Care Home: Anzac House

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What the care home does well A consistent and thorough assessment procedure was used to ensure that when people were admitted to the home, there was sufficient information to know it was the right placement for them. Prospective residents were invited to visit the home with family members as part of the pre-admission process, and to stay for a meal. As good practice, people`s families were invited to provide information about the person`s life history. This meant each care plan began with a rounded picture of the person, rather than concentrating purely on physical care needs. The Orders of St John Care Trust has introduced a standard care planning system to all its homes. This ensures that areas of care essential to all people are addressed in a consistent way, and that people`s more individual needs are also assessed and planned for. People`s specific medical conditions were subject of individual care plans. Two GPs responded to our survey. One wrote `We have no concerns over Anzac House clients and their carers currently`. The other wrote that the home provides `excellent care`. Staff kept excellent records of care. They confirmed care was given in line with care plans, and showed that all residents received regular attention. GPs or district nurses were contacted promptly if a person needed medical attention. Staff continued to record changes in condition and provision of care as they occurred. There were handovers between staff shifts, which referred to the current record for each resident, ensuring staff were up to date with people`s current care needs. Care plans were written in such a way as to promote people`s privacy and dignity. All care interactions that we observed were carried out in a way that made people appear comfortable. People were routinely offered choices about where they wanted to go and what to do. Staff were patient in their explanations. They showed awareness of private space. People living in the home appeared comfortable in how they were dressed and there was evident attention to hair and nail care. Staff in the home regarded interaction with residents, including through organised activities, as part and parcel of good care. Therefore they were maintaining a good level of care for people`s social and activity needs whilst recruitment was ongoing to fill the activities co-ordinator post. We saw different groups of residents involved in looking at the local paper, in a ball-throwing for gentle exercise, and in dancing to music. There was plentiful photographic evidence of various activities involving most residents, including a lot of use of the gardens. People living in the home were invited to help with tasks such as folding linens, laying tables and making their bed. We saw that dementia `mapping` exercises were carried out in the lounge, to feed into staff learning about successful interactions. These pieces of work had helped identify the importance of the availability of objects for stimulation and engagement. This was a good example of how the home has developed expertise in the field of dementia care. At our previous inspection we saw that the home had worked on how to provide people with a consistently pleasant dining experience. Staff confirmed this focus had been sustained. Care plans for each person identified any particular issues for them around eating and meal times, such as a need to provide supplements or finger foods. There was good availability of hot and cold drinks throughout the day. Relatives of residents told us in our survey that they knew how to raise concerns or complaints both formally and informally. All staff received training, repeated at intervals, in abuse awareness and how to respond to allegations. Senior staff had received training about the Mental Capacity Act, including deprivation of liberty safeguards. There were homely touches, such as pictures and objects, all around the home. Pictorial signs were used to show what each room was. The hairdressing room was well appointed, to make it look like a real salon. Access to both the large and courtyard gardens was well signed. In good weather, doors to the outside were left open to encourage people to go outside if they wished. Housekeeping staff we spoke to were proud of their work and felt well supported. They were rostered to work during the whole week, including weekends. We found high standards of cleaning around the home, including the passenger lift and in places not normally visible. Care staff we spoke to considered staffing levels enabled them to carry out their tasks, including spending time talking with residents or directly leading activities. They were able to `double up` when necessary. Records of how staff were appointed were kept in a consistent, logical order. Pat Lavery saw it as inappropriate to include residents directly in the recruitment process, but interviewees were observed in their demeanour around the home and with residents. Training records were well organised. They demonstrated that care and non-care staff were actively helped to keep up to date with training. All staff received accredited dementia awareness training. There were high levels of attainment of NVQ [National Vocational Qualification]. There was a clear plan for staff to receive supervision regularly through the year. Staff we spoke with confirmed they received regular and useful one-to-one supervision. We judged standards relating to staffing in the home as met to an excellent level. Within the home, there was effective delegation of management tasks, for example concerning medication, e-learning and care planning, to care leaders. Pat Lavery maintained good contact with developments in dementia care by attending conferences and through links the Trust has with dementia specialist organisations. She was strongly supported by her locality manager. Areas of management responsibility within the home, such as safe keeping of residents` monies and medications, were subject to routine audit and scrutiny. The Trust had good arrangements for overseeing and providing for the health and safety of residents and staff. An annual survey of residents and their supporters helped the manager identify any issues for improvement in an action plan. What has improved since the last inspection? The home met our previous requirement that the home must demonstrate pro-active interventions to promote tissue viability and minimise risks of pressure damage occurring. Following our pharmacist inspector`s recommendation at the previous inspection, improvements had been made to the security of the medicines room. There had been ongoing improvements to the environment since our previous inspection. The home had completed a programme of fitting all toilets with dark blue seats and hand rails, to contrast with their white surroundings. This good practice made recognition and thus use easier for some people with dementia. As we had recommended, soap and paper towel dispensers had stickers to help identify what they were, as they could be unfamiliar fittings to some people. The dining areas in the units had been refitted with laminate flooring, which was proving much easier to