Care Home: Applecroft Care Home

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What the care home does well People said the home had a friendly atmosphere and was comfortable. The people we spoke to said they are happy living at the home. Family and friends are welcome at the home and are encouraged to be involved in the care of their relatives. A relative said," I feel my relative is well cared for. She has settled well here". Another said, "My husband is safe in here. There can be difficult times but the staff are very good and manage any difficulties." Generally staff interacted and communicated well with the people who live at the home. Residents confirmed they feel their privacy and dignity is respected. What has improved since the last inspection? There is a new manager in post who is in the process of applying to the commission to become registered. She has only been in post for four months and has made improvements to the service. It is still early days for her, she is aware of the shortfalls and has plans in place on how to address these. She has been open and transparent with the commission and the other external agencies involved with the service. The service is now being managed pro-actively and run in the best interest of the people who live there. The manager is demonstrating that she has the skills and abilities to ensure that all of the residents have their individual care needs met, in a safe and caring environment. Staff told us in surveys "The new manager seems to be coping well. There is a calm about the home that hasn`t been here for a long time". "She listens to any concerns and follows them up". "With the change in management the care has improved and staff moral has improved. We are now able to take responsibility for what we do". The service has just appointed a deputy manager to support the manager in the running of the home. This will hopefully mean that any shortfalls and improvements for people will happen quicker. The information about who is providing services at the home is now up to date so people do now know who owns the home and what they can expect from the service. Everybody living at the home has a pre care needs assessment available on their file. The pre assessments are done by the manager and sometimes she asks a specialist dementia nurse to come with her. This makes sure that the home will only take people if they can be sure they can look after them. There have been improvements in the way in the way people receive their care. The personal and care/support required by people is now monitored and met. We also found when people deteriorated or develop new health issues there are care plans in place to direct and guide staff in how to manage these and look after people in the best way. Care plans have been updated to reflect the changing needs of people. This means that when people develop new health problems they will receive the support and care that they need. However we did still find some shortfalls which need to be addressed. The service is working with specialist services from the local teams to make sure they are doing things right. They are listening acting on the advice that they get from the specialists. Visiting professionals told us, "The staff listen to the professionals and attempt to change their practises. The service has improved over the last few months due to a change in the management". "The care has improved. They ask for help when they need it. They keep us up to date and informed about what is happening". There is a complaints procedure in place which people have access to. The processes and procedures to protect the residents from all types of abuse at all times have developed and improved. This means that the risk of people not being protected by the service has reduced. Staff training has improved. There are still gaps but these have been identified and there is now a training programme in place which will be on-going. This means that staff will have the training they need to do their jobs effectively and safely and in a way that best suits individuals. All safety checks are completed before people start to work at the home. Improvements have been made in the recruitment practises and procedures. This means that people are assisted and cared for by people who are trustworthy and will not take advantage of their vulnerability. The records show that most of the checks have been completed correctly. There was a gaps in the references that have been obtained for a nurse. The Manager says that this oversight will be corrected by 1st December 2009. The service has developed a maintenance and renewal program to make sure that they have identified the areas within the home that need work. They are improving the environment to ensure it is maintained to a good standard for the people who live there. The home is in the process of developing quality assurance systems to ensure that it is meeting its aims and objectives and is therefore improving the service for the residents. There is a development plan in place. Weekly audits were being done at the request of the commission to make sure the service was improving and these showed that the manager was keeping a close eye on how the systems in the home were working. She was able to identify shortfalls quickly and take the appropriate action to address them. Fire drills are now recorded against a list of staff employed by the home. Records are in place to make sure that all staff are clear of what to do in the event of a fire. The service is moving in the right direction but there is still a way to go. The service needs to demonstrate that improvements will continue and then be sustained. We will be monitoring the service closely to make sure these thing What the care home could do better: The manager is working to improve the service and provide an improvement to the life`s of the residents. We have looked all the evidence since the last inspection and can see that improvements have been made and that the manager is aware of the shortfalls at the service. We feel confident that the shortfalls we have identified during the inspection process will be addressed and sorted out by the manager. We identified that some of the health needs identified at peoples assessments were not in incorporated in to their plans. Staff were aware of the conditions and were taking action to make sure their needs were being monitored and met but for some reason there was no consistent direction or guidance in place to tell staff what to do. We also found evidence that at times some staff are not following the direction and guidance in the care plans. This means that there were incidences when people were not receiving the care that they needed. We discussed this with the manager and she told us she would take make sure that these shortfalls were addressed as soon as possible. The complaints procedure needs to say that the complaints will be addressed with a 28 day timescale. It would also benefit from being written in a format that makes it easier to understand by the people who live at the home. Staff need to receive all the training they need to meet the needs of the people living at the home. Now that the home has new providers the quality assurance systems need to be developed to make sure the people living at the home and stakeholders views impact on the improvement and development of the service. Key inspection report Care homes for older people Name: Address: Applecroft Care Home Sanctuary Close River Dover Kent CT17 0ER     