Care Home: Amerind Grove

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What the care home does well People will be provided with sufficient information about the home so that they can make a decision about whether the home can meet their needs. They will be assessed before admission to ensure that the home is the right place. Care planning processes and other records kept in respect of people is improved from the last visit however further progress is needed. People will be treated with respect and dignity. Medication procedures are well managed. Improvements have been made in the way peoples social care needs are being met and there is a wide variety of fulfilling and meaningful activities arranged that they can participate in. There is better provision for those people with dementia. A well-balanced and nutritious diet is provided and people will be well fed. The way in which any concerns or complaints people who live in the home may have are managed, means that they can be assured they will be listened to and the issues they have, looked in to and acted upon. Better processes are in place to safeguard people from harm and staff awareness of their responsibility to report concerns is improved. People are cared for in houses that are safe, comfortable and generally well furnished. The environment for people with dementia is better because the facilities are more accessible and user-friendly. There is still a way to go with establishing stable staff teams in each of the houses but this is improving. Staff have access to relevant training, and their training and development needs will be identified and met. Safe recruitment procedures ensure that unsuitable workers will not be employed. The management of Amerind Grove is significantly improved and there is a greater sense that the home is run in the best interest of the people who live in the home. What has improved since the last inspection? After the last inspection, five requirements were made and seven recommendations of good practice. All but one of the requirements have been met and improvements have been made in the following area`s - care planning is on the whole person centred, which means that people will be cared for in the way that they wish - records kept in respect of some medications administered are now being properly kept - staff, particularly those who are working in Picador and Capstan, have received training in dementia care - a programme of activities is provided that is available for every one who wishes to, or is able to participate. What the care home could do better: We have made four requirements following this inspection. One of the requirements has been carried over from the previous inspection and is in respect of assessment processes. The home must undertake proper care needs assessment to identify individual`s specific care needs, so that this information then feeds in to a person centred care plan. Wound care planning documentation must be clear and evidence accurate monitoring of progress or deterioration. Risk assessments must be completed before people are suuported to use the sit up bath/shower units. This is so that staff know that the equipment is appropriate, and that people and staff members are protected from injury. The appointed home manager must make application to the Commission for registration as this is a legal requirement. Key inspection report Care homes for older people Name: Address: Amerind Grove 124-132 Raleigh Road Picador, Regal, Embassy, Capstan & Kingsway Ashton Bristol BS3 1QN     The quality rating for this care home is:   two star good 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: Vanessa Carter     Date: 2 2 0 1 2 0 1 0 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: Amerind Grove 124-132 Raleigh Road Picador, Regal, Embassy, Capstan & Kingsway Ashton Bristol BS3 1QN 01179533323 01179533406 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 171 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Care Home with Nursing The maximum number of service users who can be accommodated is 171. Date of last inspection Brief description of the care home Amerind Grove is a 171-bedded Bupa care home, situated in the residential area of Ashton, approximately four miles from the city centre of Bristol. The home is situated within walking distance from the local shops, and is on a local bus route. The home is a purpose built care home, designed specifically to meet the needs of elderly and disabled residents. The home is split up into five houses, but one house Regal is currently closed. The other beds are arranged as follows- Kingsway 38 Embassy 33 Care Homes for Older People Page 4 of 34 70 0 Over 65 0 171 Brief description of the care home Picador 30 Capstan 40. The five houses are each of bungalow design with level access, via their own entrance. The home manager, administrative and ancillary staff, all work from the main part of the home. Car parking for visitors is available in front of all houses. Three of the houses are registered for nursing care Kingsway, Embassy and Regal and two for Dementia nursing care Picador and Capstan. Regal House is currently closed. The cost of placement at the home will be based upon an individuals assessed needs. Additional charges for a number of items are listed in the homes brochure. People funded through the Local Authority have a financial assessment carried out in accordance with Fair Access to Care Services procedures. Local Authority fees payable are determined by individual need and circumstances. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk httpwww.oft.gov.uk 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: two star good 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 completed an unannounced inspection of Amerind Grove Nursing Home as part of our planned inspection programme. Two inspectors were in the home for three days and spent a total of 35 hours there. The last inspection of this service was undertaken in February 2009 and at that time, our overall judgement about the quality of the service provided for the people who lived in the home was that they received an adequate service. Because there were a number of areas where we wanted the home to make improvements, we planned to visit again within one year. In the last year we have met with the home manager and other Bupa Care Home representatives, along with health and social care colleagues, on many occasions, in order to monitor how things are going and to ensure that they progress with the required improvements. Prior to this inspection we asked the home manager to complete the annual quality Care Homes for Older People Page 6 of 34 assurance