clean than carpets. We saw examples of new vanity units being fitted to bedrooms, this programme being almost completed. A new sluice room had been brought into service and, in line with our previous requirement, commode buckets were now numbered to ensure they were always returned to the same person. This reduced a risk of cross infection. The size restrictions of the home were reflected in the sluice room, where access to the hand washing sink was restricted. What the care home could do better: There was scope for more cross-referencing between different parts of care plans. For example, to enhance planning to avoid pressure area damage, parts of a person`s care plan, such as application of topical creams during personal care, or nutritional guidance, showed that the home was providing proactive care to reduce the risk of pressure damage. However, we would like to see that all information relevant to this aspect of care was in one place, to be sure care staff can access the information in a logical way. A significant area for development of care plans was with regard to dementia. `Mental state and cognition` was a standard component of care plans. The type of dementia that was diagnosed for each person was shown, but the care planning aims and care directions were repetitive and minimal. As Anzac House is a specialist home, we would like to see these parts of care plans developed over time. They should reflect how a person`s placement in the home enhances their life by addressing how their dementia impacts on them as an individual. Although storage of medicines and recording of their use were good, we identified shortfalls in showing the dates of opening short-life items [eye drops] and verifying the accuracy of handwritten entries in the medicines administration record charts. Excellent information about people`s life history was often obtained. Families were asked to contribute and key workers added information as they learnt more about and from the people they worked with. However, opportunities made available to people did not necessarily draw on this information. Therefore there needs to be liaison between each person`s key worker and the activity worker to agree social needs care plans. Records in the home, and notifications sent to us, indicated that staff were professional in their responses to incidents, and thorough in how these were recorded. However, we saw that staff sometimes needed more opportunities to debrief from incidents, both for analysis and reassurance. We also identified that recording of the progress of matters, once referred to safeguarding procedures, needed to be more systematic, to give the home better evidence of where responsibilities lay after measures were agreed under the procedures. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Anzac House London Road Devizes Wiltshire SN10 2DY     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Roy Gregory     Date: 2 5 0 8 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 35 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 35 Information about the care home Name of care home: Address: Anzac House London Road Devizes Wiltshire SN10 2DY 01380722623 01380730061 manager.anzachouse@osjctwilts.co.uk www.osjct.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: The Orders Of St John Care Trust care home 30 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: No more than 30 service users with dementia may be accommodated at any one time. One named service user in the category of mental disorder, excluding learning disability or dementia over the age of 65 years. Date of last inspection Brief description of the care home Anzac House provides care to older people with a diagnosis of dementia, with one place for an older person with mental health needs. The home is not registered to provide nursing care. It is run by the Orders of St John Care Trust, which has a number of homes for older people in Wiltshire and in three other counties. The accommodation is on two floors connected by passenger lift and a staircase. The home is divided into smaller units, each with its own sitting room, dining room and Care Homes for Older People Page 4 of 35 Over 65 30 1 0 0 Brief description of the care home kitchenette. There is also a main dining room and adjacent sitting room, so people have a choice of where to go in the home. They also have ready access to secure and attractive gardens. A conservatory provides a private space suitable for receiving visitors. All the bedrooms are single rooms, with vanity units. They have shared toilets and bathrooms nearby. The home has two beds for respite care made available to people with dementia in the local community. The home, which was purpose-built in the 1970s, is situated in its own grounds on the Eastern edge of Devizes. It has its own car park, and there are good bus links to other towns. People considering using Anzac House receive an information brochure. Care Homes for Older People Page 5 of 35 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: three star excellent 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 visited Anzac House on Thursday 20th August 2009, between 8:30 a.m. and 12:30 p.m. and returned on Monday 24th August between 8:30 a.m. and 5:00 p.m. During this time we toured all areas of the home, including sitting and dining rooms, bathrooms, kitchen and laundry room. We were able to see a number of individual bedrooms. We observed how residents made use of the accommodation, and how staff interacted with them. The registered manager, Pat Lavery, was available during the inspection, and we also met with her locality manager. We spoke with a group of care and housekeeping staff who were on duty each day, and also with a cook and the handyman. We looked at staff records for evidence of the homes recruitment procedure, and provision of training and supervision. Care Homes for Older People Page 6 of 35 Other records consulted included those concerning risk assessment, safe keeping of residents monies, management and administration of medicines, and the homes internal surveys of residents and relatives opinions. We examined the care plans and records of four residents in detail, to compare how care was planned and delivered. We also took account of notifications we have received from the home since our previous inspection. These concerned events that had impacted on people singly or as groups, and how the home had responded to these events. We sent out survey questionnaires to broaden the information available to us. We received responses from the relatives of two residents, from five members of staff and from two GPs. Prior to the inspection visit, Pat Lavery had returned the homes Annual Quality Assurance Assessment [AQAA], which gave some descriptive and numerical information. It indicated where the service had made improvements and their aspirations for further development. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visits to the home. They take into account the views and experiences of people who live there. What the care home does well: A consistent and thorough assessment procedure was used to ensure that when people were admitted to the home, there was sufficient information to know it was the right placement for them. Prospective residents were invited to visit the home with family members as part of the pre-admission process, and to stay for a meal. As good practice, peoples families were invited to provide information about the persons life history. This meant each care plan began with a rounded picture of the person, rather than concentrating purely on physical care needs. The Orders of St John Care Trust has introduced a standard care planning system to all its homes. This ensures that areas of care essential to all people are addressed in a consistent way, and that peoples more individual needs are also assessed and planned for. Peoples specific medical conditions were subject of individual care plans. Two GPs responded to our survey. One wrote We have no concerns over Anzac House clients and their carers currently. The other wrote that the home provides excellent care. Staff kept excellent records of care. They confirmed care was given in line with care plans, and showed that all residents received regular attention. GPs or district nurses were contacted promptly if a person needed medical attention. Staff continued to record changes in condition and provision of care as they occurred. There were handovers between staff shifts, which referred to the current record for each resident, ensuring staff were up to date with peoples current care needs. Care plans were written in such a way as to promote peoples privacy and dignity. All care interactions that we observed were carried out in a way that made people appear comfortable. People were routinely offered choices about where they wanted to go and what to do. Staff were patient in their explanations. They showed awareness of private space. People living in the home appeared comfortable in how they were dressed and there was evident attention to hair and nail care. Staff in the home regarded interaction with residents, including through organised activities, as part and parcel of good care. Therefore they were maintaining a good level of care for peoples social and activity needs whilst recruitment was ongoing to fill the activities co-ordinator post. We saw different groups of residents involved in looking at the local paper, in a ball-throwing for gentle exercise, and in dancing to music. There was plentiful photographic evidence of various activities involving most residents, including a lot of use of the gardens. People living in the home were invited to help with tasks such as folding linens, laying tables and making their bed. We saw that dementia mapping exercises were carried out in the lounge, to feed into staff learning about successful interactions. These pieces of work had helped identify the importance of the availability of objects for stimulation and engagement. This was a good example of how the home has developed expertise in the field of dementia care. At our previous inspection we saw that the home had worked on how to provide people with a consistently pleasant dining experience. Staff confirmed this focus had been sustained. Care plans for each person identified any particular issues for them around eating and meal times, such as a need to provide supplements or finger foods. There Care Homes for Older People Page 8 of 35 was good availability of hot and cold drinks throughout the day. Relatives of residents told us in our survey that they knew how to raise concerns or complaints both formally and informally. All staff received training, repeated at intervals, in abuse awareness and how to respond to allegations. Senior staff had received training about the Mental Capacity Act, including deprivation of liberty safeguards. There were homely touches, such as pictures and objects, all around the home. Pictorial signs were used to show what each room was. The hairdressing room was well appointed, to make it look like a real salon. Access to both the large and courtyard gardens was well signed. In good weather, doors to the outside were left open to encourage people to go outside if they wished. Housekeeping staff we spoke to were proud of their work and felt well supported. They were rostered to work during the whole week, including weekends. We found high standards of cleaning around the home, including the passenger lift and in places not normally visible. Care staff we spoke to considered staffing levels enabled them to carry out their tasks, including spending time talking with residents or directly leading activities. They were able to double up when necessary. Records of how staff were appointed were kept in a consistent, logical order. Pat Lavery saw it as inappropriate to include residents directly in the recruitment process, but interviewees were observed in their demeanour around the home and with residents. Training records were well organised. They demonstrated that care and non-care staff were actively helped to keep up to date with training. All staff received accredited dementia awareness training. There were high levels of attainment of NVQ [National Vocational Qualification]. There was a clear plan for staff to receive supervision regularly through the year. Staff we spoke with confirmed they received regular and useful one-to-one supervision. We judged standards relating to staffing in the home as met to an excellent level. Within the home, there was effective delegation of management tasks, for example concerning medication, e-learning and care planning, to care leaders. Pat Lavery maintained good contact with developments in dementia care by attending conferences and through links the Trust has with dementia specialist organisations. She was strongly supported by her locality manager. Areas of management responsibility within the home, such as safe keeping of residents monies and medications, were subject to routine audit and scrutiny. The Trust had good arrangements for overseeing and providing for the health and safety of residents and staff. An annual survey of residents and their supporters helped the manager identify any issues for improvement in an action plan. What has improved since the last inspection? The home met our previous requirement that the home must demonstrate pro-active interventions to promote tissue viability and minimise risks of pressure damage occurring. Following our pharmacist inspectors recommendation at the previous inspection, Care Homes for Older People Page 9 of 35 improvements had been made to the security of the medicines room. There had been ongoing improvements to the environment since our previous inspection. The home had completed a programme of fitting all toilets with dark blue seats and hand rails, to contrast with their white surroundings. This good practice made recognition and thus use easier for some people with dementia. As we had recommended, soap and paper towel dispensers had stickers to help identify what they were, as they could be unfamiliar fittings to some people. The dining areas in the units had been refitted with laminate flooring, which was proving much easier to clean than carpets. We saw examples of new vanity units being fitted to bedrooms, this programme being almost completed. A new sluice room had been brought into service and, in