Care Home: Apthorp Lodge

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What the care home does well When we spoke with residents and asked them what the service does well they told us that "it`s good living here", "the staff are all friendly", "the staff are kind and caring" , "it`s alright to live here" and "I saw other care homes....I can please myself here". Comments on survey forms completed by residents included " They try their best to meet my needs", "the staff look after me very well" and "they try their best to make me feel at home because I was terrified when I came here from hospital but I found out that this place feels like home". When we asked staff what the home does well they told us that they "ensure that the residents are given choice", "give the best possible care", "considering individual needs" and "caring about the residents, their well being and their quality of life". A health care professional said that the home is slowly improving by staff developing good relationships with residents and taking more responsibility for residents` health care needs. In service training is now more evident. What has improved since the last inspection? Residents have benefited from the improvements to the physical environment both inside and outside the home that have taken place and these have included redecoration of vacant bedrooms, a change to the layout of the entrance hall, new furniture in some of the units and raised flower beds in the grounds. Improvements in the staffing structure within the home have taken place. There are now 2 deputies in post so that carers benefit from support from a strengthened management team. Posts of senior carers have been filled and the appointment of an activities co-ordinator for dementia care residents has complimented existing opportunities for residents on the frail elderly units. What the care home could do better: Thirteen statutory requirements have been identified during this inspection including 4 in respect of the handling and administration of medication. Care and attention is still required to ensure the safety and well being of residents in this area. Although the new care plan format has been developed some residents are still to have a review and update of their care plan and it is important that the quality of the recording is consistent to ensure that there is sufficient detail to guide staff in providing a good quality service. Attention in respect of residents at risk of developing pressure sores is needed with care plans being reviewed to ensure that appropriate intervention is recorded. A dementia care training programme for carers that builds on the basic awareness training has been developed and this needs to be rolled out to all members of staff so that residents benefit from the increased knowledge, understanding and skills of the staff supporting them. Staffing levels overall need to be kept under review as currently the care home has a vacancy rate of approximately 20% and even if the home were to be full the notional staffing level would not increase significantly.There is an individual incident where odour control systems are not effectively managing a situation. Other systems or methods may be required so that the resident has a pleasant environment. Residents meetings must be arranged and take place on a regular basis so that this opportunity for residents to give feedback and to influence the development of the service is not neglected. When a lapse in following procedures is identified remedial action must be checked and monitored to ensure that staff have understood what is expected of them and that they are then carrying this out. Although compliance with Statutory Requirement Notices has now been achieved it was not achieved within the timescales specified for the first 3 notices, hence the need for further enforcement action. Non compliance affects the safety, welfare and well being of the residents and a poor outcome for residents remains until compliance is achieved. Key inspection report Care homes for older people Name: Address: Apthorp Lodge Nurserymans Road off Brunswick Park Road London N11 1EQ     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: Julie Schofield     Date: 0 7 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 38 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 38 Information about the care home Name of care home: Address: Apthorp Lodge Nurserymans Road off Brunswick Park Road London N11 1EQ 02082114000 02082114109 manager.apthorplodge@fremantletrust.org www.fremantletrust.org The Fremantle Trust Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Janet Ann Lovett Type of registration: Number of places registered: care home 108 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia learning disability old age, not falling within any other category Additional conditions: Care Home only - Code PC to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP (maximum number of places:102), Dementia - Code DE (maximum number of places: 102), Learning Disability - Code LD (maximum number of places: 6) The maximum number of service users who can be accommodated is: 108 Date of last inspection Brief description of the care home Apthorp Lodge is a large care home registered to provide care for 108 residents. The registration for the service allows care to be provided to older people, people with dementia and adults with learning disabilities. There are 50 places for people with Care Homes for Older People Page 4 of 38 Over 65 102 6 102 0 0 0 0 6 1 1 2 0 0 9 Brief description of the care home dementia, 52 places for older people and 6 places for people with a learning disability. The home is a large detached three-storey building. It is purpose built and organised on three levels, with lift access to all floors. It is divided into ten units or flats. Four units are dedicated to residents who have dementia and one unit to service users who have learning disabilities. The remaining five units are for mainstream services for older people. People with dementia can also be accommodated in the mainstream units if this is where their needs can most appropriately be met. There is a kitchen, lounge and dining room in each flat. All bedrooms are single with en-suite facilities. There is also an additional assisted bathroom in each unit. There is a car park to the side of the building and gardens to the side and rear, which are partly paved and accessible to the residents. The home is situated off Brunswick Park Road. It is well served with