Care Home: Arden Valley Christian Nursing Home

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What the care home does well Anyone wishing to move to the home has their needs assessed before they move in to ensure that their needs can be met properly. People are supported in a respectful manner and their personal care needs are met. Staff are knowledgeable about the people who use this service. They have a good understanding of their roles and responsibilities. People are supported to gain access to advice from health professionals where they need it so their health needs can be met. People are supported to keep in touch with their families and friends so that they do not lose relationships that are important to them. The service provides daily in-house activities. This provides people who live there the opportunity to participate in their interests and preferences both within and outside of the service. Comments received in surveys include: `Arden Valley is the loveliest place I have worked in, other than staff shortages, I shall stay here happily`. (Staff) `Rooms are very clean` (Staff) `Fantastic Activities` (Staff) `We all enjoy the ball games and exercises` (Resident) `Some of the staff are nice` (Resident) `Looks after me well, all my care needs met` (Resident) `I like my room with its view over the fields` (Resident) `All the staff are very pleasant, you can have a joke with them` (Resident). `The staff listen to you, which is a big thing` (Resident) What has improved since the last inspection? All requirements made at the last inspection have been met. Improvements have been made to identify and minimise risks to the health or well being of people living in the home. This includes the risk of developing pressure sores. The home has a good system in place with regard to the appointment of staff. Records seen show that references are always obtained and staff are not appointed prior to safety checks being undertaken. The home has demonstrated that improvements have been made in their reporting of incidents to us and the local authority. This is in line with the homes polices and procedures and Warwickshire`s multi agency approach to safeguarding people at the home. What the care home could do better: The needs to ensure all people should be provided with contracts by the home detailing the terms and conditions of their stay at the home and what they can expect to receive for their money. The home must ensure that all areas of risk are identified, and appropriate plans in place to minimise any risk. This relates specifically to behaviour management. This will ensure the appropriate safeguards and actions to support and protect rights and wellbeing of people. Care plans for the people at the home could be improved to demonstrate a person centred approach to care planning. Person centred care ensures people who use the service are at the centre of their care treatment and support by staff should be carried out whilst ensuring that everything that is done is based on what is important to that person from their own perspective. The management of medication must improve to ensure safe handling and administration of peoples medicines. The manager needs to ensure all staff have supervision and annual appraisals to help in staff development and ensure staff have the appropriate knowledge and skills to carry out their jobs. The home needs to address staff shortages, this is to ensure there are sufficent levels of staff availlable to work at the home at all times. The manager must submit an application to become the registered manager of the service. This is to ensure the manager takes action to comply with the Care Standards Act. The home must ensure the Annual Quality Assurance form is completed and returned to us within the required timescales. Key inspection report Care homes for older people Name: Address: Arden Valley Christian Nursing Home Bearley Cross Wootton Wawen Solihull West Midlands B95 6DR     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 McGarry     Date: 1 8 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 34 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Arden Valley Christian Nursing Home Bearley Cross Wootton Wawen Solihull West Midlands B95 6DR 01789731168 01789731883 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.southerncrosshealthcare.co.uk Trinity Care Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 48 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 accommodated is: 48 The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia over 65 years of age (DE(E)) 24 Old age, not falling within any other category (OP) 24 Date of last inspection Brief description of the care home Arden Valley is a purpose built home providing accommodation for 24 people with dementia and 24 people who are frail elderly. Accommodation is provided on the ground and first floor of the property. Care Homes for Older People Page 4 of 34 Over 65 24 24 0 0 2 8 1 1 2 0 0 8 Brief description of the care home Residents from both units have access to a secluded garden at the rear of the building. Each unit provides a variety of communal living space with a light and airy conservatory area. The home is located in a rural area, which is not easily accessible without a car. Fees at the home are from £795.00 per week. The fees do not include newspapers, toiletries, hairdressing or private telephones. The fee information given applied at the time of the inspection; persons may wish to obtain more up to date information from the service. Care Homes for Older People Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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 was a key unannounced inspection visit. This is the most thorough type of inspection when we look at key aspects of the service. We concentrated on