assessment (AQAA). This is a self assessment document that focuses on how well outcomes are being met. The assessment had been completed in detail and provided a clear overall view of the service. We also sent out survey forms to people who live in the home, relatives, and health and social care colleagues who have an interest in the home. During the inspection we looked at records kept by the home, including care records and those that are kept in respect of the running of the home. We spoke to the home manager, the deputy manager, the Bupa quality compliance manager and those staff on duty. We observed the interactions between staff and the people who they were looking after. We spoke to some of the people who live there and any visitors or relatives that were in the home. A short observational framework for inspection (SOFI) is a methodology we use to understand the quality of the experiences of those people who use the service but are unable to provide feedback due to their cognitive or communication impairments. SOFI helps us assess and understand whether people who use services are receiving good quality care that meets their individual needs. At this visit we used SOFI in both Picador House and Capstan House. At the time of this report the fees for placement in the home range from 382 pounds per week for a residential or personal care basis only, and up to between 551 and 750 pounds per week, for nursing care. The fees payable will be determined following assessment and will be based on an individuals dependency needs. Additonal charges are made for a number of other services and these are detailed in the homes brochure. The home currently has a significant number of vacancies in both the general nursing care units and the dementia care units. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? What they could do better: We have made four requirements following this inspection. One of the requirements has been carried over from the previous inspection and is in respect of assessment processes. The home must undertake proper care needs assessment to identify Care Homes for Older People Page 8 of 34 individuals specific care needs, so that this information then feeds in to a person centred care plan. Wound care planning documentation must be clear and evidence accurate monitoring of progress or deterioration. Risk assessments must be completed before people are suuported to use the sit up bath/shower units. This is so that staff know that the equipment is appropriate, and that people and staff members are protected from injury. The appointed home manager must make application to the Commission for registration as this is a legal requirement. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be provided with sufficient information about the home so that they can make a decision about whether the home can meet their needs. The assessment of each persons care needs is not completed thoroughly, which may mean individuals would not receive a person centred approach to their care. Evidence: The Statement of Purpose remains a true reflection of the service and a copy of the document is displayed in the main reception of the administration block. The statement sets out the services and facilities available at the home. Everyone who lives in the home is provided with a copy of the Service Users Guide - copies were seen, placed in BUPA care home folders, in peoples bedrooms. A copy of the last inspection report, completed in February 2009 was located in each of the foyers of the four houses. Each person will be provided with a contract or a set of terms and conditions of stay. Care Homes for Older People Page 11 of 34 Evidence: For those people who are part funded by the local authority, or funded by the primary care trust, a schedule of payments will be set up with the funding authority. Before any new admission is made into the home, a pre-admission assessment will be completed and we looked at the documentation completed for at least one person in each of the four houses. The pre-admission assessment enables the person undertaking the task to make a judgement about whether the home is able to meet the persons needs and whether the staff have the right skills and competencies. Whilst we acknowledge that comprehensive assessments can not be completed during a visit to a hospital ward, a full and detailed assessment must be undertaken, as part of the care planning process. The document, when completed properly should capture a complete picture of each persons care needs, however those looked at were only completed in a tick-box fashion. On admission the initial assessment is reviewed but no specific details regarding the persons care needs are recorded. These assessments must be more person centred as they are used as a basis for the care planning documentation. We made a requirement following the last inspection in respect of this shortcoming and the expected improvements have not been made. This shortfall has the potential to mean that people will not be cared for in the way that they wish, or their specific care needs will not be met. Further improvements are necessary to fully meet the required standard. We saw that the home obtains copies of social care and healthcare assessments, as part of their information gathering process, and this is good practice. The home provides placement for those with general nursing needs or specific dementia care nursing needs. People with a dementia will be looked after in either Picador or Capstan, but may well be looked after in the general nursing units, (Embassy or Kingsway), if their nursing needs outweigh their mental health needs. All new placements will initially be for a trial period with a review meeting being held at the end of this time. We were told that there are plans to arrange trial days before admission, particularly for those people who have dementia and are being considered for placement in Capstan or Picador. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning processes and other records kept in respect of people is improved from the last visit however further progress is needed in some areas, to ensure that care is provided to each person as needed. People will be treated with respect and dignity. Medication procedures are well managed. Evidence: Care plans are prepared for each person using the standard Bupa documentation and personal care and risk management plans are devised. We looked at a minimum of three plans in each of the four houses, plus other plans to check out specific information. On the whole there has been a marked improvement in the quality of the plans, but there are a number of areas where further work is still needed. Care plans in general were written in a person-centred way and evidenced that they were based upon peoples likes, dislikes and preferences. Some plans were extremely wordy and important information was lost amongst unnecessary text. We discussed with the manager the ways in which care plans had been prepared by one particular member of staff - these were clear, concise and readable. Plans of this style should be prepared for every person who lives in the home. Although we are aware that there has been Care Homes for Older People Page 13 of 34 Evidence: some work undertaken with particular staff members in respect of their handwriting, we would suggest that there are other staff members who need to be improving their record keeping skills. Along with the care plans, risk assessments are completed in respect of the likelihood of developing pressure sores (waterlow), continence, nutritional needs, the probability of falls, and to identify the risks involved in any moving and handling procedures. Following the moving and handling assessment, a hoist and sling assessment is completed where necessary, and a full Residents Moving and Handling Plan is devised. These are detailed and give clear instructions to staff on what they needed to do. These documents have been introduced since the last inspection. We saw other risk assessments in the dementia care houses in respect of smoking and refusal of personal care support - these were well written and sufficiently detailed in order to inform and guide staff practice. We did not see risk assessments regarding people who may refuse their medications and spoke with the manager and would recommend that further consideration be given to this matter in order to ensure a consistent and clear approach. We looked at wound care planning documentation in all four houses and found there were inconsistencies in all the records pertaining to wound care that we looked at. In Capstan House we saw that one persons care plan had recently been reviewed. A care plan for dated January 2010, stated that the person had a grade 1 pressure sore. The plan detailed the equipment needed in order to support them, however other wound care assessment and evaluation sheets referred to the wound as being a grade 3 pressure wound, with no other information provided about any change in the wound or the treatment given. On Embassy, the plan we looked at was very unclear. It referred to the presence of a wound, stated that no pressure relieving equipment was in place (despite the person being at risk) and only one entry had been made in the wound reassessment record. The plan looked at in Kingsway was only written after a pressure sore had developed. We looked at other records, for example the waterlow risk assessment (assessing the likelihood of a person developing pressure sores) and these showed that the level of risk had increased significantly When the person had become bedbound due to illness, but there was no evidence of review of that persons care, at that time, in order to prevent pressure sore formation. For one other person in Kingsway, wound measurements were recorded but it could not be evidenced that these were accurately measured recordings, as there was no measuring devices available. These shortfalls were discussed with the home manager and other senior staff members. There needs to be an improvement in the actions taken by staff to prevent pressure sores, and also in the records kept in respect of wound management - those records must be accurate and contain true descriptions of the wound. Other means of monitoring effectiveness of wound care treatment plans involves photography, and we also saw that the specialist tissue viability nurse had been Care Homes for Older People Page 14 of 34 Evidence: contacted for advice, for one person. A record is kept for each person, of GP and other healthcare professionals contact, the reason for the referral, and any outcomes from this, such as what treatment may be required. Examples of healthcare professionals involved in peoples care include chiropody, dentists, opticians, speech, language and swallowing therapists, continence advisors, specialist diabetic nurses and dieticians. People who come to live in the home may retain the services of their family GP if this is a local GP and they are in agreement to visit as and when necessary. If not, the current arrangments are that for each of the houses one of the local doctors practices is allocated. The GPs visit each of the houses on set days plus in addition, as and when needed. We spoke to a visiting health professional who told us they had noted significant improvements at the home during the past few months, when we asked them for examples they said that communication between them and the home had improved, that staff appeared to understand the needs of individuals better and the home were supporting people in line with their assessed needs, as recorded within their plan of care. Medication systems are unchanged from the last inspection. We were told that Safe Medication Administration training is currently being introduced by Bupa for all trained staff with an expectation that all nurses will complete this. Medication audits are completed on a very regular basis and feed in to the overall quality assurance mesaures of the home. A desinated member of staff in each house takes responsibility for the ordering of new supplies. During this inspection we checked out the procedures in place in just two of the house. We checked the systems in place for the recording and administration of medication in Capstan House. Medicines are supplied to the home using a blister pack system. All the medicines used in the home are given by a qualified member of staff. We checked the medication systems used to make sure that they meet the required standards. The home uses a local pharmacy for their medications and gets support from them. Good practice guidelines are followed such as having a photograph of the person needing the medication on their chart. The pharmacy provides printed medicine administration record (MAR) charts for staff to complete when they give medicines. Medicines may also be given from labeled boxes provided by the pharmacy. Staff signed the MAR charts as they dispense the medicines. There are some people at the home who are prescribed PRN (as required) medications, but no guidance is provided on the MAR charts. Clear protocols should be in place in order to ensure that all staff know what this means for each individual person for whom this is prescribed. When we spoke to staff about this they were prompt to address this and a protocol was written up and implemented whilst we were