community services and facilities located along Russell Lane and East Barnet Road. The home has a day centre, which provides services to twenty-six service users specifically from the outside community. Information about the service and about the fees charged may be obtained, on request, from the manager of the home. Care Homes for Older People Page 5 of 38 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The inspection took place over 2 days in May 2010. On the 4th May the lead inspector was accompanied by another inspector and by a pharmacy inspector. The visit began at 9.45am and finished at 6pm. The lead inspector returned on the 7th May and the visit began at 10.20am and finished at 4.30pm. During the inspection we checked compliance with statutory requirements identified during the key inspection in November 2009 and the random inspection in March 2010. We case tracked the care of residents and referred to policies and procedures. We examined records, including those belong to staff and those associated with the running of the home. We looked at the handling and administration of medication. We looked at the handling of residents finances. We carried out a site visit and we saw the serving of the midday meal. We observed care practices. We spoke with the manager, deputy managers, members of staff and with residents. We would like to thank everyone for their assistance and comments during the inspection. Care Homes for Older People Page 6 of 38 Prior to the inspection we sent survey forms to the home to distribute on our behalf. We would like to thank the people that completed survey forms and returned them to the Care Quality Commission. Care Homes for Older People Page 7 of 38 What the care home does well: What has improved since the last inspection? What they could do better: Thirteen statutory requirements have been identified during this inspection including 4 in respect of the handling and administration of medication. Care and attention is still required to ensure the safety and well being of residents in this area. Although the new care plan format has been developed some residents are still to have a review and update of their care plan and it is important that the quality of the recording is consistent to ensure that there is sufficient detail to guide staff in providing a good quality service. Attention in respect of residents at risk of developing pressure sores is needed with care plans being reviewed to ensure that appropriate intervention is recorded. A dementia care training programme for carers that builds on the basic awareness training has been developed and this needs to be rolled out to all members of staff so that residents benefit from the increased knowledge, understanding and skills of the staff supporting them. Staffing levels overall need to be kept under review as currently the care home has a vacancy rate of approximately 20 and even if the home were to be full the notional staffing level would not increase significantly. Care Homes for Older People Page 8 of 38 There is an individual incident where odour control systems are not effectively managing a situation. Other systems or methods may be required so that the resident has a pleasant environment. Residents meetings must be arranged and take place on a regular basis so that this opportunity for residents to give feedback and to influence the development of the service is not neglected. When a lapse in following procedures is identified remedial action must be checked and monitored to ensure that staff have understood what is expected of them and that they are then carrying this out. Although compliance with Statutory Requirement Notices has now been achieved it was not achieved within the timescales specified for the first 3 notices, hence the need for further enforcement action. Non compliance affects the safety, welfare and well being of the residents and a poor outcome for residents remains until compliance is achieved. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 38 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 38 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. Information about the home helps prospective residents make an informed choice about its suitability. Rolling out a dementia care training programme will develop the skills and understanding of carers. Evidence: We looked at the copy of the Statement of Purpose and the Service Users Guide that were on display in the entrance hall of the care home. Since the last key inspection the acting manager has been appointed to the post of manager. We noted that the documents had been reviewed and updated and that the new managers details had been included in the documents. The service users guide was very informative and contained photographs. We were told that it can be provided in a large print format and that it can also be translated into a different language, depending on the need of the prospective resident. The manager said that a copy of the guide is also placed in each residents bedroom. Care Homes for Older People Page 11 of 38 Evidence: When we surveyed people living in the home we asked whether they had received enough information to help them to decide if this home was the right place for them, before they moved in and they agreed that they had. We asked whether they had been given written information about the homes terms and conditions and they agreed that they had. Since the last key inspection in November 2009 the Care Quality Commission has issued a Notice of Decision in which new admissions to the care home have been prohibited. This was effective from the 5th March 2010. We reviewed a statutory requirement identified during the last key inspection. This was in respect of the service provided to residents with learning disabilities. The requirement stated that contact must be made with the local authority to request copies of the minutes of review meetings that were held in March 2009 for residents of Harbour Lodge unit. It was important to have a record of agreements reached and targets set so that the home could monitor whether the service provided was in accordance with the needs of each individual resident. The manager is now in receipt of both the 2009 and the 2010 review meeting minutes and is reviewing the impact of decisions reached and responding to these. We also discussed the dementia care training programme as a statutory requirement had been identified in relation to this during the 2009 key inspection. The manager and deputy manager are building on the