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Mary Cochrane     Date: 2 2 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 39 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 39 Information about the care home Name of care home: Address: Applecroft Care Home Sanctuary Close River Dover Kent CT17 0ER 01304821331 01304821551 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Applecroft Care Home Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 75 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommmodated is: 75 Date of last inspection Brief description of the care home Applecroft is a large, detached, purpose-built care home, situated in a quiet residential area of River, Dover. The premises are in a cul-de-sac, and the home has a secure gate at the rear as an entrance to the attractive public gardens of Kearsney Abbey. The home is owned by Applecroft Care Home Limited. The provider also has other homes in different parts of the country. The home has a total number of 75 beds, divided into different units. Accommodation is provided in single en-suite rooms, with 30 beds on the second floor for older people Care Homes for Older People Page 4 of 39 Over 65 0 75 75 0 Brief description of the care home with nursing needs; 30 beds on the first floor for older people with dementia and nursing needs and 15 beds on the ground floor for adults aged over 18 years with nursing needs and dementia. The units take their names from different types of apples, in keeping with the name of the home. The top floor is divided into two wings of 15 beds called Russet and Pippin; the 30-bed first floor dementia unit is called Permain: and the ground floor unit is the Discovery Suite. The home has a large passenger lift which enables easy access to all floors. It is close to local facilities and shops, and near to the town of Dover and the sea. Fees range from £510 - £750.00 per week, depending on the level of care needed. Information about the home can be found in the Statement of Purpose and Service Users Guide. The latest CQC report is available on request. Care Homes for Older People Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This visit to the service was an unannounced Key Inspection which took place over one day. We were joined by an Expert by Experience. She has a thorough knowledge of the special needs of older people. She spent about over four hours in the Service. During this time, she watched what was going on in the lounges and she talked with people who live in the Service and with members of staff. She also had a look around the main parts of the accommodation. This included going into some of the bedrooms by invitation. Since the last inspection the new owners of the service have registered with the Commission. The registered manager has left and there is a new manager in post. The manager was available throughout the day to help us with the inspection. The people living at the home and the staff on duty were helpful and co-operative throughout the visit. They told us things about the home and the support and care they Care Homes for Older People Page 6 of 39 receive and give. The visit included talking with residents and the nursing and care staff. General observations were made during the day of how people are supported. One of the inspectors conducted a Short Observational Framework for Inspection (SOFI) for two hours on the Discovery Unit. This was to look at the daily life and social activities experienced by the residents. We observed how staff supported residents during social activities and when offering care. We looked at interactions and communication. We looked at whether people were supported to engage in general day to day life and whether their experiences were positive or negative or some where in between. Unfortunately people living at the home did not receive surveys so we were unable to use these in our inspection process. But we did receive four surveys from visiting health and social care professionals and seven from the staff who work at the home. We will refer to these in the report. We had a look around the home and various records were inspected. We looked at and discussed residents individual support plans and their risk assessments. We looked at medication procedures and records. We also looked at staff files and training records. We saw how the service recruits their staff and the homes quality assurance systems. An annual quality assurance assessment (AQAA) is usually requested by commission. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. Because we brought the date of this inspection forward we did not ask for an AQAA. We will be requesting one later on. We also took into account the things that have happened in the service; these are called notifications and are a legal requirement. There has been a social services led safeguarding adults investigation at the home. This means the safe guarding team has concerns about the home. They have offered support, advice and input from multidisciplinary agencies to move the home forward in the right direction. This is to make sure the people living at the home are safe and their needs are being met. At the time of writing this report the alert and investigation remain open. But at the last multi-agency meeting with the service it was agreed that care and support given to the residents has improved and the home is moving in the right direction. It was decided that the risk to residents has reduced significantly and although the alert remains open it was decided that people are now safe living at Applecroft. The service have started to take new admissions. Further multi-agency meeting have been planned to make sure that improvements continue and are sustained. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We will do another key unannounced inspection within a year. However we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Care Homes for Older People Page 7 of 39 What the care home does well: What has improved since the last inspection? There is a new manager in post who is in the process of applying to the commission to become registered. She has only been in post for four months and has made improvements to the service. It is still early days for her, she is aware of the shortfalls and has plans in place on how to address these. She has been open and transparent with the commission and the other external agencies involved with the service. The service is now being managed pro-actively and run in the best interest of the people who live there. The manager is demonstrating that she has the skills and abilities to ensure that all of the residents have their individual care needs met, in a safe and caring environment. Staff told us in surveys The new manager seems to be coping well. There is a calm about the home that hasnt been here for a long time. She listens to any concerns and follows them up. With the change in management the care has improved and staff moral has improved. We are now able to take responsibility for what we do. The service has just appointed a deputy manager to support the manager in the running of the home. This will hopefully mean that any shortfalls and improvements for people will happen quicker. The information about who is providing services at the home is now up to date so people do now know who owns the home and what they can expect from the service. Everybody living at the home has a pre care needs assessment available on their file. The pre assessments are done by the manager and sometimes she asks a