Care Homes for Older People Page 15 of 34 Evidence: still at the premises. When we spoke to a member of staff who gives out medication at the home they were very clear about their role and responsibilities in this area. They were clear about what to do in the event of a person refusing their medication and also what they should do if an error was made, demonstrating a sound understanding in this area. We also looked at medication procedures in Kingsway and found everything to be in order. We spoke to one person who lives in Kingsway who was under the impression that they were not allowed to administer their own medications and this was discusssed with staff. We were told that if a person wishes to be responsible for their own medications consultation with the GP will take place along with risk assessment and written affirmation of responsibility. Each house has adequate medicines storage facilities including medicine trolleys, fridges and controlled drugs cupboards (medicines needing additional security). Records are kept of the controlled drugs. We are assured that all medication systems in respect of the ordering, receipt,administration and disposal of medicines are in line with safe practice. Since the last inspection the home have strived hard to ensure that people are treated with respect, and that staff have regard for peoples dignity and privacy. Any incidents where staff conduct or attitude has not been acceptable have been appropriately dealt with and there is a zero tolerance towards poor care provision. There is ongoing staff training in a Personal Best programme to ensure that people are looked after in the way that they wish. On the whole people looked well cared for and were nicely dressed. People we spoke with during the course of the inspection had the following comments to make - I have my favorite girls but they are all very helpful and polite, I am given the help and support that I need and I am quite content thank you very much. One relative wrote on our survey I find the carers very kind and caring to my sister. Negative comments were made about the length of time it can take for call bells to be answered at times in Kingsway - several people commented that it can take too long for call bells to be answered particularly at night. This was discussed with the home manager who reported that there have been some concerns about call bells not registering on the system. This is already being looked in to. All staff however, must ensure that people receive the care and support that they need within a timely manner. We talked to staff and the home manager about end of life care planning and the documentation that they complete and there continues to be a lack of real understanding by those completing the plans about the need to complete these forms. We again saw care plans where they were not needed. For example one person had an end of life plan that stated their health was stable. Whilst we are aware of the need for the home to be gathering information about peoples wishes, (for example funeral Care Homes for Older People Page 16 of 34 Evidence: wishes) this should not be recorded upon an end of life care plan. Since the last inspection we were contacted by one relative who told us that they had been very impressed with the management of their loved ones last days of life. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements have been made in the way peoples social care needs are being met and there is a wide variety of fulfilling and meaningful activities arranged that they can participate in. There is better provision for those people with dementia. A wellbalanced and nutritious diet is provided and people will be well fed. Evidence: There are three Activity Organisers, one holding a senior role and having responsibility for the provision of a varied activity plan and monitoring the work of the other two staff members. Since the last inspection it is evident that there is greater support and supervision in respect of what happens in order to meet peoples social care needs, on a daily basis. We spent time with the activities organiser and one of the activities staff. Activity staff will spend time with each person to find out what they like to do and will find out information about peoples past life. We were told that a new activity centre has been introduced and regular gentleman and ladies groups have been instigated, away from the units. In each house there is a displayed notice about the activities that will happen during that week. We saw that there was a mixture of music sessions, balls games, quizzes and reminiscence sessions as well as one to one work with those people who are room bound. Care Homes for Older People Page 18 of 34 Evidence: During our visit we observed people in both Picador House and Capstan House using SOFI - a short observational framework inspection. We did this because we wanted to see how the needs of people with dementia were being met. We spent time in the lounge and dining areas of both houses and saw that staff engaged with those who live at the home in a meaningful way. People were spoken to politely and respectfully. Staff on the whole, were attentive and supported people in an appropriate manner. During our visit a quiz took place about landmarks in Bristol, staff encouraged people to reminisce and talk about places which had influenced their life - people appeared to enjoy this activity and it encouraged lively discussion. We also saw an entertainer who was visiting Picador House, he was very person centred in his approach, and was caring in his manner. He spoke to each person in turn and encouraged them to engage in what ever way they could, for some people this was singing and playing a musical instrument for others it was a smile. Although the engagement with some people was only minimal it was clear that they responded to his approach and communicated in the best way that they could. We also noted during this process that care staff in both Picador and Capstan were very involved in meeting peoples social and emotional needs, and this was not seen as just the remit of the activities staff. This is a vast improvement from the previous inspection. In both Embassy and Kingsway the care staff are still less engaged with the programme of activities but work continues in involving them in the things that are happening in the unit. An activities committee has been set up with carers attending from each unit, plus the activities team and the quality team. We were told that the carers represent the views of the people in their house but it would be a good idea if people could be given the opportunity to represent themselves. People will be