basic awareness training that forms part of the induction training programme. They will deliver training that incorporates the Alzheimers Societys Tomorrows Another Day. One training course was taking place during the week of the inspection and the next course was due to take place 2 weeks after this. There are 8 places on each course and the manager has given priority to members of staff working on the dementia care units, although in time the training is to be rolled out to all members of staff. When members of staff were surveyed a person commented, when asked what the home could do better, more appropriate and adequate training is required for all members of staff who care for or engage with dementia care residents. The care home does not provide an intermediate care service. Care Homes for Older People Page 12 of 38 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. Not all residents are assured of a comprehensive care plan as implementing the new format is incomplete. Planned intervention would encourage more active pressure relief. Although systems for managing medication have improved, residents need to be confident that safe systems are consistently maintained. Discreet and caring support is given so that the privacy and dignity of the resident is respected. Evidence: We discussed the 3 statutory requirements in respect of care plans that were identified during the previous key inspection. The process of introducing the new care plan format is still underway, although we were told the new care plan format has been completed for approximately 60 of residents. The operations manager who was present for part of the inspection confirmed that the timescale for completing this task is the end of June and the manager assured us that they were on target to meet this timescale. She has told the staff team that the updating of care plans is not a copying process so changes in the likes or dislikes of a resident will be reviewed and amended, as necessary. The training for senior staff as part of the launch of the new format went ahead at the end of 2009 and the senior staff have cascaded this Care Homes for Older People Page 13 of 38 Evidence: information to their team of carers. No mental capacity assessments have been carried out so far. When we looked at care plans that had been completed using the new format we noted that the quality of the recording varied. We saw an excellent example of an informative care plan that readily gave the reader a comprehensive insight into the needs of the resident. We saw other new care plans that contained brief comments and which needed more detail to evidence a person centred approach. We shared these comments with the manager during the inspection and recommended that the excellent example be used as a training tool. Case files containing information regarding access to health care services were viewed. We saw that appointments had taken place on an out patient basis at the local hospital. We also saw that residents had attended appointments with their GP, the optician, the dentist and the chiropodist. Residents had also had the opportunity to have a flu jab, if they wished. An dentist was visiting the home on the second day of the inspection. When we surveyed social and health care professionals we were told that the home could provide more active pressure relief as residents are often sitting in one position for most of the day, also at night the home is not very pro-active. During the inspection we met a resident who had their foot bandaged as a pressure ulcer had flared up again. The manager said that the protocol was that they referred concerns to the District Nurse. A complaint had been received by the CQC, since the last key inspection, which concerned the action(s) taken by the home after a resident had a fall and sustained a small cut on their forehead. Later that day they were taken to hospital after being found in their room, unconscious. At a meeting that was held to discuss this, where the local authority and the CQC attended, it was agreed that the policy of the home would be amended so that in future any accident or fall that resulted in a head injury would automatically result in calling for an ambulance. A pharmacist inspection was carried out at the same time as the key inspection to assess the safe handling of medication following previous concerns and the issue of four Statutory Requirement Notices (SRNs) and a Notice of Decision to prohibit new admissions to the home. An application has been made by the home for the removal of the Notice of Decision and this restriction. We looked at medication storage, recording and administration of medication in all the flats in the home. We looked at the daily checks of the Medication Administration Records (MAR), the stock checks and Care Homes for Older People Page 14 of 38 Evidence: audits the managers had put in place to improve the safe handling of medication in the home. We observed medication being administered to one service user and noticed that it was given with reassurance and professionally. The MAR was signed prior to the medication being given however, which is not the practice detailed in the homes medication policy. In one flat, it was the second day of a new medication cycle and we observed that there was no stock available for one service user for one of their morning medicines. We were shown a fax ordering the medicines for this service user from the GP, and we saw on the prescription issued the same day that this item was missed off the prescription. It was five days however before it was identified- a non working day the afternoon before the medicine was due to be given. For another service user in another flat there was no stock for one medicine for three days at the beginning of the medication cycle. We noticed that the improvements in recording receipts and administration of medication on the MAR were generally being maintained. We did notice overall three gaps in recording administration. One was for an antibiotic and when we audited the stock held, the count supported the view that one tablet was not given. For another two medicines in a monitored dosage unit the tablets had been removed so we assumed they had been given but not signed for. We audited a total of 50 samples of medication and had difficulty in reconciling a further 8 of these. For two the medicine had been discontinued, temporarily in one case, but this was not documented on the MAR. For two service users prescribed the same tablet, stocks had been confused. For