specialist dementia nurse to come with her. This makes sure that the home will only take people if they can be sure they can look after them. There have been improvements in the way in the way people receive their care. The personal and care/support required by people is now monitored and met. We also Care Homes for Older People Page 8 of 39 found when people deteriorated or develop new health issues there are care plans in place to direct and guide staff in how to manage these and look after people in the best way. Care plans have been updated to reflect the changing needs of people. This means that when people develop new health problems they will receive the support and care that they need. However we did still find some shortfalls which need to be addressed. The service is working with specialist services from the local teams to make sure they are doing things right. They are listening acting on the advice that they get from the specialists. Visiting professionals told us, The staff listen to the professionals and attempt to change their practises. The service has improved over the last few months due to a change in the management. The care has improved. They ask for help when they need it. They keep us up to date and informed about what is happening. There is a complaints procedure in place which people have access to. The processes and procedures to protect the residents from all types of abuse at all times have developed and improved. This means that the risk of people not being protected by the service has reduced. Staff training has improved. There are still gaps but these have been identified and there is now a training programme in place which will be on-going. This means that staff will have the training they need to do their jobs effectively and safely and in a way that best suits individuals. All safety checks are completed before people start to work at the home. Improvements have been made in the recruitment practises and procedures. This means that people are assisted and cared for by people who are trustworthy and will not take advantage of their vulnerability. The records show that most of the checks have been completed correctly. There was a gaps in the references that have been obtained for a nurse. The Manager says that this oversight will be corrected by 1st December 2009. The service has developed a maintenance and renewal program to make sure that they have identified the areas within the home that need work. They are improving the environment to ensure it is maintained to a good standard for the people who live there. The home is in the process of developing quality assurance systems to ensure that it is meeting its aims and objectives and is therefore improving the service for the residents. There is a development plan in place. Weekly audits were being done at the request of the commission to make sure the service was improving and these showed that the manager was keeping a close eye on how the systems in the home were working. She was able to identify shortfalls quickly and take the appropriate action to Care Homes for Older People Page 9 of 39 address them. Fire drills are now recorded against a list of staff employed by the home. Records are in place to make sure that all staff are clear of what to do in the event of a fire. The service is moving in the right direction but there is still a way to go. The service needs to demonstrate that improvements will continue and then be sustained. We will be monitoring the service closely to make sure these things happen. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 39 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information about the service is now up to date and contains the required information. People know how much they are paying for the service they are receiving. People can be sure they will receive a thorough pre-assessment and that all their needs are identified. Evidence: We looked at the statement of purpose and service users guide written by the service. This is information which tells people about the company, the home and the service it provides. We found that these documents have now been updated to tell people living at the home about the new company that is providing the service. There is a copy of these documents in the reception area of the home. A Service Users Guide was Care Homes for Older People Page 12 of 39 Evidence: available. The manager told us that everyone receives a copy of the guide when they move into the home. It contains most of the information that people need to know about the home. We were told that everybody living at the home has a contract. The manager said that they are in the process of updating peoples contracts who were at the home before the new company took over. All new people have a up to date contract. This means that people and their representatives know what services to expect and what they are paying for. We looked at the pre-admission assessments of four people. We saw that the manager visits prospective residents in their own home, in hospital, or in their existing placement. This helps the service decide on whether they will be able to offer the person the support and care they need. Three of these people had recently moved to the home. The pre-admission assessments for these people had been done by the manager. The forth person needed care on the dementia unit. This assessment was done by the manager and a registered nurse who has specific skills and knowledge about people with dementia. The assessments identified the persons care and support needs and also looked at different aspects of their lifes. They gave information about their past, their likes and dislikes. Pastimes and religious and cultural preferences. The home also uses the assessment undertaken by the local care management team. All this information is brought together to make a decision as to whether or not the home will be able to look after the person and is used to form the basis of a care plan. People are admitted for a trial period. At the end of this time a review takes place, which involves the resident, next of kin, care manager and the home. At this point it will be decided whether the home is suitable for the person. There are no intermediate placements at this home. Care Homes for Older People Page 13 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be sure that their personal care needs are met but they cannot be sure all their health care needs will be identified and consistently monitored and met. People are treated with respect and there are ongoing improvements to ensure their dignity is upheld. People can be sure they will receive their routine medication on time. They might not receive their when required medication in a consistent way. Evidence: We looked at all the evidence we have received since the last inspection and found that there have been improvements in the standards of care and support given to the residents at Applecroft. However there is still a lot of work to do make sure that all people are receiving all the care they need all of the time. The manager of the service is aware of the shortfalls and is working to make sure these shortfalls are addressed. Care Homes for Older People Page 14 of 39 Evidence: Since the last inspection the home is demonstrating that it is working pro-actively to improve the services it gives to people. We have received a lot of information telling us what they are doing and how this is being monitored. We have received feed-back in safe guarding meetings and from