line with our previous requirement, commode buckets were now numbered to ensure they were always returned to the same person. This reduced a risk of cross infection. The size restrictions of the home were reflected in the sluice room, where access to the hand washing sink was restricted. What they could do better: There was scope for more cross-referencing between different parts of care plans. For example, to enhance planning to avoid pressure area damage, parts of a persons care plan, such as application of topical creams during personal care, or nutritional guidance, showed that the home was providing proactive care to reduce the risk of pressure damage. However, we would like to see that all information relevant to this aspect of care was in one place, to be sure care staff can access the information in a logical way. A significant area for development of care plans was with regard to dementia. Mental state and cognition was a standard component of care plans. The type of dementia that was diagnosed for each person was shown, but the care planning aims and care directions were repetitive and minimal. As Anzac House is a specialist home, we would like to see these parts of care plans developed over time. They should reflect how a persons placement in the home enhances their life by addressing how their dementia impacts on them as an individual. Although storage of medicines and recording of their use were good, we identified shortfalls in showing the dates of opening short-life items [eye drops] and verifying the accuracy of handwritten entries in the medicines administration record charts. Excellent information about peoples life history was often obtained. Families were asked to contribute and key workers added information as they learnt more about and from the people they worked with. However, opportunities made available to people did not necessarily draw on this information. Therefore there needs to be liaison between each persons key worker and the activity worker to agree social needs care plans. Records in the home, and notifications sent to us, indicated that staff were professional in their responses to incidents, and thorough in how these were recorded. However, we saw that staff sometimes needed more opportunities to debrief from incidents, both for analysis and reassurance. We also identified that recording of the progress of matters, once referred to safeguarding procedures, needed to be more systematic, to give the Care Homes for Older People Page 10 of 35 home better evidence of where responsibilities lay after measures were agreed under the procedures. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 11 of 35 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 12 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A personalised approach to prospective residents ensures their needs are assessed professionally before a place is offered, and as part of the admission process. Evidence: The assessment and admission records for a person who moved into the home recently showed Pat Lavery met them and obtained a great deal of information by observation, talking with the persons family, and from hospital records. On this basis, Pat Lavery was able to identify areas of risk, and the care and support needs that admission to the home would address. The Orders of St John Care Trust had a well designed standard set of documentation to guide staff through the assessment process to ensure comprehensive information was gathered. This then linked to creation of peoples care plans, so staff knew from the outset about needs to be met. A dependency scoring system was used, and we saw that this was further refined immediately after admission, as home staff began to learn more detail about peoples needs, preferences and responses to care provision. It was also good practice that the Care Homes for Older People Page 13 of 35 Evidence: persons family were invited to provide information about the persons life history during the assessment period. This meant their care plan began with a rounded picture of the person, rather than concentrating purely on physical care needs. Pat Lavery said it had proved more successful to seek this social dimension of information at the earliest stage, than leaving it until after admission. A set process was followed on the day of admission, to ensure the persons room was ready for occupation and that the kitchen staff were aware of dietary needs and likes and dislikes. Pat Lavery said that whenever possible, prospective residents were invited to visit the home with family members as part of the pre-admission process, and to stay for a meal. This provided people with further reassurance as well as adding to the assessment of how they might adjust to living in the home. Care Homes for Older People Page 14 of 35 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. Peoples personal and health care needs are met through care planning. People are treated with respect and their right to privacy is upheld. Residents are protected by the homes procedures for the safe handling of medicines, subject to additional checks on accuracy of information to staff carrying out administration. Evidence: The Orders of St John Care Trust has introduced a standard care planning system to all its homes. This ensures that areas of care essential to all people are addressed in a consistent way, and that peoples more individual needs are also assessed and planned for. Initial assessment information, including risk assessments, was clearly used as the basis for care plan contents. Peoples relatives had been asked to sign agreement to plans. The care plans we sampled gave generally good guidance on how to deliver care to people in an individual way. There were, however, instances where more specific guidance was desirable. For example, a direction to ensure sufficient fluids to prevent dehydration would benefit from guidance on how this was to be achieved and monitored. Care Homes for Older People Page 15 of 35 Evidence: The care plan format required care staff to identify the aims being pursued, followed by the intervention to meet the aim. These two aspects of care planning were frequently confused, which in turn led to a lack of clarity on reviews of care plans. However, these kinds of issues had been recognised by Pat Lavery and the care leader who acted as care plan champion. It had been a major task to introduce the care planning system and to train staff in what was expected. Staff had recently been instructed how to show that they had engaged directly with residents in monthly reviews of care plans, to avoid continuous restatements of no change. There was a current emphasis on helping staff appreciate the difference between setting aims, and describing how care is delivered. A good example we saw had as an aim, to help maintain daily living skills and to feel relaxed and settled in the home. There was clear guidance in the intervention about ways to achieve this, and the monthly review showed how the persons key worker had checked with the person that the aims were being achieved. Peoples specific medical conditions were subject of individual care plans. We saw examples relating to asthma, diabetes and