assisted to go along to activities that are based in other houses if they wish and can choose not to participate in some or all of the activities. One person said I am aware of what is going on but I prefer to make my own arrangments. I have my TV and computer. We spoke to one person in Embassy who had not lived in the home for very long - they said I welcome any opportunity to have a good old chat with someone, not everyone here is able to do that, so I hope the staff will have time to speak with me. In Picador and Capstan rummage boxes and items that may be of interest have been placed around the communal areas of the home, with the aim of prompting a memory or a meaningful conversation. This has been introduced by the new centre manager and activities supervisor. The home has a four-week menu plan, and a copy of the days menu is displayed in the reception area of each house. Since the last inspection the provision of the main meal of the day has been moved to the early evening. This change was made because Care Homes for Older People Page 19 of 34 Evidence: some people choose not to have their breakfast until later and would then not eat a full midday meal. This change has brought about significant improvements in peoples behaviour in the evening, a time when people with dementia can often become more agitated or distressed. At midday, soup and sandwiches, a hot or cold snack meal or a main meal is served. People living in Picador and Capstan are provided with a visual choice whereas those people in Embassy and Kingsway will make their choices the day before. A copy of the days menu is displayed on each table. Meals are prepared in the central kitchen and wheeled over to each house in heated cabinets. A Nite Bite menu is avaiable in each of the house so that care staff can prepare snack meals for those people who want additional food. We looked to see how people were being supported at lunchtime as part of the SOFI process in both Picador and Capstan. We saw that there were sufficient numbers of staff present to assist people, some people were encouraged through verbal prompting and encouragement, some people were given minimum assistance, others were supported on a one to one basis to eat their meal. We did note in Picador House that two people ate their soup with their spoon and a knife. We spoke to the manager about this and questioned the need for a knife and fork on the table as it was felt that this would confuse already confused people. We saw one person in Capstan House who drank their soup through the hole in the lid of a beaker cup rather that the spout. If staff had noticed this we would hope that they would have offered more appropriate utensils. This same person did not eat their sandwiches, they were only reminded once to eat them before they were taken away uneaten. Staff still need to be more observant. We saw staff helping people to eat in all four houses. Whilst some staff were good at talking with people, giving them eye-contact, not rushing them and helping at the persons own pace, others were distracted by their colleagues or did not engage with the person they were assisting. We observed one person on Embassy who was helped by five different carers during the course of the midday meal - it appeared that they each had difficulty getting the person to eat, therefore gave up and started another task. There needs to be a consistent approach to how staff support people. Care Homes for Older People Page 20 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. The way in which any concerns or complaints people who live in the home may have are managed, means that they can be assured they will be listened to and the issues they have, looked in to and acted upon. Better processes are in place to safeguard people from harm and staff awareness of their responsibility to report concerns is improved. Evidence: The homes complaints procedure is displayed in the main foyer of the administration block and the reception areas of each of the four houses. It is also included in the service users guide placed in peoples bedrooms. Posters displayed contain up to date information about how to contact the Care Quality Commission (CQC), but other leaflets had the wrong address for CQC. These leaflets may be taken away by relatives or other visitors who may wish to contact us. Although a Bupa Quality Compliance manager is still present in the home, overseeing the progress of improvement in the home, the management of any complaints being made about the service, is dealt with primarily by the home manager. We looked at the complaints log for the last 12 months. Some of the issues we have been contacted about as well and were therefore aware of how they had been dealt with. It is evident that the management of complaints has improved since the last inspection however if all documentation in respect of each individual complaint was kept together it would be easier to demonstrate compliance with their complaints procedure. In the AQAA, Care Homes for Older People Page 21 of 34 Evidence: the home manager told us that they had dealt with 20 complaints in the last year. CQC have been notified directly about four complaints and in these cases we asked the home manager to investigate the issues raised. One of the complainants was not satisfied with how the issues they had raised were dealt with and we had to ask a senior Bupa manager to take further action. Surveys were returned to us from 12 people who live in Amerind Grove or relatives. Each indicated that they were aware of the complaints procedure. Those people/relatives spoken with during the course of the inspection said they were were satisfied with the care and support that they receive - care staff are very kind and helpful, I am very happy with the care that my wife receives, staff are kind are caring, I would speak to the person in charge if there was something I had to say and things have greatly improved here, and the staff are alot more happier and friendly. Suggestion feedback boxes, and a supply of forms, are placed in the foyer of each house. Neither inspector received any complaints during the time spent in the home. The home has a protection of vulnerable adults policy (POVA) and clear guidance is available for the staff to follow if abuse is suspected, alleged or witnessed. Notices about the procedure and Bristol City Council No Secrets guidance is available in all four houses. The training matrix showed that the majority of staff have already completed the Bupa POVA training session, but the manager feels that there is still a culture amongst a very few members staff where their attitude affects the care of people living in the