health and social care specialist who have been visiting the home to support the staff and are monitoring the outcomes for the residents. Visiting professionals have told us The staff have now started to use preventative interventions and not just reacting to issues. All staff are receptive to all advice and external input. They will ask for help if they need it. Any changes or concerns are reported to all the necessary professionals. Staff are aware of the residents care needs and seek advice when they need it. We looked at a selection of care plans from the different units at the home. We looked at six of the care plans in detail and looked for specific information in four other plans. We found that there are there have been improvements in the personal and health planning for the people who live at Applecroft. We saw that in most areas people are receiving the care that they need from the staff to make sure they are looked after in a way that suits them best and keeps them as safe as possible. However we did find some shortfalls. Each person living at the home does have a care plan. The staff are in the process of developing new care plans for everyone. These plans do focus on what people can do for themselves and the support and care staff need to give them. They have started to promote independence and maximise peoples abilities. Some contain detailed information about how people like to have things done and give direction and guidance to staff about how to meet their individual needs. We found on the whole residents are receiving the personal care that they needed. The home uses a tick charts to indicate that personal care needs have been met. The charts we saw had been completed and were dated. We cross referenced these with the daily record and saw that people were well cared for. They looked fresh and their hair and nails were clean. They were dressed in appropriate clean clothes and looked comfortable. We did find that one chart indicated the person been assisted to shave that morning but obviously they had not. Another persons care plan said they need a shower twice weekly but there was no evidence this had been done. Staff told us this was because the person refused a shower but there was nothing written to indicate Care Homes for Older People Page 15 of 39 Evidence: this. The expert by experience told us that residents appeared clean and well cared for and staff did spend some time with individuals where they could. We found when peoples conditions change, deteriorate or those who have more complex needs they will receive the care that they need. The plans also gave details on how best to support people with regards their nutrition, skin and how best to manage some behaviours. On admission to the home all residents have a skin integrity assessment. This makes sure that anyone who is at risk of developing pressure areas is identified on arrival. The appropriate aids are then put in place to help prevent skin breakdown. People had special mattresses on their beds and they were sat on cushions that help prevent the skin from breaking down. Some people had cream applied to their pressure areas. The assessments are reviewed at regular intervals. We found that there are thorough plans in place for people who are at risk of developing pressure areas or have nutritional needs. If a person does have a pressure area then there is step - by- step guidance in place on how this is to be cared for. We saw evidence that pressure areas have improved and the incidences have reduced. We did find that some of the charts kept to make sure people are moved regularly were not kept up to date. There fore it seems that people are not being moved when they should be. The unit manager told us that peoples positions are changed but staff sometimes forget to complete the charts. She told us she would address this with the staff concerned. We also found that if people are not eating enough there are assessments and plans in place to give staff the direction and guidance they need to make sure residents are supported to eat an adequate diet. We found that when a person had lost weight this information had been transferred to the persons care plan to say how this is going to be managed and dealt with. In SOFI staff were observed helping one person have lunch The person was often agitated and frail and unable to communicate. The staff member spent time talking, and explaining what food was on the plate. The staff member persevered giving her small spoonfuls of food. She knew that although the resident showed no sign of wanting more after a few minutes they would take another spoonful when it is offered to her. She also knew when she had enough and wanted to move on to her pudding. When the resident said sweet the staff member picked up on the word and was able to interact. At the end of the meal event the resident smiled which was the only facial animation seen in the whole observation period. Care Homes for Older People Page 16 of 39 Evidence: We saw that another person was receiving the care that had been planned for by a nurse specialist. Information and instructions had been transferred in to the care plan to give instructions and guidance to staff about what they had to do. We saw that staff were adhering to this. We saw that one persons behaviours was being monitored carefully and staff are to look out for triggers that might cause aggressive outbursts. Another plan gave clear directions on how staff were to communicate with a person and we saw them doing this. We spoke to staff and they were able to explain about the support and care they give to people and how they do this in a way that best suits that person. We saw evidence that they did this according to the individuals care plan. Residents told us that the staff are very good We did find shortfalls in meeting peoples health needs. Some of these were regarding health conditions people had before they came in to the home which were identified when they were assessed. We have made a requirement in the report (with time scales) about this and have asked the service to tell us how they are going to make sure this improves. We found that one person was diagnosed as a diabetic in their initial assessment, but there was nothing in their care plan as to explain how this is managed. Staff did know they are diabetic and checked their blood sugars twice a week. We were also concerned to find that a supplement drink had been left on this persons table which she was not supposed have. The staff could offer no explanation for this but to say it was a mistake. The person had not drunk any of it. Another person had a diagnosis of epilepsy before coming into the home, but this was not in the care plan. The staff told us this shortfall had been identified and the new care planning system will make sure these needs are incorporated into the plans. We were concerned to find that no action had been taken by staff when a person had not been to the toilet for six days. In the care plan it stated what to do after four days. The nurse on duty told us that the appropriate action had been taken but we could find no evidence of this in the daily records or in the records kept for when medication is given. We discussed this with the manager who told us she would make sure it was sorted out. Care Homes for Older People Page 17 of 39 Evidence: We saw another person was on insulin. The care plan said to make sure that emergency treatment was given should blood sugars go up or down but it didnt say what emergency treatment