how well the service performs against the outcomes for the key national minimum standards and how the people living there experience the service. We carried out this unannounced key inspection over two days. As the inspection was unannounced the registered owner, manager and staff did not know we were going. A Pharmacy Inspector was also involved in the inspection; she carried out a full inspection of the medication management systems and safety. We asked an expert by experience to meet with people who use the service. An expert by experience is a person who, because of their shared experience of using services, and / or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. Care Homes for Older People Page 6 of 34 Surveys were sent to 10 people who use the service, their relatives/ representatives and 10 members of staff to complete prior to our visit. Before the inspection we looked at all the information we have about this service such as information about concerns, complaints or allegations; incidents; previous inspections and reports. Registered care services are required to complete an Annual Quality Assurance Assessment (AQAA). The AQAA provides information about the home and its development. At this key inspection we used a range of methods to gather evidence about how well the service meets the needs of people who use it. Some time was spent sitting with residents in the lounge watching to see how residents were supported and looked after. These observations were used alongside other information collected to find out about the care they get from staff. We also looked at the environment and facilities provided and checked records such as care plans and risk assessments. There were 42 people in residence on the day of our inspection. Three people using the service were identified for case tracking. This is a way of inspecting that helps us to look at services from the point of view some of the people who use them. We track peoples care to see whether the service meets their individual needs. Our assessment of the quality of the service is based on all this information plus our own observations during our visit. Throughout this report, the Care Quality Commission will be referred to as us or we. At the end of the visit we discussed our preliminary findings with the manager of Arden Valley Nursing Home. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? What they could do better: The needs to ensure all people should be provided with contracts by the home detailing the terms and conditions of their stay at the home and what they can expect to receive for their money. The home must ensure that all areas of risk are identified, and appropriate plans in place to minimise any risk. This relates specifically to behaviour management. This will Care Homes for Older People Page 8 of 34 ensure the appropriate safeguards and actions to support and protect rights and wellbeing of people. Care plans for the people at the home could be improved to demonstrate a person centred approach to care planning. Person centred care ensures people who use the service are at the centre of their care treatment and support by staff should be carried out whilst ensuring that everything that is done is based on what is important to that person from their own perspective. The management of medication must improve to ensure safe handling and administration of peoples medicines. The manager needs to ensure all staff have supervision and annual appraisals to help in staff development and ensure staff have the appropriate knowledge and skills to carry out their jobs. The home needs to address staff shortages, this is to ensure there are sufficent levels of staff availlable to work at the home at all times. The manager must submit an application to become the registered manager of the service. This is to ensure the manager takes action to comply with the Care Standards Act. The home must ensure the Annual Quality Assurance form is completed and returned to us within the required timescales. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 34 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are considering moving into the home benefit from having their care needs assessed before admission so that they can be sure the home can meet their needs. People and their families are not consistently provided with information and visit the service prior to admission to enable them to make an informed choice. Evidence: In the AQAA the manager stated we encourage potential clients to visit our home and have a look around at the initial enquiry, we do not put a time or day on this and leave it entirely up to the client when they want to visit. This makes the client feel that it is about them. Brochures are handed to them or posted if it is a telephone enquiry. We involve relatives residents multi-disciplinary teams and our own documentation to complete accurate assessments in order for us to meet the service users needs. To find out whether this was the case, three people were case tracked during this inspection. This involved looking at their care files talking to them and their family Care Homes for Older People Page 11 of 34 Evidence: where possible, and talking to the staff that care for them. Their living accommodation and the facilities available to them were also looked at. The care files of the two most recently admitted people to the Home were reviewed to identify whether appropriate pre-admission processes take place at Arden Valley. Sufficient information is obtained about people before the Home confirm that they are able to meet their needs. Assessments provide details of peoples health and personal care needs which include information on physical and mental health history, mobility, nutrition and communication. The availability of this information helps to