three medicines for the same service user the amount carried forward was not correct. We counted an iron tablet for one service user and found one too many suggesting that one had not been given but signed as given. We saw that there was an improvement in accurately recording variable doses but noticed that for a liquid, prescribed two or three spoonfuls, there was no accurate record. Several service users were prescribed as required medicines for helping with their behavior. We saw a corporate policy for giving these medicines but there were no individual protocols indicating how and when they should be given, as suggested in the policy. One service user was prescribed an anticoagulant and we were unable to find evidence Care Homes for Older People Page 15 of 38 Evidence: of the current prescribed dose because the record book had been sent to the clinic with a blood test. Another resident was prescribed as required pain relief but a care worker recorded no stock when there were three boxes available in the spare stock cupboard. We looked at the controlled drugs and the storage. All were secure and balances inspected were all correct. We looked at the daily checks of the MAR, the daily stock checks and the weekly audits the managers had put in place. Audits and stock checks were complete and rigorous in some flats. In others there were gaps in the MAR checks and in two flats stock checks had ceased completely for two weeks. There was no weekly management audit for the week prior to the inspection w/c 24/4. The manager had identified the issue with the stock checks and a meeting with team leaders was already planned for the day of the inspection. The waste records were available for inspection and we could see that all waste was now being recorded. We discussed privacy and dignity with residents and they confirmed that these were respected when carers assisted them with personal care tasks. A female resident confirmed that women bathe us and another residents told us that staff are willing to help us. During the inspection we saw that assistance was offered by carers in a manner which was discreet and tactful. We noted that members of staff used the term of address preferred by the resident and the preferred term of address was noted in the care plan. The manager pointed out that one gentleman preferred the use of his surname, without the prefix of Mr. There was a good rapport between residents and members of staff. Care Homes for Older People Page 16 of 38 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. A programme of activities provides residents with opportunities for stimulation and enjoyment. Visitors to the home are encouraged so that residents enjoy the company of relatives and friends. There are opportunities for residents to exercise choice in their daily lives. A varied and wholesome diet meets the residents nutritional needs. Evidence: We met and spoke with the newly appointed activities co-ordinator for the dementia care units and for Harbour Lodge unit. We discussed her plans for supporting dementia care residents and had the opportunity to see her ideas put into practice. Much thought had been given to ensure that activities were appropriate to the understanding of these residents and providing ones in which the residents may wish to participate. A statutory requirement identified during the previous key inspection highlighted these needs. We also spoke to the activities co-ordinator supporting the frail elderly residents. We discussed the programme of activities that was in place and when we spoke with residents they told us about bingo sessions, crosswords, a film session, singsongs and entertainers. We were told that another casino night had taken place recently and that there were plans to have a farm day in the home again this summer. When we Care Homes for Older People Page 17 of 38 Evidence: spoke with residents a resident told us about the animals visiting the home last year. We saw that good use is made of the outside space and that, weather permitting, meals are taken outside on the balcony decking areas. We surveyed residents and asked them if the home arranges activities that they could take part in, if they wished. They told us that it usually or always did although one resident commented that the home could take us out a bit more on outings. When we spoke with one resident they said that that there used to be monthly outings but pub lunches did not appeal to them. They thought that things would improve when the weather improved. A member of staff commented, when surveyed, that the coffee mornings for residents that are held on 3 mornings a week are very successful but that they would like the care staff to do more with the residents. We noted that residents have access to a hairdressing services within the home and saw that residents looked smart after their visits. The spiritual needs of residents were discussed with the manager. Residents are able to observe their religious practices and a priest visits the home on a monthly basis and holds a mass for Catholic residents. There is also an Anglican service that is held in the home on a regular basis. Volunteers from the church organise and operate a trolley that visits each unit so that residents can buy small personal items. Residents told us that their visitors were made welcome when they arrived at the home and that residents could either entertain visitors in their own room or in the communal areas. They confirmed that visitors are offered refreshments. A resident told us that they could refuse to see a visitor, if the visit was not welcome. When we surveyed residents we asked them if staff listen to them and act on what they say and they agreed that they did. When we spoke with the person dealing with residents finances, if they need support, she confirmed that where possible, relatives helped residents with their finances, if the resident was unable to continue to handle their own financial affairs. There is information in the home about advocacy services and a member of the service has been invited to attend the next residents meeting to introduce themselves to residents. An arrangement has been made for an advocate to support a resident who has capacity but lacks communication skills. We noted when walking around the home that some residents have brought with them ornaments, pictures and photographs and small items of furniture to personalise their rooms and to make them more homely. When we spoke with a resident in Harbour Lodge he told us about