home. We are assured that the home manager and Bupa are dealing with any staff conduct issues appropriately. All staff are expected to undertake POVA training an an annual refresher basis. In the last year there have been seven events that we have worked together, with the home and Bupa senior managers, social care officers from the planning & commissioning team of the local authority and healthcare staff from the primary healthcare trust (PCT) to ensure that people are safeguarded. Three of the cases were raised by the home themselves when they were concerned about a persons behaviours. Discussions with those staff on duty, on all four units evidenced that they are aware of their responsibilities to safeguard people from harm and are aware of the actions they should take. The staff team however must ensure that when there are altercations between two or more people who live in the home, that the concerns get reported properly. Care Homes for Older People Page 22 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are cared for in houses that are safe, comfortable and generally well furnished. The environment for people with dementia is better because the facilities are more accessible and user-friendly. Evidence: Amerind Grove is a purpose built care home and is arranged as five separate single storey houses, each accommodating between 30 to 40 people. One house has been closed for the last year. The service facilities are all located in a sixth building, along with the managers office and administrators. The grounds are surrounded by walled gardens, and the entrance has large steel gates that are locked overnight. Additional fencing surrounds the two dementia care units (Picador and Capstan), enabling these people to wander safely out into these parts of the gardens. Each of the houses are similarly laid out, decorated and furnished, although there are new rooms in Capstan, Kingsway and Embassy - these have ensuite facilities and an upgraded specification. There is a rolling programme of redecoration for the home and Embassy is due to have the corridors and communal areas attended to soon. There were areas in Capstan lounge that showed signs of wear and tear and these have already been earmarked for redecoration. After the last inspection we suggested that Bupa seek the advice of a specialist dementia care organisation, in order to see how they could improve the environment. Although this advice has not been taken up, Care Homes for Older People Page 23 of 34 Evidence: improvements have been made in both Picador and Capstan. New signage has been purchased to indicate location of toilets and bathrooms and memory boxes have been placed on the walls outside of peoples bedrooms. It would be good to see these boxes in use as many were bare. Each of the houses are generally well maintained and well decorated throughout and regular maintenance audits are undertaken. Each house has a maintenance log where staff can report any jobs that need attending to - we were told that often things dont get reported properly. During our tour of each of the four houses we noted a few areas where attention was needed. In Capstan House the paintwork was scuffed in the dining area, but we were told that this area had already been identified for redecorated, and in one of the shower rooms, the curtain was hanging off. In Picador House a handrail was missing in one of the toilets, and in some bedrooms curtain pelmets had come away from the curtain track and looked unsightly. Of more concern was that in one persons bedroom the light over their bed was broken and potentially a danger. This was brought to the attention of the manager who assured us this would be dealt with immediately. We found the inside of the home to be clean tidy and odour free, however, we did note that some residents appear to discard items out of their bedroom windows, making some areas looking unsightly, Whilst we acknowledge that it may be difficult to prevent this happening the home should be more observant and remove items in a more timely manner. The front doors to each of the houses are secured with a keypad door entry system, and all fire exits are linked into the call bell system. This creates a secure environment for people. Each house has a large communal area consisting of a lounge and dining area. There are plans to provide a new sensory room in the dementia care centre. In Capstan and in Kingsway, the larger of the units, the new building works included a second lounge area. Furniture and furnishings throughout the communal rooms are generally of a homely nature and in good condition. Each lounge has a range of different types of seating to meet the different needs of the people who live there. However, two chairs, one in Embassy and one in Capstan were found to be soiled and odorous. This was discussed with the home manager during the inspection who will need to remind housekeeping and night staff of their duties. Toilets and bathrooms are located throughout each of the houses. The bathrooms are fitted with bath hoists or other types of specialist bathing equipment. Care staff spoke about the difficulties of using the sit up baths and shower units with people who need moving and handling support. The use of this equipment must be risk assessed to Care Homes for Older People Page 24 of 34 Evidence: ensure that the safety of people and staff is maintained. They should only be used by those people where the risk has been assessed as low. Each house has separate sluice room facilities and these are kept locked. Each of the houses are well equipped with a range of equipment to enable the care staff to undertake their duties and to move people safely, in line with good manual handling techniques. All beds are electric profiling beds, have integral bed rails and the ability to be lowered close to the floor. There is a plentiful supply of pressure relieving mattresses, between the houses. A nurse call bell system is installed in each bedroom and the communal areas of each of the houses, and calls for assistance are registered on pagers carried by some of the staff team. There appears to be an ongoing problem with the nurse call system in some parts of Kingsway House (calls for assistance do not register) and two people told us that call bells are not always answered in a timely manner. This was discussed with the manager who told us that the engineer was due to return. All bedrooms are for single occupancy, have fitted wardrobes, a chest of drawers and a bedside cabinet with lockable drawer. The 120 original bedrooms currently in use, have a wash hand-basin in the room and a commode is provided in peoples rooms where needed. The 21 new bedrooms