ensure that the specific care needs of each person can be identified and used to help complete a plan of care. Relatives and people who may wish to use this service are encouraged to visit have a look around and stay for the day before they decide if they would like to move in. One relative told us that they were able to visit the home to make a choice about which care home would best meet their relatives needs prior to them moving in, and the manager of the service at the time of their admission, visited their relative at home to carry out an assessment. The Homes statement of purpose and service user guide was looked at as part of the inspection. Both documents clearly identify the levels of service that could be offered to specific user groups. They are detailed informative and reflective of the actual service being provided. This ensures that people have enough information to make an informed choice about whether they would like to live at Arden Valley. One relative spoken to could not recall having received a copy of the Homes statement of purpose of service user guide. Informant surveys received from people who live at the home tells us that four out of ten people felt they received enough information before moving into the home. The manager agreed that the updated service user guide and statement of purpose would be provided to all residents and their relatives / representatives. The expert by experience met with some people who live at the Home as well as their relatives the expert informed us I had an opportunity to chat to two relatives. Both of them said they had gone through the motions of looking for a convenient setting for the loved one and they had identified Arden as the rightful place. One Individual Placement Agreement from the Local Authority was seen for one persons stay, however, the home does not routinely provide people with contracts of their stay there. The manager and Operations Manager agreed that this would become standard practice. Care Homes for Older People Page 12 of 34 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each resident has a plan of care but a lack of consistent detailed recording may result in inconsistent care being provided. Residents have access to health care services that meet their assessed needs. Staff have a good understanding of how to offer care and support to each person. Medication management must improve to ensure appropriate action is taken by nursing staff when medicines are not administered as prescribed. There appears to be an over reliance on the use of anti psychotic medication for the people on the dementia unit. Evidence: The AQAA completed by the manager tells us We have developed good relationships with our local GPs and other visiting professionals. The homes auditing process ensures that medication care plans, kitchen and activities are consistently monitored internally and externally e.g. Boots and other home managers. Care plans identify action required by care staff to meet the needs of the service user. To find out whether this was the case three people were case tracked during this Care Homes for Older People Page 13 of 34 Evidence: inspection. This involved looking at their care files talking to them and their family where possible, and talking to the staff that care for them. Seven peoples medication records were looked at by a pharmacy inspector. People at the home were seen to rise at their own pace and receive unhurried support eat their breakfast of choice. Everyone was well groomed and dressed in appropriate good quality clothing indicating they are supported to maintain a good self image. However the survey from one relative tells us At the moment there is as staff shortage.. shortage of staff can mean that X isnt always shaved or dressed properly, sometime Xs looks very disheveled.. he is quite embarrassed about this and so am I. It is evident that since the last inspection have made improvements in peoples care plans. Three peoples care plans were looked at. The care files covered all the main areas of care including medical history, personal care, pressure care, nutrition, behavioural needs continence and mobility. Risk assessments are also available for areas that may cause a problem such as falls, nutrition, and the development of broken skin due to prolonged pressure. The care of a person who has a history of pressure sores to the skin was viewed. It was evident that staff had devised a suitable care plan for monitoring the skin to ensure any red areas or breakdown of the skin was identified. A risk assessment had also been completed showing this person was at high risk of skin damage. The support of the tissue viability nurse had been sought when a pressure sore had been identified so that an appropriate dressing could be applied. Records stated that a pressure relieving mattress was in place. Care plans were individually dated and signed so there was a clear audit trail of when the care needs had been identified. This is helpful to know particularly when care needs change so that it is possible to see if a persons health has improved or deteriorated. Falls risk assessments had been carried out for each person whose care file was reviewed. Staff were recording any falls that people had sustained in the daily records. Daily fluid records and monthly weight records are being maintained. The care plans are evaluated on a monthly basis or more often if needed and changes are made to the care plans if there is a change in the need of the person. Despite some improvements to care planning and risk management, further improvements are required to ensure all areas of risk are identified and appropriate Care Homes for Older People Page 14 of 34 Evidence: plans are in place all residents receive consistent care from staff, care planning is person