his involvement in the choosing of the colour scheme when the unit was redecorated. Another resident told us that they can choose what time they wish to go Care Homes for Older People Page 18 of 38 Evidence: to bed and this resident told us that she chooses to go to bed early. A male resident told us that he goes to bed at midnight. During the inspection we saw the serving of the midday meal on one of the units in the home. We noted that residents wanting to sit in the dining area for their meal had the choice of a number of small tables that were attractively set for the meal and where a menu had been placed on the table. Residents may choose to take their meal in their room, if they prefer. Lunch consisted of fried fish or steamed fish in a sauce. It was served with a choice of mashed or chipped potatoes and peas or baked beans. Vegetables were placed in dishes on the table so that those residents able to serve themselves were able to do so. Residents needing assistance with feeding were offered choices as the carer placed food on the plate. We noted that when a carer saw that a resident was not eating very much the carer went to sit beside the resident to offer support and encouragement. The main dessert consisted of apple and raspberry tart with ice cream. When we looked at the menu we noted that alternatives were listed so that a resident could select an different meal if the main meals on the menu did not appeal to them. A resident confirmed that they had selected alternatives and one resident that was surveyed commented that if I am not happy with the meal they order something that I like. We saw that the home has a rolling menu and that that the meals listed on the menu provided a varied and wholesome diet. The home has been awarded a 5 stars score on the door by the local authority environmental health department for its food hygiene standards. Care Homes for Older People Page 19 of 38 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. A complaints procedure is in place to protect the interests of the residents. Protection of vulnerable adults training for staff promotes the welfare and safety of residents. Evidence: There is a complaints procedure in place, which includes timescales for the procedure and that makes reference to the regulatory body, with contact details. A statutory requirement was identified during the previous inspection that a comprehensive record of complaints must be maintained because there were none recorded during a 9 month period. We noted during this inspection that full records are now kept and that since the start of 2010 a total of 4 complaints have been recorded. We looked at these and were satisfied that appropriate follow up action had been taken, where required. We noted that in each case an investigation had taken place and that the outcome of the investigation and details of any follow up action were relayed to the complainant. The summary sheet at the front of the book identifies each complaint with a reference number and this makes it simple to check back to individual complaints. The summary sheet also allows the manager to monitor complaints received to detect any patterns or significant features. When we surveyed residents they told us that there was someone they could speak to informally if they were not happy and that they knew how to make a formal complaint. We discussed the issue of safeguarding with the manager. She said that 1 Care Homes for Older People Page 20 of 38 Evidence: safeguarding referral has been made to the local authority since the last key inspection in November 2009. The police have taken the role of investigating officer and the member of staff is suspended, pending the outcome of the investigation. Training in respect of safeguarding is mandatory for carers and when we surveyed carers and asked whether they knew what to do if someone has concerns about the home 5 of the 6 carers ticked yes. Care Homes for Older People Page 21 of 38 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. Residents live in a home that offers comfortable and homely surroundings. Residents are satisfied with bedrooms that have en suite facilities. Odour control systems are not always effective. Evidence: During the inspection we carried out a site visit. The building is large and consists of 3 floors, ground, first and second. There are 10 separate units or flats, nine of which are known by a number but the unit for residents with learning disabilities has been named Harbour Lodge. The choice of name was made by its residents. The layout of the entrance hall has been altered and the large desk removed and comfortable seating etc put in its place. This is an area that residents and their visitors now like to use. Access to the building has also been reviewed so that visitors do not have to wait unduly after ringing the bell to gain admittance. We noted while walking around the home that areas were comfortably furnished and provided a homely environment for the residents. Each flat had lounge and dining areas that were sufficient in size for the number of residents. There were also activity rooms on some of the units and in corners along corridors there were small seating areas where residents looking for privacy of for peace and quiet could enjoy. We reviewed odour control measures in the home and noted that areas where there Care Homes for Older People Page 22 of 38 Evidence: had previously been an odour of urine were now odour free. However 1 of the bedrooms still has an odour of urine and we commented on this when the manager showed us around the home. We noted that vacant bedrooms had been redecorated and that the chairs in the lounge where smoking is permitted, that were worn and stained, have been replaced. We also noted the colourful new furniture in Harbour Lodge, again chosen by the residents. When we spoke with residents we asked them about the home and in particular asked about their individual accommodation. One resident told us that they had a good bedroom. Another resident said that they had a nice room and their own armchair. Residents were appreciative of en suite facilities. We noted walking around the home that bedrooms, which are all single rooms and contain en suite facilities, were of a good size. Since the last key inspection the care home successfully applied for a capital grant from the local authority and has installed 3 raised garden beds. The path around these is sloping so that the height of the raised garden bed is suitable for residents in wheelchairs on one side