was. It also did not tell staff what to do if the persons blood sugars went too low. We saw that people were taken to their rooms for private consultations when the doctor came. The expert reported some residents were in bed and the staff on both floors knocked before entering the rooms and spent a little time with each one talking to them. This was very natural action and the residents appeared pleased to see them. Staff were polite and respectful in their approach and conversation with people. We looked at medication procedures in the home. Medication is stored in a trolleys and cupboards. We found that drugs are kept securely and safely in each unit. The service has changed the pharmacy they deal with for supplying medication. They told us they now get more support and guidance with regards medication. They now order and get their medication on time. We did find on the Discovery unit that one person had run out of medication but this was being dealt with. We also found on one occasion there was a tablet missing that could not be accounted for. The manager told us she would investigate this to find out what had happened. We looked at the medication people are receiving. We saw that people are receiving their medication safely. We saw that people are receiving their medication they need it. Records for the administration of medication are well maintained Residents were asked if they wanted pain relief medication and the outcomes were recorded. We did find that in some incidences there was no guidance or direction for staff on when to give medication on when required basis. This means that people cannot be sure they will receive their medication when they need it and they cannot be sure they will not be given extra medication. It also means the staff wont be consistent in giving the medication. We did observe that when supplement drinks are given to people, staff make sure they are taken or record if they are not and why. This means people are receiving the nutrition they need to keep them as healthy as possible. Controlled drugs are stored and monitored safely. We were told they are disposed of according to policies and procedures and in conjunction with pharmacist. Care Homes for Older People Page 18 of 39 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some residents have a good level of activity and contact with staff and peers, but others do not. Some choices are offered. This means that there is an unequal balance of opportunities. Family links are encouraged and maintained wherever possible. The home provides nutritious and varied meals for the residents. People are receiving the nutrition they need to stay healthy. Evidence: The home employs a full-time activities organiser and a full time assistant to work in all areas of the home. The home does have an activities room but the majority of the activities take place in the units. This encourages more people to participate. Activities are varied and tailored to meet some of peoples individual needs. Some activities are held in groups and some are individually planned. The service has just re-introduced a newsletter which tells people about what is happening at the home. It also includes quizzes and information about meetings. Care Homes for Older People Page 19 of 39 Evidence: During our visit we observed how people were spending their time and we also spoke to some residents. We looked at the activities and interactions that were happening on all the units. Some of this was done by the expert by experience on Permain and Pippin and Russet and by the SOFI observational tool on the Discovery unit . We saw that a record is kept in each persons file to say whether the person participated in an activity. We saw that for the more able people living at the home records are kept about what they did and the level of participation. We saw that some people are encouraged and supported to carry on doing hobbies that they enjoyed before coming to the home. Others were watching TV, listening to music or reading. Some people are able to make decisions about how they spend their time. This shows that some people are being supported to do what they like and enjoy helping them live a fulfilling life. However we saw that the people who are less able and have difficulty communicating have limited opportunities. It was documented that they were asleep or refused but there was nothing recorded as to what activity was offered, what encouragement and support was given or if an alternative was available. On Discovery the SOFI observation was completed over a two hour period from 11.15 to 13.15. Three service users were observed in blocks of ten minutes using the standard scoring profile. On the whole the findings were positive. We found that staff engaged with people in a meaningful way. Most of the passive readings related to one person who seemed to be agitated sitting in their chair and who seemed to be very difficult to engage even when health care assistants sat with her. Some of the service users interactions with each other were quite heated exchanges but support workers interceded and diffused the situations. We found that staff were able to redirect people to prevent the escalation of the situation. From the interaction scores there were eight good scores with none being neutral or poor. One feature observed in the unit was quite a lot of general pacing around with much of it appearing to be aimless. This pacing often the trigger of conflict incidents, when one person came too close to another or seemed to be invading someones personal space. On three 10 minute periods three people were walking around the unit together and the impression was of an event waiting to happen at any moment. The atmosphere was increased by some racy music that was played that had a fast beat to it. There were other much more positive observations. One of the staff members Care Homes for Older People Page 20 of 39 Evidence: welcomed resients in a warm manner. The expert by experience focused on Permain and Pippin and Russet. She had a look around, spoke to people and observed what was going. She told us in her report that she spoke at length to the activity organiser who was in one of the lounges with the residents. The activities organiser said there was a weekly activity board which was varied i.e. Monday ball games. Tuesday singer, Wednesday shopping trolley, Thursday instruments and singing and Friday arts and crafts. The organiser did say it was difficult to engage people in activities and that she was looking at what could be done in the future. She said there was a minibus available but she would have to travel to London to get it and take it back, which was not a sensible option. The organiser said that those who wanted to could be taken out into the garden or the park but as everyone was in a wheelchair this was difficult. Relatives sometimes took people out and staff if they could find the time. There is an activities room but this is used now as a training room. This was a large bright room with a book shelf offering a wide variety of videos. These are used in the unit lounges about twice or three times weekly. The expert reported that, the television was on in both lounges although nobody was watching it. It was not stimulating and there were no magazines or anything else to do. Relatives told us that they are made to feel welcome at the home at all reasonable times and no restrictions are imposed. Residents are able to receive their visitors in the privacy of their own rooms or in the communal