centred, and assessments are carried out in line with current legislation and good practice. For example, on the three care files viewed we found a mental capacity assessment carried out by the home. For each individual the assessment recorded that each person lacked capacity. From information on the tool and discussions with the manager and operations manager it was apparent that this is not an appropriate method of determining peoples ability to make decisions and was not in line with current legislation. The Mental Capacity Act requires decision- specific assessments of capacity and this was not the case at the home. Following the inspection we further contacted the manager regarding this as was informed that the assessments have been removed from all residents files. One person case tracked has been assessed as having behavioural needs. There is a care plan and risk assessment plan in place however we raised concerns with the manager that the first action on the plan is to administer medication when X becomes very aggressive. We also found this has individual has other behavioural needs that are not recorded in the care plan. From discussions with staff we found inconsistent approaches to supporting this person when they display challenging behaviour. One member of staff informed us that they do not refer to the care plan as they feel it does not guide them in managing this persons behavioural needs. On the day of the inspection, the manager accepted at the inspection that further work is required to ensure that this individuals care plan reflects the care and support to be delivered to ensure safe and consistent care is delivered. We saw that care plans are not written from the point of view of the person using the service. A more person centred approach to care planning would help remind staff about the way the person would wish to be treated and how they would like their care to be delivered. The manager informs us that all care plans are currently being reviewed and where appropriate updated to reflect peoples needs and consideration to a person centred approach to care planning will be considered. Examination of the care files found people had regular access to GPs, district nurses, optician, chiropodist, and dentists. Discussions with people who live at the home and with two relatives confirm that appointments to meet peoples health needs are arranged and people supported to attend the appointments. One survey from a health professional tell us that The home is clean, senior staff usually helpful and eager to provide relevant information, some of the staff do not seem to understand the role of the GP, how to use the service appropriately, because of the variability in the quantity of staff it is difficult to trust what we are being told on Care Homes for Older People Page 15 of 34 Evidence: the telephone - the clinical picture when we arrive can be radically different to that given. People who use the service told us that staff always promote and respect their privacy and dignity. Staff were seen referring to people by their preferred form of address and we saw staff knocking on peoples doors and waiting for a response before they entered the room. One relative spoken with told us that the manager and her staff keep the family informed of any changes and are always available to discuss care and other needs as they arise. They also told us that the care is excellent and that when they leave they are confident that all their relatives needs will be met to a high standard. Two relatives spoken to during the inspection were positive about the care being provided. When asked about the care and if they were happy with this one stated oh yes very happy and the other said wonderful. The pharmacist inspection lasted three and a half hours. Seven peoples medicines were looked at together with their Medicine Administration Record (MAR) chart, care plans and daily records. Two nurses were spoken with and all feedback was given to the manager and deputy manager. All the medicines were stored in dedicated medicine rooms that have an air conditioning systems to maintain a cool environment to maintain their stability. However two medicines that should have been stored in the medicine refrigerator to maintain their stability were found in the trolley. On pointing this out to the nurse on duty they were not moved immediately as anticipated. The home had installed good systems to check the prescriptions and dispensed medicines received into the home. All quantities of medicines received had been recorded enabling audits to take place to check whether they had been administered as prescribed. The home had installed a quality assurance system whereby staff counted the medicines dispensed in traditional boxes or bottles each night to confirm that they had been administered as prescribed and records reflected practice. It was noted that despite these audits identifying that the medicines had been administered incorrectly nothing had been done to rectify the problem or speak to the nurse responsible for the error. In one instance four anti epileptic tablets had been signed as administered when they had not been. This may have been detrimental to the health and wellbeing of the person. In another instance two capsules were Care Homes for Older People Page 16 of 34 Evidence: unaccounted for. It was possible that twice the prescribed dose i.e two not one capsule had been administered in this instance. This is of concern as it indicates that the nursing staff are not reading the MAR chart before the administration of medicines and not accurately recording exactly what they have administered. The nursing staff failed to act on the information found from the quality assurance system to address and prevent errors found. The medicines dispensed in the monitored