osteoporosis. There was scope for more cross-reference between different parts of care plans, for example, to ensure someones risk of falls, moving and handling needs, and care needs relating to osteoporosis, contained the same core information. This would ensure that staff consulting any one of those plans, possibly under pressure of time, would see all relevant information. This would particularly enhance planning to avoid pressure area damage. Individual assessments of the risk of suffering pressure damage were good. Care plans specific to this risk were in place for all people, but usually guided staff simply to report any concerns arising, e.g. observation of redness, for district nurse attention. Yet other parts of a persons care plan, such as application of topical creams during personal care, or nutritional guidance, showed that in fact the home was providing proactive care to reduce the risk of people sustaining pressure damage. Therefore the home met our previous requirement that the home must demonstrate pro-active interventions to promote tissue viability and minimise risks of pressure damage occurring, but we would like to see that all information relevant to this was in one place. A significant area for development of care plans was with regard to dementia. Mental state and cognition was a standard component of care plans. These always showed the type of dementia that was diagnosed for an individual, but the care planning aims and care directions were repetitive and minimal. As Anzac House is a specialist home, we would like to see these parts of care plans developed over time. They should reflect how a persons placement in the home enhances their life by addressing how their dementia impacts on them as an individual. Over time, these might become the Care Homes for Older People Page 16 of 35 Evidence: central elements of care plans, since they relate directly to the reasons why people live in the home, and the evident expertise of staff. Staff kept excellent records of care. They confirmed care was given in line with care plans, and showed that all residents received regular attention. A good example was provided in respect of a person whose care plan directed staff to assess daily how well the person was able to mobilise. The nature of care was to be varied in response to this. Records showed clearly how the staff made their observations and adjusted their care interventions accordingly. Where there were concerns about peoples wellbeing, records showed staff were quick to observe changes and to record these. This meant that GPs or district nurses were contacted promptly if a person needed medical attention. We saw a care leader requesting nurse attendance to assess a skin concern that had just been reported by a carer. Staff continued to record changes in condition and provision of care as they occurred. There were handovers between staff shifts, which referred to the current record for each resident, ensuring staff were up to date with peoples current care needs. Residents were weighed regularly, usually monthly, and actions were taken in response to any significant changes. We saw where a fall in weight over a month had been referred to the persons GP. The doctors visit and outcome were recorded. A record was kept for each person of all visits from or to health professionals. When people were admitted to hospital, a form was used to make sure core information, including medications, was available to medical staff receiving the person. These always emphasised that the person had dementia. Notifications sent to us concerning emergency situations that have arisen in the home, such as medical deterioration and falls, have demonstrated staff competence in assessing and responding appropriately. Two GPs responded to our survey. One wrote We have no concerns over Anzac House clients and their carers currently. The other wrote that the home provides excellent care. Care plans were written in such a way as to promote peoples privacy and dignity. All care interactions that we observed were carried out in a way that made people appear comfortable. People were routinely offered choices about where they wanted to go and what to do. Staff were patient in their explanations. They showed awareness of private space. Care plans included guidance on ensuring people got full benefit from aids such as spectacles and hearing aids. Peoples preferences about male or female carers were established, and care plans showed clearly whether personal or other care was to be provided by carers of one gender only. It was noted how people liked to dress and wear jewellery. People living in the home appeared comfortable in how they were dressed and there was evident attention to hair and nail care. Care Homes for Older People Page 17 of 35 Evidence: One of the care leaders had primary responsibility for medication-related issues in the home. She carried out competency checks on care staff who administered medicines. Staff training to do so included a period of shadowing experienced staff, followed by administering under supervision. The Orders of St John Care Trust has a medications policy and provides training in safe administration under the policy. We have been notified of a few medication errors since the previous inspection, some of which were followed up by our pharmacist inspector. We have seen that appropriate measures have been taken to make people safe and to establish and address the cause of errors, including disciplining and retraining staff when indicated. The Trust arranges internal and external audits of medicines practices. Storage of medicines was safe, including secure storage for controlled drugs. Following our pharmacist inspectors recommendation at the previous inspection, improvements had been made to the security of the room. All storage was orderly and logical, but the date of opening eye drops, which have limited life once opened, had not been noted. Medicine Administration Record [MAR] charts were well kept, showing that people received their medicines as prescribed. However, where a person had medicines added to the MAR chart after it had been printed by the supplying pharmacy, a second member of staff had not counter-signed the handwritten entry as a check on its accuracy. Some medicines were prescribed for use as needed. For these, the terms of usage were documented, and there was an additional record kept, to show precisely when they were given and the reason why on each occasion. Care plans indicated if there were dietary consequences for people taking certain medicines. One person was occasionally given medicines covertly. The history of this was documented, as was family and GP agreement to the practice. The GP had indicated in writing which medicines must be given by this means when the person was resistant to normal administration, and which could be safely left to be given at a later time. Care Homes for Older People Page 18 of 35 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is active in identifying and meeting peoples social, religious and recreational needs. People keep in contact with family and friends and go out into the community with support. People have a choice of meals, served in a homely