and well being of people living in the home is safeguarded. 31/01/2010 7 37 13 The management systems must ensure that the premises and equipment have robust risk assessments and evidence of satisfactory maintenance and servicing as required by legislation. This is to ensure people living at the home are safeguarded at all times. 31/01/2010 8 38 13 Extended height bedrails must be provided where overlay pressure reliving mattresses are used and height dimensions do not comply with Heath and Safety guidance. This is to safeguard people at the home from risks of harm. 31/01/2010 Care Homes for Older People Page 34 of 37 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 homes statement of purpose and service user guide should be revised, updated and reissued to people living at the home in easy to understand formats suited to their capabilities. The contract / terms and conditions of residence should be revised, updated and reissued to each person living at the home to and should reflect good practice guidance issued by The Office of Fair Trading. All care files should be reorganised to easily access information. There should be evidence such as signatures to show person or their representative had been actively involved in the development of their care plan and monthly evaluations. Each person should have access to all community health care services, including dentists and chiropodists to meet their assessed needs. Moving and handling risk assessments should include information about how staff should provide assistance and details of any equipment to be used such as walking aids, hoists and slings. All risk assessments should be signed by the person completing or reviewing the assessment. There should be allocated time for activities for a minimum of 15 hours per week, with staff training to ensure appropriate social stimulation was offered to everyone and especially to people with dementia and sensory disabilities. This is a previously unmet good practice recommendation. Inventories of each persons possessions should be recorded and should be kept up to date, signed and dated by the person or their representative and witnessed by the member of staff. Menus should include choices for all meals, including supper and should be available in appropriate formats so that every person can make informed choices for their meals and snacks. The complaints procedure should be revised and updated and should be available in appropriate formats so that Page 35 of 37 2 2 3 4 7 7 5 8 6 8 7 8 8 12 9 14 10 15 11 16 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations people can understand their rights. 12 18 All staff should be given time to read and familiarise themselves with the homes safeguarding procedures and the Safeguard and Protect procedure for vulnerable adults with signatures and dates to evidence their awareness. This was a previously unmet good practice recommendation. The home policies and procedures relating to safeguarding vulnerable people should be revised, simplified and updated to reflect current good practice guidance. The management should closely monitor the impact of ancillary duties on allocated care hours available and make alternative arrangements as necessary so that every persons needs are met at all times. Staff rotas should be expanded to show full names, designations, and designated person responsible for running the home on each shift including night shifts and include the on call arrangements. The manager should be supported and developed with regular, recorded supervision meetings. There should be recorded meetings with people living at the home and their representatives at appropriate frequencies so that their views can be heard and acted upon. A competent person should undertake a visual check of bedrails in the home on a daily basis to ensure that they are safe. A record must be made of these checks. This was a previously unmet good practice recommendation. A copy of the DoH guidance Essential Steps should be used to audit and improve infection control measures at the home. This was a previously unmet good practice recommendation. 13 18 14 27 15 27 16 17 31 33 18 38 19 38 Care Homes for Older People Page 36 of 37 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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