dosage system (one tablet per day in a blister) had though been administered correctly and records reflected practice The care plans were brief and did not record all the clinical information regarding the people. Without such information it would be difficult for staff to fully support the clinical needs of the people they care for. Many people had been prescribed medicines but there were no supporting care plans, so it was not possible to ascertain why they had been prescribed them. It was noted on the dementia unit that a very high proportion of people (over 60 ) were prescribed anti psychotics to manage their behaviour. One letter was seen from the old age psychiatrist stating that one medicine was to be given when required for agitation but it was seen to be administered routinely four times a day. There was no care plan for this medicine or protocol detailing when or under what circumstances it should be administered. This is of serious concern. Another person had been prescribed a medicine to control aggressive behaviour but again this was given routinely and at double the recommended dose each morning despite a review taking place only two months ago detailing when and at what dose it should be administered. In light of the recent government report it was strongly recommended that medication reviews were sought to reduce the reliance of these medicines. The care plans gave no indication why the people were taking these medicines and the nursing staff did not identify any underlying mental illness to support their use. The manager agreed to address this very serious issue. The nursing staff had a reasonable understanding of the medicines they administered but failed to question the over reliance of anti psychotics. All controlled drug entries were correct and they were stored in compliance with current regulations. Care Homes for Older People Page 17 of 34 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a planned programme of activities so that people in the home can maintain their enduring interests. People would benefit from improved support in meeting their nutritional needs. Open visiting arrangements encourage regular contact with relatives and friends. Evidence: The AQAA states Well balanced nutritional meals are provided using the nutmeg system. Residents have the choice to eat their meals in the dining area lounge or in the privacy of their own room. Residents are given a choice of meals with alternatives to the main menu. The Head Chef is involved in monitoring the nutritional status of each resident and the implementation of interventions prescribed by the nurse or dietician. Individual diet notification forms have been completed and nurses carers and catering staff are aware of its contents in order to improve the standards of mealtimes for service users. To assess whether this was the case we observed the interactions between people and staff, talked to the people who receive a service, and looked at the programme of activities and discussed peoples nutritional needs with the manager and staff. We looked at a range of documents and we looked carefully at the care provided to three Care Homes for Older People Page 18 of 34 Evidence: people from the point of their admission to the present time. We also looked at the information in surveys that staff relatives and people who live at the service had filled in. As stated at the last inspection The home employs a full time activities coordinator who is responsible for arranging individual or group activities for the benefit of the people who live there. The coordinator is employed to work 37.5 hours per week Monday to Friday from 10am to approximately six pm. The hours are flexible to meet the needs of the people who use the service. An activities schedule is in place which shows that there is an activity being provided each weekday. People we talked to said that they were happy with the daily routine. They said that they were free to get up and go to bed whenever they chose. They also said they were satisfied with the range of social and leisure activities provided in the home. These included music and reminiscence groups visiting garden centres and pre-arranged entertainment groups. Information displayed at the home tells us that a number of activities are planned for November and December, namely Christmas trip to the Christmas lights and chippie, carol service, Christmas Party, and Christmas eve entertainment, Advent service, reminiscence group, residents meeting, and musical entertainment by external agencies. The Expert by Experience told us the second visitor said they particularly liked the flexibility at the Valley Christian Nursing Home as they could come alone for some of the coach outings that are part of the activities programme also the relative commented, I really liked the Red Nose day photos. Relatives and friends were seen coming and going from the home and appeared comfortable and welcomed. We spoke to one relative who told us she was always made welcome when visiting. Relatives spoken to commented positively on the care being provided. One lady is able to continue to see her dog when visited by her daughter. There is evidence that residents are able to maintain links with their families and friends. Also visits from members of the clergy are arranged at the home to enable people to practice their faith. The Expert by Experience met with people in the dementia unit over lunch time. The expert informs I sat in with some of the residents and sampled their food. There was Care Homes for Older People Page 19 of 34 Evidence: an open seating plan and newly decorated dining area. They created a warm and colourful environment for residents and visitors. A number of the residents needed support with feeding. There was a choice of Lamb or an Omelette. Advance