each have en-suite facilities of a toilet and wash hand-basin. People are encouraged to bring in items of furniture to make their bedrooms their own. We looked at the bed linen and towels and saw that replacement linen and towels have already been provided and we were told that more is on order. During a tour of Kingsway we looked in the linen cupboards - the cupboards were untidy and we saw clean bedding on the floor. This is not hygienic and does not indicate good infection control procedures. This was referred to in the last inspection report as well. Each house is provided with housekeeping support each day. All housekeepers and laundry staff work under the direct supervision of a supervisor and the hotel services manager. All of the houses were clean and tidy and fresh smelling, on the days of inspection. One relative we spoke with during the inspection told us since the new manager has been here the home has no odour and is much cleaner and tidier. We did point out that there needs to be regular checks of the garden areas outside of peoples bedrooms. Care Homes for Older People Page 25 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. There is still a way to go with establishing stable staff teams in each of the houses but this is improving. Staff have access to relevant training, and their training and development needs will be identified and met. Safe recruitment procedures ensure that unsuitable workers will not be employed. Evidence: There have been a number of management changes since the last inspection. A new deputy/clinical manager has been appointed who is over seeing the management of both Kingsway and Embassy - there is a house manager appointed for Embassy but not for Kingsway. A new dementia centre manager has been appointed for Capstan and Picador who will be supported by a lead nurse for each of the houses. There continues to be an ongoing recruitment procedure to employ nurses with leadership and management skills. Shifts in each house are covered by both registered nurses and care assistants. We were told that staffing numbers required for each shift are based upon the collective dependency levels of the people who live in the house. The numbers of staff on duty are audited at regular intervals throughout the day - staff may be moved from one unit to the other during a shift, depending upon workloads. Those staff we spoke with during the course of the inspection said that staffing levels were much improved. Staff were observed going about their duties and appeared to be present in sufficient Care Homes for Older People Page 26 of 34 Evidence: numbers. We were told that some working practices have been altered in order to promote better communication between care staff and registered nurses. There appeared to be better day-to-day supervision of care staff by the nurses and the other managers. A new postion of senior carer has been introduced - this worker will provide greater support and supervision for junior workers and new recruits. The care team are supported in meeting peoples daily living needs by a team of administrative, housekeeping, catering, laundry and maintenance staff. The numbers of care staff who have achieved at least an NVQ Level 2 in Care qualification currently stands at approximately 33 , a slight increase on last year. Some staff we spoke with wanted to do the training but were unsure whether they were being considered for the next cohort. The home manager told us that now the home was beginning to settle down, they would be increasing the numbers of staff undertaking NVQs. An NVQ Assessor is funded by Bupa to visit the home on a weekly basis to work with staff who are working towards attaining the qualification. Some care staff have achieved NVQ level 3 as well as the Level 2. The home follows a thorough recruitment procedure and expects written application and attendance for an interview. Two written references are obtained, with one reference being obtained from a previous employer. CRB disclosures and POVAfirst clearance is always completed prior to employment commencing. Six staff files were checked and found to be all in order and in line with safe recruitment procedures. The home provides a good induction programme of training for all new recruits. We spoke to two new members of staff who told us that their first shifts had been supernumerary to the staffing numbers and that they had an induction progamme to complete. They said they felt well supported when they first started. The new senior carer post will mentor new carers when they first start working in the home and will support the worker in completing the induction programme. We were provided with a copy of the current training matrix that shows what training courses each staff member had attended. Mandatory training includes fire awareness, manual handling, COSHH (control of substances hazardous to health), infection control, POVA and dignity awareness, and personal best training. Other examples of training food hygiene, nutrition, dementia awareness, health and safety and various clinical updates. We spoke to many staff about the dementia training Yesterday, Today and Tomorrow and all reported how it had increased their ability to care for people with dementia. All training tends to be provided in-house or via distance learning courses with a workbook to be completed. Care Homes for Older People Page 27 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of Amerind Grove is significantly improved and there is a greater sense that the home is run in the best interest of the people who live in the home. Evidence: The Home Manager has been in post since October 2008, however still has not made application to the Care Quality Commission to be the registered manager despite frequently being reminded of the need to do this. Bupa have been advised that it is an offence under section 11 of the Care Standards Act 2000 for a person to manage an establishment or agency without being registered with the Care Quality Commission, and that application must be made immediately. The manager has previously been a registered manager at another nursing homes in the local area and is a Registered Nurse. Aside from this though, the home manager has instigated significant improvements in the home which have resulted in an improved service for people who live in the home. The home manager has overall responsibility for the home and the care of up to 171 people who can reside at Amerind Grove. The management team has been enhanced by the recruitment of a deputy manager and a dementia centre Care Homes for Older People Page 28 of 34 Evidence: manager. A Care Home Residents Survey is completed by Bupa on