areas. The people spoken to felt they are able to have some choice in regards to their dayto-day lives. Examples given were that they could get up and go to bed when they liked. They could choose what to eat and where to eat their meals. Generally they felt happy with the limited choices they are offered. There was still no evidence to demonstrate how the home offers more diverse choices to people so they are encouraging them to be as independent and in control of their lives. Residents are encouraged to bring their own personal possessions into the home. The expert said, there are bedrooms on each floor where the residents were either bedridden or preferred to stay in their rooms and not socialise. There could have been Care Homes for Older People Page 21 of 39 Evidence: more stimulation in these rooms. We spoke to residents about the food and meal times at the home. The majority of people said they like the food. Some told us they found it bland. Some people said they are given a choice on a daily basis. Other told us they did not know what they were going to eat it was just there is front of them. They said they were not aware of the menu. Some of the residents have difficulties making choices. The staff are aware of the residents preferences and likes and dislikes. This is done in conjunction with relatives. The catering manager also keeps a record of peoples food preferences. It was observed in some of the dining areas that most of the people were in wheel chairs at the dining room tables. When we asked why this happened we were told it is was difficult and time consuming to transfer people from wheel chairs into dining room chairs. We were told that people are transferred to comfortable seating between mealtimes. This does restricts peoples choice and is task orientated. On the day of the visit we found that meals were served on time. A lunchtime meal was observed in all areas of the home. There was a friendly, relaxed and sociable atmosphere in the dining room on Permain We saw that residents there were offered a choice of main course and puddings. Staff were available to offer assistance if required and did this in a way that was respectful. The expert told us, lunch arrived in hot trolleys and was dished out. The plate sizes were good and some residents ate well, others did not and the plates were taken away with little being consumed. This was on the second floor. On the first floor most food was smooth or pureed with smaller portions. These residents were assisted when needed and the waste was minimal. Some residents ate in their rooms because they were immobile or they chose to have their meals there. The expert observed that not much was consumed. The expert did observe carers trying to assist in some of these rooms by encouraging residents to eat. The expert said, One of the staff team was seen taking mid morning refreshments to residents which consisted of tea/coffee and a small dish of grapes which looked very appetising and fresh. She said told me that there was always a snack which would be a scone, biscuits or fruit. She also said, All members of staff were courteous and caring to residents and supported people to eat there meals. Staff were busy with tasks all the time which did Care Homes for Older People Page 22 of 39 Evidence: mean that they did not have a great deal of time to spend with residents, although at no time did was anyone observed being ignored. A record is kept of food eaten by individuals. This is so any eating problems can be quickly identified and the appropriate action taken. We did see that people who did not eat there meals are given supplements. We saw staff assisting and supporting people to have these. A record was kept of what they had. Care Homes for Older People Page 23 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service who have complaints or concerns will be listened to and the concern/complaint acted on. People can be sure they will be safe and protected from abuse. Evidence: The home has a complaints procedure which was displayed in various areas of the home. The procedure did not include the information that all complaints would be responded to within a 28 day period. The procedure is not written in format to make it more accessible for all the people living at the home. Because some of the residents do have communication difficulties the manager needs to identify ways to assist them to voice any complaints or concerns. The manager told us she would address these shortfalls. There has been one complaints made to directly to the home since the last inspection. The manager was able to show us how this complaint was dealt with and how it was resolved to the satisfaction of the complainant. Residents and staff told us if they have any concerns the manager responds immediately and sorts things out. Its very important that people who live in the home are confident that they are safe from being taken advantage of. Staff said that if they saw any form of abuse taking Care Homes for Older People Page 24 of 39 Evidence: place in the home that they would report the incident to a more senior person on duty. They also demonstrated that they know how to follow the homes whistle blowing policy. The staff training matrix shows that some staff have received training in safeguarding vulnerable adults and further training has been planned. This means that staff will have the knowledge to identify all the forms of abuse that can occur in a care home. The safeguarding alert at the home remains open. This means that social services are still monitoring the progress being made to make sure people living at the home are safe. There was a meeting on the 22nd September 2009 with the manager and area manager of Applecroft, care managers, specialist nurses who visit the service and the commission The level of concern about the home has reduced but it is still being monitored. Input and monitoring from social services and health professionals is continuing. At the last visit it was agreed with the service that there would be no further admissions to the home until improvements were made. Improvements have been made and the home are now able to accept new people into the home. Care Homes for Older People Page 25 of 39 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There have been improvements made to the environment since the last key inspection. It is important that the ongoing programme of redecoration and refurbishment continues. The residents benefit from a clean environment. Evidence: We had a look around most areas the home. The home is divided up into four units over three floors. The ground floor Discovery Suite has fifteen beds and provides care for people with nursing needs and dementia care, and may include people with early onset dementia, and so can include a wide variety of ages. The first floor Permain has thirty beds and provides care for older people with nursing and dementia needs. The second floor has two units (Russet and Pippin) of fifteen beds each and offers nursing care. The dementia care units are fitted with keypad locks to keep people safe. The home employs a full time maintenance person and there is now a planned programme of routine maintenance. The maintenance programme identifies the areas that need work and how and when this is going to be done. Some carpets have been replaced on one of the units. We saw that there is new linen, blankets and towels and Care Homes for Older People Page 26 of 39 Evidence: the laundry person now has a monthly budget to make