menus were also pinned to a board. There was a designated dining room coordinator whose role it is to oversee what happens in the dining room as well as the probing and recording of food in line with the Food Safety Regulations of 2006. During meal time I managed to check with a few residents regarding their meal. They were all happy with the meals at Arden valley. A discussion with the cook told us that there is currently a shortage of kitchen staff however this is being addressed by the manager. This does not impact upon breakfast or lunchtime however it is having an impact upon the variation of the evening meal in that, the cook prepares soup and sandwiches which are left for staff to distribute. The cook was able to inform us of peoples different dietary needs including how the home supports one person who requires a low potassium diet and a controlled fluid intake. There is a care plan in place for this persons dietary needs and weight and fluids charts are being maintained. However fluid chart records show that there have been a number of occasions when this person had more fluids than the upper limit, and there are no clear guidelines in place to advise staff what action they need to take should this individual drink in excess of their fluid limits. From discussion with the manager and information from the Pharmacy inspector we found a large proportion of residents who take supplements. The manager is aware of this and states that she reviews this on an individual basis of need. Further efforts need to be made to reduce peoples dependency on supplements to enable people to enjoy well balanced meals. Staff were available to offer discreet timely and sensitive assistance to residents who needed help eating their meal. Care Homes for Older People Page 20 of 34 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People and their representativesknow how to raise any concerns. There are systems are in place to ensure any allegations of abuse or complaints are investigated and acted upon appropriately to safeguard people living in the home. Evidence: The AQAA states All complaints are logged and investigated within 48 hours of their receipt by the home manager. Our complaints policy and procedure are available to all. The complaints procedure is up to date and on display in the home reception area. We use complaints as a positive for it gives us an opportunity to put things right. The rights of our service users are protected, where the service user lacks capacity a form has been devised to identify this and supported by relevant care plans and advocates are available for the service user if they so wish. To find out if this is the case, we requested the concerns, complaints and compliments folder, looked at staff records and talked to staff about complaints and safeguarding the people who live there. The home has a complaints policy, this is displayed in the home for the benefit of the people who use the service or visitors. People who live here and relatives spoken were clear about who they would speak to should they have any concerns. The home has received one complaint since the last inspection. Records of this Care Homes for Older People Page 21 of 34 Evidence: complaint were seen and show that it was addressed in line within the homes complaints policy. The Home has policies and procedures regarding adult protection which according to information received on the AQAA, were updated in July 2009. There have been eight referrals to the local authority in relation to the safeguarding of vulnerable adults. Four staff spoken with demonstrated a satisfactory understanding of the types of abuse they might encounter and to whom they should report any concerns. The home does not manage finances on behalf of the people who live there. The home has a good system in place with regard to the appointment of staff. Records seen show that references are always obtained and staff are not appointed prior to safety checks being undertaken. Care Homes for Older People Page 22 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with clean attractive well furnished and comfortable surroundings to live in and enjoy. Evidence: The AQAA states We provide a safe secure, warm clean and comfortable environment for our clients, window restrictors are placed on all our windows above ground level. General maintenance and repairs are dealt with promptly and the maintenance person is fully up to date with his role and his responsibilities. Clients are encouraged to make their rooms as homely as possible by adding their own personal belongings and personal touches. There have been no changes to the homes environment since the last inspection. The home provides accommodation over two floors. People who have general nursing needs live on the ground floor and people with dementia care needs live on the first floor. Each floor has 24 single occupancy bedrooms with ensuite facilities. There is a dining room in the centre of each house and a lounge at either end. Decorating work is ongoing throughout the home and in the dementia care house an artist has created scenes on the walls of some of the corridors to provide a more stimulating environment for people living there. Care Homes for Older People Page 23 of 34 Evidence: The quality of the furnishings and fittings in peoples rooms were generally good. Call systems in rooms are accessible to people. We looked at some of the bedrooms of the people involved in case tracking. They were clean and well furnished. The rooms were personalised with their own belongings. Equipment is available to assist residents and staff in the delivery of personal care which includes assisted baths profiling beds accessible showers and moving and handling equipment including hoists. A range of pressure relieving equipment including