and for those not wishing or able to bend over on another side of the box. A greenhouse has also been built and plans to grow soft fruits, salad items and vegetables are in progress. The outdoor space available to residents is pleasantly arranged and there are also balcony decking areas. When we spoke with residents they told us that the home was very clean. A resident said that they go over her room every day. Training in infection control procedures forms part of the induction and refresher training programme for carers. Laundry facilities consist of commercial appliances and there is a system of marking clothing with a button that is attached to an item of clothing, in a discreet position. A device reads the button at the end of the laundry process and the name of the resident owning the item of clothing appears on the screen. Care Homes for Older People Page 23 of 38 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Keeping staffing levels under review assures residents that their needs and preferences continue to be met. Residents benefit from support by staff that have developed their understanding and awareness through NVQ training. Recruitment procedures promote the safety and welfare of residents. Members of staff have access to a programme of training to develop skills and knowledge. Evidence: At the time of the inspection there were 21 vacancies. We discussed staffing levels with the manager. She told us that only minor changes have been made to overall levels and that most units have retained their staffing levels even though there may be vacant beds in the unit. The only reductions have been on units 2 and 6. Current levels consist of 20 members of staff covering 10 individual units. Each day they are supported by a senior member of staff who takes on the role of the duty officer. This is in addition to the deputy managers and the manager, who may or may not be on duty. At night there are 7 carers and a duty officer undertaking waking night duties. The dementia care units are each allocated a carer while other units may share a carer. These are minimum staffing levels but the impact of the level of cover was not fully apparent due to the high number of vacancies i.e. nearly 20 of the total number of beds in the home. Concerns had been expressed in relation to Harbour Lodge unit at Care Homes for Older People Page 24 of 38 Evidence: recent review meetings. However, staffing levels in Harbour Lodge have now been reinstated and when we talked to a resident that relies on the support of a member of staff to go out to the local shops etc recent problems with one of his feet had caused him to prefer to remain in the home until the pain that he was experiencing passed. When we spoke with residents, a resident told us that there were not enough staff for their unit (which was not full) and that staff came from upstairs. When surveyed residents said that staff were available when they needed them. The operations manager contacted the companys head office during the first day of the inspection and received confirmation of the current percentage of carers that hold either an NVQ level 2 or level 3 qualification. The figure supplied to the CQC was 58.7 of carers holding either an NVQ level 2 or level 3 qualification. The manager said that currently there are 3 carers undertaking their NVQ level 2 training and that a further 3 members of staff were to enroll shortly. We looked at 6 staff files when we reviewed recruitment practices. We noted that each file contained an application form, passport sized photograph and 2 satisfactory references. The application form process included a declaration by the applicant regarding any criminal convictions or cautions and there was a health declaration. Files contained evidence of an enhanced CRB disclosure or a pova first check if the CRB was still to be returned. The manager confirmed that in these circumstances the member of staff worked under supervision and did not provide assistance with personal care on their own. Proof of identity was in the form of passport details and where necessary, the right to work or to reside in the UK had been established. Appointments are made subject to a satisfactory probationary period and there was evidence of formal reviews being carried out and recorded during the probationary period. When we surveyed members of staff we asked whether their induction covered everything that they needed to know to do the job when they started. Three carers told us mostly and 3 carers told us very well. We then asked the carers if the training that they have received since their induction has been relevant to their role, helps them to understand and meet the individual needs of the residents, keeps them up to date with new ways of working and gives them enough knowledge about health care and medication. Most people ticked yes to each part of the question although one person ticked that it was not relevant to their role and another carer ticked that it did not give then enough knowledge about health care and medication. During the inspection we discussed training with the manager. The company has a Care Homes for Older People Page 25 of 38 Evidence: training department that is based at head office. At present there is a 6 day corporate induction training programme that includes 1 days manual handling training. This is then followed by a 2 day in house induction and then a period of approximately 8 days where the new carer shadows an experienced carer. There is an annual programme of training and the home is waiting for details of the 2010-11 programme. The programme includes mandatory training e.g. manual handling, safeguarding of vulnerable adults (sova), infection control etc. It also includes optional training e.g. Parkinsons, strokes, continence care etc. The programme is designed for staff in all roles in the home and managers training includes customer service, recruitment, risk assessment etc. At the moment there are managers in the home that have completed train the trainers courses to enable them to deliver manual handling training or sova training. We asked about training for supporting adults with learning disabilities and the manager said that this is organised by the local authority and that a course had taken place recently. Many of the training records are held on the computer system and the manager demonstrated these. We saw the training matrix and noted that a record was kept of the date on which a member of staff attended a particular training course. We were told