sure that all laundry is replaced when needed. The expert reported that she was able to speak to and observe the cleaners at work. She said, They were friendly and helpful. They were very good with residents with a bright cheery manner which the people responded to. The corridors were clean and free from odours and the bedrooms were large and airy. She was told that more cleaning staff are being recruited. The experts overall observations was that Applecroft provided a good environment which was clean and generally well maintained in all areas. In all the units there is space to move around. It is fully accessible throughout for people with physical disabilities. There are single rooms with en-suite rooms available for everyone. Each unit has its own communal lounge. The two units upstairs have separate dining areas. People told us that they are always warm. The garden area at the back of Discovery suite has now been attended to and is a pleasant place for people to spend time in when the weather is good. The expert told us that a sensory garden has been developed and this is an excellent facility, especially for people with dementia needs The laundry facility is sited well away from any food preparation areas and soiled laundry is placed in dissolvable bags and all laundry is washed appropriately to clean and control the risk of infection. Policies and procedures are in place in relation to the control of infection, including the safe handling and disposal of clinical waste, dealing with spillages and provision of protection clothing. Evidence of this was seen during the inspection. Residents said that the laundry service was good and they had no complaints. At the last visit the home did not have any extractor fans in the en-site bathrooms and relied on passive ventilation. Concerns had been raised by relatives about the odour in bedrooms. At the time of this visit four fans have been replaced and the remaining sixteen were being done gradually and timescales are in place for this work. People have the necessary aids and equipment to assist them in maximising their abilities and improving their comfort and health. These including pressure relieving equipment, specialist chairs, walking frames and wheel chairs. Care Homes for Older People Page 27 of 39 Evidence: Care Homes for Older People Page 28 of 39 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is enough staff on duty to enable people to receive an adequate level of care and support. There are some limited gaps in the security checks on new nurses and health care assistants. There are some gaps in the training being provided for health care assistants. Evidence: Each of the Units is staffed separately. On Discovery where there are fourteen people currently in residence, there is one Registered Mental Nurse and three health care assistants during the day and the evening. On Permain where there are twenty-three people in residence, there is one Registered General Nurse and five health care assistants. On Pippin and Russet where twenty-two people live at the moment, there is one Registered General Nurse and four health care assistants. Each of the Units has a waking nurse and waking health care assistants on duty at night. In addition to these members of staff, there are other people such as housekeepers, people who work in the kitchen, laundry staff and the two part time activities coordinators. There are several nurses and health care assistant posts vacant at the moment. The Manager says that she hopes to recruit to them soon. In the interim, vacant shifts are being filled with people doing overtime or by agency staff. These latter people are not employed directly by the Registered Provider. They are brought in to work shifts as and when they are needed. Care Homes for Older People Page 29 of 39 Evidence: The Manager said that the service is adequately staffed given the number of people in residence and given their needs for nursing and personal care. One nurse/health care assistant said, overall, the staffing levels are very tight. There is a sense of staff having to rush a bit and if someone is unwell or needs extra care, this can quickly put a real strain on the staff team in that particular unit. This is particularly the case on Discovery. We always seem to have only just enough care staff to do the basics. We manage, but only just. Someone else said, I think we have enough staff on Discovery to get things done, sure its hard work but there are always three health care workers on duty. Ive never known the number go below this. When we were in the Service we looked for direct evidence that might give us a clue to how well the place is being staffed in practise. The call bell sounded on several occasions and each time it was answered promptly. On Discovery, people who needed it were given individual assistance to eat their lunch. People were also promptly supported to leave the main lounge when they wanted to use the toilet. However, there were periods of time when the nurse and the health care assistants were busy doing other things. This resulted in people being left to their own devices. On several occasions this ended up with several people walking about without any apparent purpose. These occasions often resulted in misunderstandings and conflicts as people bumped into one another or went too close to someone. Health care assistants then had to quickly leave what they were doing to intervene and prevent the situations from escalating. The Registered Provider is required to complete a number of security checks on new nurses and health care assistants. These include things such as confirming their identity, taking up references and doing a police check. This is done to make sure that they are trustworthy people to work in the home. We looked at the checks that have been completed for two nurses and two health care assistants. The records showed that the checks have been completed correctly. New nurses and health care assistants receive introductory training before they work on their own. The records show that the subjects they cover include how to assist people to safely move about, infection control, fire safety and general health and safety. One health care assistant says, when I started I was shown around and I did get quite a lot of training about how things work and about my job. I worked with someone first until I was more confident and knew what to do. I was given time to settle in. Care Homes for Older People Page 30 of 39 Evidence: There is also ongoing training for both nurses and health care assistants in a number of core courses. These include things such as first aid, food hygiene, dementia care and safeguarding people who may be vulnerable to abuse. We looked in detail at the training courses that four health care assistants have done. Most, but not all, of their training is up to date. One health care assistant says, I was a nurse (overseas) and so I have had a lot of training over the years. Still I have done a lot of courses since I have worked here. I have done things like the care plans, how to lift people, how to stop cross infections and how to protect people from bad things happening. Another health care assistant says, I have learnt quite a lot from the training and I was told the other day that there is more to come quite soon. There are forty-three health care assistants employed in the Service. The records show that more than half of them have completed a relevant National Vocational Qualification (NVQ). This Award is designed to further