way. Evidence: The homes staff complement includes an activities co-ordinator. This post had been vacant for some weeks when we visited, but applicants for the post had been shortlisted. Meanwhile, activities promotion was seen as part of the care workers daily duties, with one in particular taking a lead. Staff meeting minutes showed the care staff had discussed how best to ensure continuity of activity provision until a coordinator was again in place. On the first day of our visit, different groups of residents were involved in looking at the local paper; a ball-throwing exercise for gentle exercise; and dancing to music. We saw that different people in the main sitting room were often asked whether they wanted music playing, and to make requests for CDs, which resulted in a variety of music styles being heard during the day. The volume was engaging for those that liked the music, without being intrusive to others. The television was used sparingly. Some people liked to watch their own televisions in bedrooms. Care Homes for Older People Page 19 of 35 Evidence: We saw that all staff engaged readily and naturally with residents as they went about the home. People living in the home were invited to help with tasks such as folding linens, laying tables and making their bed. A garden club enabled people to help with simple outdoor tasks, including making choices of planting and placement. People were encouraged to go out into the garden, where activities included games like croquet as well as simple walking and chatting. Plentiful photographs around the home provided evidence of such activity. Perhaps as a reflection of the lack of an activities co-ordinator at the time, recording of what activities people were involved in did not represent the range of things that were actually happening. This would make it difficult to evaluate how far peoples individual preferences and identified needs were being met. Ideally the activities co-ordinator appointed will be involved in care planning to ensure individual social and stimulation needs are assessed and planned for. We saw that excellent information about peoples life history was often obtained, as the care planning format made space to ensure this was done. Families were asked to contribute and key workers added information as they learnt more about and from the people they worked with. However, opportunities made available to people did not necessarily draw on this information. Therefore there needs to be liaison between each persons key worker and the activity worker to agree social needs care plans, including identified emotional and spiritual needs. In the main lounge a start was being made on creating a memory corner, using items and pictures that related to the 1950s in particular. We saw that dementia mapping exercises were carried out in the lounge, to feed into staff learning about successful interactions. These pieces of work had helped identify the importance of the availability of objects for stimulation and engagement. This was a good example of how the home and Trust have developed expertise in the field of dementia care. There were staff available to take people out into the community. Arrangements were in place for people to maintain religious involvement, if they wished. Visitors could come to the home at any time. The small kitchenettes on the units were available to visitors to make hot drinks. There had been a change of kitchen staff following a period of reliance on agency catering staff. We spoke with a recently appointed cook. She saw her job as going beyond the kitchen. She valued involvement in serving food and getting direct feedback about meals from the people that live in the home. Menus provided for choices at all meals. Lunch on one of the days we visited was a choice of beef curry, or cod with parsley sauce. Breakfasts were provided from the main kitchen and included porridge and cooked options. Care Homes for Older People Page 20 of 35 Evidence: People could eat in the main dining room, the small unit dining rooms or their bedrooms. The dining rooms all had a pleasant atmosphere for the enjoyment of meals. At our previous inspection we saw that the home had worked on how to provide people with a consistently pleasant dining experience. Staff confirmed this focus had been sustained. Care plans for each person identified any particular issues for them around eating and meal times. For example, one person was identified as fairly often refusing meals. Their plan showed alternative ways of encouraging good nutrition, such as by provision of finger foods. When weight recording showed any person was losing weight, this triggered a care plan review to consider the reasons, and often led to a food chart being put in place. This enabled staff to monitor the success of strategies to help people eat sufficiently. In the care office there was a list reminding staff which residents were currently to have their food intake recorded. Pat Lavery said more work was planned on establishing for each individual what their favourite meals were, to ensure these favourites figured prominently in the menus. There was good availability of hot and cold drinks throughout the day. Care Homes for Older People Page 21 of 35 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. There is good provision for receipt of and response to complaints. Staff and management understand and exercise responsibilities in respect of keeping residents safe. Evidence: The organisation had recently reviewed and revised its complaints procedure and documentation. This was made known to people by display in the home and inclusion in the service user guide. No complaints had been received by the home, or by us in relation to the home. Relatives of residents told us in our survey that they knew how to raise concerns or complaints both formally and informally. All staff received training, repeated at intervals, in abuse awareness and how to respond to allegations. Senior staff had received training about the Mental Capacity Act including deprivation of liberty safeguards, whilst other staff received some input, and printed material, about this aspect of their work. All staff were provided with copies of the No Secrets guidance to local inter-agency safeguarding procedures. The home has had cause to refer some matters to these procedures since the previous inspection. As a result of a recent referral, there was agreement between agencies for additional monitoring of a person whilst they awaited reassessment of their mental health needs. The monitoring was funded and was being undertaken by an agency worker. Staff of the home were aware of this persons specific brief, which was successfully incorporated into the working of the home. Care Homes for Older People Page 22 of 35 Evidence: Records in the home, and notifications sent to us, indicated that staff were professional in their responses to incidents, and thorough in how these were recorded. They showed staff were aware of the policies underpinning their work. However, we saw that staff sometimes needed more opportunities to debrief from incidents, both for analysis and reassurance. We also identified that recording of the progress of matters, once