that the system flags up when the next refresher training is due. The records are used to prompt head office in terms of the types of training needed and the number of places required. The operations manager monitors the matrix. Care Homes for Older People Page 26 of 38 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents have benefited from the recent appointment of the new manager to the home. Although improvements have been made, residents health and wellbeing have been put at some risk through continued non compliance with regulations relating to medication. A lack of residents meetings denies residents the opportunity to give feedback on the quality of the service. The financial interests of residents are protected. Appropriate supervision of staff would ensure that procedures are being followed. The testing/servicing of equipment in the home assures residents and staff that it is safe to use. Evidence: Since the last key inspection the acting manager successfully applied for the permanent post of manager and was in the process of applying to the CQC to be the registered manager. (Subsequent to the inspection she was approved as the registered manager by the CQC). She has recently completed the RMA and will register for the Leadership and Management qualification. There are also now 2 deputy managers with clearly defined roles and they are providing management cover Care Homes for Older People Page 27 of 38 Evidence: in the home at weekends. The manager holds regular meetings with heads of departments. When we surveyed social and health care professionals they told us that the new leadership is having a positive effect. When we surveyed members of staff working in the care home we asked them if their manager gives them enough support and meets with them to discuss how they are working. Four people ticked regularly and 2 people ticked often. One person added the new management will make a difference. However, after the last key inspection in November 2009 a Statutory Requirement Notice (SRN) was issued in respect of failings in the administration and recording of medication. A random inspection took place in January 2010 to check compliance. The inspection identified non-compliance and a further SRN was issued. A Notice of Decision was then issued which prohibited the admission of any new residents to the home because of the concerns regarding medication. A random inspection in March took place and although the home had made progress and was deemed to be compliant with the SRN further statutory requirements in respect of medication were identified in the report. The CQC is concerned that a total of 4 SRNs were issued in respect of medication (2 were issued prior to the November 2009 inspection and 2 were subsequent to the key inspection). Regular monitoring of practices, thorough quality assurance systems and robust auditing would have resolved this matter more quickly. A statutory requirement was identified during the last key inspection in relation to the quality of the report format for Regulation 26 visits. We viewed the report for the most recent Regulation 26 visit. We were pleased to note that an appendix had been added, where compliance with the statutory requirements and outstanding statutory requirements was checked during the visit. The manager told us that the format of the report is under review in light of the need for compliance under the new legislation. We looked at other quality assurance measures in place. We saw a copy of the Home Selection questionnaire sent out by head office after a new resident is admitted. The form includes both questions and space for recording suggestions. Everyone in the home was invited to take part in a questionnaire about cultural issues and whether cultural needs are met. Questionnaires are also sent to residents and to staff to obtain feedback and quarterly themed audits or the home are carried out. Information from all audits and questionnaires is analysed at head office and feedback sent to the home, with a quality rating. When we asked about residents meetings, as a resident had told us that they hadnt happened for some time, the manager told us that they had slipped of late because they were concentrating on the medication but the meetings had restarted again. Care Homes for Older People Page 28 of 38 Evidence: The pharmacy inspector noted that stock check forms, an audit tool, had not been completed in 2 of the flats and this was discussed with the manager. We were told that the deputy manager had identified this during the week prior to the inspection and had spoken to the members of staff concerned. However, the forms were still not being completed during the inspection. We examined residents finances and spoke with the person who is responsible for this. She told us that a person at head office is the appointee for approximately 10 of the residents. Within the home each resident has a financial record. Residents receiving support from the home with handling their finances are able to draw all or part of their weekly personal allowance, as needed. Where possible the resident signs to acknowledge receipt of the money. Accounts are kept on the computer system and these were demonstrated to us. Each record included a date on which a transaction had taken place, what item had been purchased and the balance remaining. Residents balances at head office are kept in a separate non interest bearing account although if balances are large, independent advice regarding savings accounts can be arranged. Relatives may choose to leave some money to be spent on behalf of a resident while other relatives reimburse items of expenditure after receipt of an invoice. Financial records are subject to random audits and to auditing by a member from head office. A statutory requirement was identified during the last key inspection in relation to the need for regular, recorded individual supervision sessions for carers. Most seniors have now completed a supervisory skills training course and a programme of individual supervision sessions for carers, held every 2 months, has now commenced. In addition to the formal supervision sessions there is a duty officer each day to support the staff team. Full staff meetings are to be held each quarter and staff working together in a unit or flat meet on a monthly basis. Although a discrepancy on the stock check forms in 2 of the flats had been identified and brought to the attention of the members of staff concerned this had continued. More close supervision and monitoring