develop health care assistants ability to work jointly with nurses to provide people with the care and support they need. The Manager says that all of the health care assistants will be encouraged to study for the Award. Our observations show that in general the nurses and the health care assistants are adequately supported by the training and guidance they receive to care for the people who live at Applecroft. Care Homes for Older People Page 31 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people live in home that is well managed and it is run in their best interests. Nurses and health care assistants are provided with support and guidance. There are some shortfalls in the quality assurance system but the systems are being developed. People can be sure that their health and safety will always be protected. Evidence: The manager of Applecroft has only been in this position since July 2009 prior to this she was the deputy manager of the home but had only been in this post for a short time. She is a qualified nurse and has began to apply to a local college to start a registered managers award. She is in the process of applying to the commission to become the registered manager of Applecroft. The manager has had training Care Homes for Older People Page 32 of 39 Evidence: regarding the Mental Capacity Act and in Deprivation Of Liberties. She knows what action to take if there are any concerns in these areas. The company have just appointed a deputy manager to support the manager. Since she accepted the post she has made significant improvements in the standards of care given to the people living at the home. There is still a lot of work to do to make sure the improvements continue and are then sustained. The manager is aware of the shortfalls within the home and is working pro-actively to address them. Visiting professionals, staff and residents have told us that the care and the atmosphere at the home has improved. Care has improved and so has the moral of the staff. This has come about because of the endless support of the new manager. The manager shows direction and guidance to the staff team. They said, she is approachable, listens to what they say and acts on it. We have found that the manager is open and transparent. We feel confident that she will continue to improve the service for the people at the home. The Manager says that a number of things are done to quality assure the service that people receive. She says that house meetings are going to be held regularly on Pippin and Russet and on Permain. These will give the people who live there the chance to suggest any improvements they might like to see. These meetings are still in their early days and to date only one has been held. That was on Permain and the records show that various people suggested a number of developments. There is evidence to show that some, but not all, of the suggestions have been implemented. The former Manager invited relatives to complete a questionnaire about the Service. The records show that a copy of the results was sent to all of the head of department. This was so that they could prepare an action plan to deal with any issues relating to their section. The action plan was not done and there has been no other organised follow up to the questionnaires. More recently, the current Manager has asked the people who live in the home to complete a questionnaire. The subjects covered include the quality of the care provided, the adequacy of the meals and the suitability of the activities offered. Only twenty -one people chose to complete the questionnaire. The Manager says that she Care Homes for Older People Page 33 of 39 Evidence: will think about how more people in the future can be supported to take part. Following the concerns raised in the safeguarding meetings we asked the new manager to complete weekly audits and send them to us. This meant that she was able to monitor and tell us about the improvements and events that were happening at the home. This demonstrated that she was keeping a close eye on things to make sure that people were receiving the care and support that they needed and that things were improving at the service. She told us that she plans to continue this practise although she is no longer required to submit these to the commission. A senior manager appointed by the Registered Provider calls regularly to the service to see how things are going. Once a month he completes a formal audit of things such as the individual plans of care and support, fire safety and health and safety arrangements. The records of these audits show them to be a thorough and organised evaluation of how things are going. There is evidence that any problems the audits identify are corrected. The manager and two administration staff look after personal allowance monies. Each person has a detailed record in place and their cash is kept in individual bags securely. Statements are given to relatives or representatives when money is exchanged. When the organisation representative visits the premises on a monthly basis a random check is made on the finances to confirm everything is in good order. If they are able the people who live in the home are encouraged to sign for their monies and be involved in their finances as much as possible. Receipts for all transactions are in place. There is a system whereby each nurse and each health care assistant meets regularly with someone senior to discuss their work. This means that they can talk through any work problems they may have. The staff told us they now feel supported by management. Staff told us they now get the guidance they need to do they jobs well and develop their knowledge and skills. There had been problems with the former management notifying the commission about untoward events, but the new manager has been quick to both tell us about events and what she is doing to resolve them. At the last inspection fire drills had not been carried out and a requirement was made. This has now been addressed. Records show that the most recent fire took place on 7th October 2009. All other fire safety checks have been done. The records now show Care Homes for Older People Page 34 of 39 Evidence: that there are fire drills and all members of staff have regular fire training. This is important because the level of protection largely depends upon members of staff doing the right thing at the right time if there is a fire safety emergency. There are up to date reports from engineers about the gas appliances, the wiring installation, the passenger lift and the mobile hoists. The manager told us that all safety checks have been done and everything is in good working order. Care Homes for Older People Page 35 of 39 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 36 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 12 All the assessed health care needs of the residents need to be identified and met. Care plans need to be followed by the staff who are giving care and support. To ensure that proper provision is made to meet the health and welfare needs of the residents. Regulation 12 of the Care Homes Regulations 2001 requires you promote and make proper provision for the health and welfare of service users. Failure to comply with this regulation is an offence. 31/12/2009 Care Homes for Older People Page 37 of 39 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 Care Homes for Older People Page 38 of 39 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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