a yearly basis, and people are asked about the quality of the care they receive, the staff and the environment. The most recent survey was completed in October 2009 and the results of this are not due to be published until February 2010. In addition to formal quality assurance measures, a number of audits are completed on a regular basis. These include auditing of complaints received and trends in any issues raised, health and safety checks, environmental checks (we suggest this should include a review of the state of the gardens), medication audits and a review of care planning documentation. We were told at the last inspection that a relatives forum was to be set up however this did not happen. Residents and relatives meetings are held in each of the houses but we did not look at the minutes of the meetings during this inspection. We looked at the administrative procedures that are in place where the home looks after peoples money. All transactions in to, and out of each persons account are logged and receipts given. Some families have arranged that they will be invoiced for extra services such as hairdressing. We were told that all financial records are reconciled on a two weekly basis. Staff supervision was reviewed. Evidence from those records viewed showed that staff have received supervision. All staff are issued with a supervision contract. Formal, recorded supervision provides staff with the opportunity to express their opinion about the services provided at the home and to discuss areas of concern in relation to individuals care and also to discuss their training and development needs and work performance. Staff on both Embassy and Kingsway said that a formal programme of regular supervision has only just been re-introduced, but we saw some records of supervision sessions that have already taken place. During our SOFI observations in Picador and Capstan we saw staff moving people in a safe manner. We saw staff assisting people with the hoist and also with a standaid, on both occasions staff explained to the person what they were doing, they checked that the person understood what had been said to them and the move was completed in a calm, reassuring and safe manner. In both Kingsway and Embassy we also observed safe moving and handling procedures. All staff have to receive yearly manual handling updates and would not be allowed to use hoisting equipment if they hadnt received trained. The new members of staff said they had manual handling training as part of the induction programme. We looked at the training matrix and this evidenced those staff who were due for update training as they have not had training for nearly a year. Care Homes for Older People Page 29 of 34 Evidence: Monthly checks are completed in respect of hot and cold water storage temperatures, the nurse call bell system, the lifting and moving equipment,and all the homes wheelchairs. The fire log was up to date and evidenced that all the necessary weekly and monthly checks had been completed. All staff will receive regular fire awareness training. The maintenance person told us that they have completed LOLER training and will be completing PAT testing training within the next month. We saw that within peoples care records, health and safety checklist of the bedroom had been completed. We saw that there are some people at the home who have their bed lowered close to ground level and also have a crash mat in place beside their beds in case they fall out of bed during the night. It is recommended that this is included with the bedroom health and safety checklist as this is an important aspect of this persons care during the night and should be part of a risk assessment process. Accident and incident forms are completed when people have falls. We were able to see that forms had been completed when a record of a fall had been made in the persons daily records, but we could not see how staff were checking up, for a period of time after the event, that the person was not suffering any adverse effects. All accident forms are just countersigned by the home manager and we recommend that the manager also be checking what actions the staff have taken. Care Homes for Older People Page 30 of 34 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 3 15(1) The registered person must ensure that assessments of peoples needs record individuals holistic care needs. This is so that care-planning processes can be person centred and based around individual specific needs. 16/04/2009 Care Homes for Older People Page 31 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 3 15 The registered person must ensure that care needs assessments are fully completed on admission or re-assessment of needs. This is so that peoples individual care needs are identified and form the basis of care plans. 22/03/2010 2 8 15 The registered person must ensure that wound care planning documentation is completed properly and contains accurate information. This is so that people receive the treatment that they need and the effectiveness of the care is monitored. 22/03/2010 3 22 13 The registered person must 22/02/2010 ensure that risk assessments are undertaken for each person before the sit up bath/shower units. Page 32 of 34 Care Homes for Older People 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 so that people and staff are prevented from being injured 4 31 11 The home manager must make application to the Commission for registration. This is because it is a legal requirement. 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 22/03/2010 1 2 7 8 Care plans would be easier to follow if they were clear, concise and written in a legible format. Records must be made of all actions taken to evidence the prevention of pressure sores. This should include reviews of waterlow risk scores. Ensure call bells are answered in a timely manner so that peoples dignity is maintained. Consider the inclusion of people who live in the home, on to the Residents Activity Committee. People should be provided with the appropriate equipment at meal times to promote independence. There needs to be a consistent approach provided to those people who require help with feeding. Ensure that the all areas of the home are kept clean tidy and odour free. This to include the armchairs which should be cleaned on a daily basis. Clean linen should not be stored on the floor. Records should be kept following any accidents or incidents to evidence that appropriate monitoring has taken place and to ensure that any adverse effects do not go unmissed. 3 4 5 10 12 15 6 20 7 8 26 38 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). 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