referred to safeguarding procedures, needed to be more systematic, to give the home better evidence of where responsibilities lay after measures were agreed under the procedures. Care Homes for Older People Page 23 of 35 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. The home is restricted in space but homely, safe and well-maintained. There are good standards of hygiene around the home. Evidence: There had been ongoing improvements to the environment since our previous inspection. The home had completed a programme of fitting all toilets with dark blue seats and hand rails, to contrast with their white surroundings. This good practice made recognition and thus use easier for some people with dementia. Refurbishments of some toilets were planned for the year ahead. As we had recommended, soap and paper towel dispensers had stickers to help identify what they were, as they could be unfamiliar fittings to some people. The dining areas in the units had been refitted with laminate flooring, which was proving much easier to clean than carpets. The kitchenettes were about to be refitted with new worktops, units and sinks, as they were at the end of useful life. One of the corridors was being decorated during our visit. We saw examples of new vanity units being fitted to bedrooms, this programme being almost completed. Pat Lavery said there was a programme of gradual replacement of furniture. We saw no furnishings that were unacceptable. There were homely touches, such as pictures and objects, all around the home. The main lounge presented as uncluttered but homely. There was a dresser, book case and ornaments on shelves, also a budgie in a Care Homes for Older People Page 24 of 35 Evidence: cage. In the dining room was a sideboard with old photographs, and there were picture cubes on the tables. Pictorial signs were used to show what each room was. Toilet doors had been painted yellow to aid recognition. The hairdressing room was well appointed, to make it look like a genuine salon. Access to both the large and courtyard gardens was well signed. We saw that in good weather, doors to the outside were left open to encourage use. Individual rooms that we saw were well decorated and personalised, but some appeared cramped. The handyman said rooms that became vacant were the priorities for redecoration before they were reoccupied, although he had experience of redecorating rooms whilst occupants were away in hospital. He felt well supported in his job. The maintenance book showed he made a quick response to all matters notified by other staff. When maintenance issues were passed on to the Trust, they also were responded to quickly. A new sluice room had been brought into service and, in line with our requirement, commode buckets were now numbered to ensure they were always returned to the same person. This reduced a risk of cross infection. Many staff regretted they no longer had a conventional sluicing sink, but a macerator was installed in the refurbished sluice room. The size restrictions of the home were reflected in this room, where access to the hand washing sink was restricted. Housekeeping staff we spoke to were proud of their work and felt well supported. They were rostered to work during the whole week, including weekends. We found high standards of cleaning in most parts of the home, including the passenger lift and in places not normally visible, such as the undersides of toilet surrounds and bath seats. There were no unpleasant odours. The one area that presented less well was the laundry. This may have been related in part to the fact that the laundry worker post was currently vacant. The walls of the laundry needed cleaning. There was some leakage of chemicals from containers onto the floor. Pat Lavery undertook to request the supply company to visit immediately to address this issue. Housekeeping staff had identified through their staff meeting that the area behind the washing and drying machines was very difficult to access and thus to keep clean. However, the area was reasonably clean, and Pat Lavery confirmed that alternative configurations of the room had been considered but proved impossible. The home used a resident of the day system, which ensured that every month or so, specific criteria in the care of each individual resident received close attention to ensure the home was meeting its planned commitment to meeting their needs. This included detailed cleaning of the persons bedroom on that day, such as cleaning Care Homes for Older People Page 25 of 35 Evidence: furniture and curtains and removal of the radiator cover. Care Homes for Older People Page 26 of 35 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have good support from competent, trained staff who are provided in sufficient numbers. People are protected by sound recruitment practices that ensure nobody works at the home until checks on their background are complete. The provider invests in the development of staff, to maintain a specialist and mainly qualified team. Evidence: The rota for care staffing aimed to provide six care workers through the mornings, four during the afternoon and five in the evening. Shifts included a care leader. The record of rotas worked showed these figures were mostly achieved, although Pat Lavery acknowledged that at weekends, provision of six care workers at any time proved difficult. Care staff we spoke to considered staffing levels enabled them to carry out their tasks, including spending time talking with residents or directly leading activities. They were able to double up when necessary. When there was an activities worker in place, this obviously made an appreciable difference to staff availability to groups of residents and individuals. Staff conveyed a sense of professionalism and described a strong feeling of mutual commitment to a team approach. Three care staff were deployed at night. Their duties included some cleaning. The home had some availability of bank staff and otherwise covered shortfalls by staff offering to do extra duties. There was no recent record of any need to take on agency staff. Records of how staff were appointed were kept in a consistent, logical order. They Care Homes for Older People Page 27 of 35 Evidence: showed that no member of staff started work before checks on their background were completed, to ensure there was no known reason why they should not work with vulnerable people. For each role in the home, e.g. care worker, housekeeper, kitchen staff, there were specific interview questions. Responses were noted and scored. Pat Lavery saw it as inappropriate to include residents directly in the recruitment process, but interviewees were observed in their demeanour around the home and with residents. For a recently appointed person there was a record of these observations. New staff underwent a recorded induction period. Training records were well organised. They demonstrated that staff were actively helped to keep up to date with training. The Trust provided e-learning for core subjects which staff were required to undertake, as well as an appropriate range of courses. All staff received accredited dementia awareness training. This was supplemented at Anzac House by feedback