is needed to ensure that staff are compliant with the homes policies and procedures. We spoke with the person who has responsibility for health and safety and for ensuring that the maintenance of the home and of the equipment in the home is carried out. We have previously seen the yearly planner and the monthly lists that he uses to keep track of when servicing is due and he referred to his files during the discussion. There was evidence that there were valid certificates in respect of the testing of the portable electrical appliances, the Landlords Gas Safety Record, the lifts, the fire extinguishers, the fire alarms and smoke detectors, the water supply Care Homes for Older People Page 29 of 38 Evidence: within the home, the hoists and the electrical installation. There were records of weekly fire alarm tests being carried out and regular fire drills taking place. The record of accidents occurring in the home was up to date and contained a monitoring sheet so that trends or patterns could be identified and acted upon. Care Homes for Older People Page 30 of 38 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 31 of 38 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 4 18 The registered person must 01/08/2010 ensure that the programme of dementia care training developed, that builds on the the basic awareness training, is rolled out to all members of staff working on the dementia care units as a priority and then to members of staff working on the other units within the home. This will enable carers to offer support based on a greater understanding and knowledge of the needs of residents with dementia. 2 7 15 The registered person must ensure that the quality of the recording in the new care plans is consistent and of a good standard. This will assure residents that their care plans are comprehensive and that the 01/07/2010 Care Homes for Older People Page 32 of 38 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 support to be provided to meet their needs is clearly identified. 3 7 15 The registered person must ensure that the programme for rolling out the new care plan to each resident is completed. This will assure residents that their individual needs are identified and addressed. 4 8 13 The registered person must review the care plans of residents with pressure sores or those at risk of developing pressure sores and ensure that appropriate intervention is recorded in the plan of care. This will assure residents that appropriate support is given by the home to promote healing or prevention. 5 9 13 The registered person must 01/06/2010 ensure that there are individual protocols for medicines prescribed as required which are agreed with the GP, as suggested in the home medicines policy. 01/07/2010 01/07/2010 Care Homes for Older People Page 33 of 38 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will enable the home to maintain the health and welfare of the service users. 6 9 13 The registered person must 01/06/2010 ensure that there is continued attention given to the accurate recording of receipts of medication, balances carried forward and administration including variable doses such as liquids and warfarin. When medicines are discontinued this must be clearly stated on the MAR . This will enable the home to maintain the health and welfare of the service users. 7 9 13 The registered person must 01/06/2010 ensure that they work with the GP/pharmacist to ensure that service userss medication does not run out. This will enable the home to maintain the health and welfare of the service users. 8 9 13 The registered person must ensure that there is evidence of safe handling of medication throughout the home and that this is maintained through regular robust auditing. 01/06/2010 Care Homes for Older People Page 34 of 38 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will enable the home to maintain the health and welfare of the service users. 9 26 16 The registered person must review odour control systems in the bedroom identified during the site visit and ensure that an effective system is in place. This will ensure that the resident in this room has a pleasant environment in which to relax. 10 27 18 The registered person must 01/06/2010 continue to carry out regular reviews of staffing levels to check that they match dependency levels of residents and allow residents to take part in activities outside the home. Adjustments must be made to staffing levels, as required. This will assure residents that there are sufficient members of staff on duty to meet their needs and respond to calls for assistance in a timely manner. 11 31 24 The registered person must 01/06/2010 ensure that when an area of concern and non compliance 01/07/2010 Care Homes for Older People Page 35 of 38 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 is identified compliance is achieved within the stated timescale. This will assure residents of consistent standards of care that are of a good quality. 12 33 24 The registered person must ensure that residents meetings take place on a regular basis. This will give residents the opportunity to express their views, wishes or concerns and an opportunity to take part in the running of the home and the decision making process. 13 36 18 The registered person must ensure that when a lapse in following procedures is identified this is monitored and checked until there is evidence that the correct procedure is being followed. This will assure residents that the homes procedures are being followed at all times and the safety and well being of the resident is promoted. 01/07/2010 01/07/2010 Care Homes for Older People Page 36 of 38 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 12 That the activities programme is reviewed to ensure that there are sufficient opportunities for residents to take part in activities and outings in the community. That at the next staff meeting the complaints procedure, whistle blowing procedure and safeguarding adults procedures are discussed so that carers are aware of the content of these and their own role within the procedures. That a survey is carried out by the company regarding the range of training provided and the quality of the content of individual courses so that the efficiency and effectiveness of the programme is reviewed and, if necessary, changes are made to the programme and to the content of courses. 2 18 3 30 Care Homes for Older People Page 37 of 38 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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