to staff on the observations from dementia mapping exercises carried out in the home, to help improve practice. Some staff had been identified to receive training from an external professional source on working with behaviours that may present a challenge. There was an expectation on all staff to gain NVQ [National Vocational Qualifications]. In the case of care staff, 22 out of 29 staff had achieved NVQ to at least level 2, and 3 care staff were to be in the Trusts NVQ intake commencing in September 2009. The chef had the benefit of occasional organised meetings with chefs from other Trust homes, and there were plans for activities co-ordinators to have a similar support group. Housekeepers followed their own NVQ route. The home had achieved Investors in People accreditation. Care Homes for Older People Page 28 of 35 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their supporters experience an open and competent style of management that upholds provision of a quality service. The views of people living in the home, and their supporters, are sought and acted on. People have good quality support because the staff are regularly supervised. People are safeguarded by the arrangements made for handling their finances. Sound health and safety policies and practices help create a safe home in which to live and work. Evidence: Pat Lavery has maintained good contact with developments in dementia care by attending conferences and through links the Trust has with dementia specialist organisations. She was strongly supported by her locality manager who, along with the training manager, was at the home when we visited. The locality manager visited the home monthly to give Pat Lavery individual supervision, and to carry out routine monitoring of the management of issues such as medications practice, care planning, staff supervision and training, complaints handling, care of residents monies and matters of particular significance at the time. In addition the Trust organised monthly Care Homes for Older People Page 29 of 35 Evidence: unannounced visits, including interaction with residents, as another check on standards of care practice, the environment, residents activities etc. Records of these visits suggested they were fairly superficial compared to the rigour of the locality managers visits. Within the home, there was effective delegation of management tasks, for example concerning medication, e-learning and care planning, to care leaders. They had a certain amount of their working hours off rota so they could keep on top of administrative duties without compromising availability to residents. There was a schedule for the year of whole staff meetings and separate meetings specifically for senior staff, carers, night staff and housekeepers. Minutes of each showed good attendance and a productive exchange of information and ideas. In addition to the routine monitoring visits and annual audit, there was an annual satisfaction survey to help identify and address any quality shortfalls. The survey was mostly circulated to peoples relatives, although some residents were able to complete forms with assistance. The 2009 survey was to be completed at the end of August, so analysis had not been completed when we were at the home. Pat Lavery said the main issue people raised was the lack of private space in the home for visits. One relative had drawn attention to a piece of furniture that required replacing, and this had been attended to at once. An action plan would be drawn up in response to the survey findings. There was a safe keeping facility for personal monies, which most residents made use of. This was overseen by the administrator, but the safe containing peoples monies was in the managers office and only senior staff had access to it. We saw that peoples monies were kept separately from each other, and records of deposits and withdrawals were sound, being double-signed and with receipts attached. Key workers were asked to check on the money available to people to pay for items such as hairdressing and taxi fares, and to ensure relatives or other advocates were asked to top up funds when they were running low. There was a clear plan for staff to receive supervision regularly through the year. Staff we spoke to confirmed they received regular and useful supervision. It was a care leader responsibility to supervise care workers, and Pat Lavery supervised care leaders and kitchen staff. Examples of supervision records showed a consistent recording form was used. At each session, staff were asked to consider their care practice and planning, with special reference to their key carer roles, as well as their personal development and training needs. A date was set each time, for the next supervision, in order to sustain momentum. Care Homes for Older People Page 30 of 35 Evidence: The Orders of St John Care Trust has good policies and systems in place for promotion of health and safety for residents and staff, including maintenance contracts for machinery, aids and lifts. In the home, responsibilities for health and safety, risk assessments and fire safety were delegated to care leaders. We saw that these functions received appropriate oversight. There were individual fire risk assessments in peoples care records. All staff received training in health and safety, food hygiene, infection control and fire safety. The incidence of falls by residents was tracked. When any person had a record of three falls, action was taken to investigate further. This was the case for a resident when we were at the home. They were referred to their GP with a view to referral to the falls clinic. Care Homes for Older People Page 31 of 35 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 32 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Medicines with a short shelf life after opening, such as eye drops, must be marked with the date of opening. This will ensure such products are not used after their recommended period of efficacy has expired. 31/10/2009 2 9 13 Handwritten entries in the Medicines Administration Record chart must be counter-signed by a second member of staff. This will act as a check on the accuracy of the entry. 31/10/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 Care plan directions should be specific about the care interventions necessary to achieve stated aims, including to demonstrate measures in place to minimise the risk of development of pressure ulcers. Page 33 of 35 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 2 7 Dementia care plans should show recognition of the impact on individuals of their experience of dementia, and explain how placement in the home seeks to manage that impact. Key workers should liaise with the activities co-ordinator to devise social needs care plans that reflect individual interests, backgrounds and preferences. Keep a running log of each matter referred to safeguarding procedures, from initial referral to final outcome. Ensure staff who are affected by incidents arising in the home have adequate opportunity to debrief. 3 12 4 5 18 18 Care Homes for Older People Page 34 of 35 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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