specialised air mattresses are available. Systems are in place to reduce the risk of infection. Disposable gloves, aprons and hand scrub were available and were used by staff when handling soiled linen and when supporting people with personal care. The home has a modern well organised laundry room with dedicated laundry staff. Residents clothing looked well laundered and ironed. The kitchen was clean and well organised. Records are kept of the fridge and freezer temperatures showing appropriate temperatures to maintain good food safety. Care Homes for Older People Page 24 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People would benefit from a staff team who are appropriately trained. This would help in staff development and ensure staff have the appropriate knowledge and skills to carry out their jobs. Staffing shortages results in some peoples care needs not being fully met. Evidence: The AQAA states We have 2 qualified nurses on the premises 24 hours a day. Some of our staff are trained to NVQ level 2 and 3 in care. We have an in house trainer and a moving and handling trainer and home manager has achieved managers award. Staff are recruited in line with company policy and procedures including two references, POVA and CRB. Staff have a weeks induction and will also shadow a more experienced member of staff until they feel more competent. To check that this is the case, we looked at three staff files, spoke with staff and the manager. The manager told us that the usual staffing complement planned in order to meet the needs of the 42 people currently living in the home includes two qualified nurses and six care staff throughout the day. Waking night staff are on duty, including two nurses and three carers to meet peoples needs should they required assistance. This was seen from three weeks duty rotas. Care Homes for Older People Page 25 of 34 Evidence: Staff spoken to told us that there are currently staff shortages. This was acknowledged by the manager who states that the home requires 11 more care staff and kitchen staff. On the day of the inspection, one member of kitchen was employed at the home. The manager states that other kitchen staff had unexpectedly left their jobs earlier than their notice period. The manager assures us that action was being taken to address this matter. Under 32 of permanent care staff have achieved a minimum of level two in the National Vocational Qualification in care. This is below the required level of 50 of staff. One survey from a professional told us Care staff could be better trained. Nursing staff could have more spoken English and be better qualified. Evidence was available that new care staff undertake an induction programme and have access to mandatory training in fire safety, abuse awareness and moving and handling. This should mean that staff are updated in safe working practice. No induction program was available when new nursing staff commence employment. The Expert shared her observations with us commenting When chatting to staff they appeared to be relaxed and engaging when they worked with residents during feeding and relaxation times. There was mostly full time staff I saw one agency member of staff. The staff mentioned that it would be preferable if there was more staff capacity given the high level of support that the residents needed. The personnel files of two recently recruited staff were examined and both contained evidence that satisfactory checks such as Criminal Record Bureau (CRB) Protection of Vulnerable Adult (PoVA) and references are obtained before staff commence employment in the home. From records and discussion with staff, we found evidence to show that staff starting work with a PoVA first are being supervised until CRB checks are received. Robust recruitment procedures and pre-employment checks should protect the vulnerable people living in the home. Care Homes for Older People Page 26 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A lack of continuity in the management of the home does not ensure the service is run in the best interests of people living in the home. The people who live their and their families are provided with opportunities to make their opinions of the service known and the organisation has systems in place to monitor quality performance. Evidence: The manager took up her position in May 2009. She is not currently registered with us and has been advised that this is required to comply with the Care Standards Act 2000. Staff were aware of lines of accountability within the home. The AQAA states Manager is a qualified Registered mental health nurse NVQ Assessor and has Registered Managers Award. There is an effective system of communication between the home and outside professionals and visitors which keep them up to date on the progress within the home. Receive a give support to other managers within our Care Homes for Older People Page 27 of 34 Evidence: patch Have regular health and safety meetings and deal with the issues as they arise. Operations managers and project managers who support the home managers. The Annual Quality Assurance Assessment (AQAA) was completed by the manager. The manager was late in returning the completed document. The home is required to complete this document and must return it to us within the given timescales. As stated at the last inspection, there is a lack of continuity in the management at the home, there has been three managers at the home since the last inspection. This impacts upon the delivery of care at the home and peoples experiences of the care they receive. One relative spoken to stated that the new manager was excellent, very calm. This person stated that there have been a lot of managers at the home in recent years. Surveys received from relative so peoples who use the service commented on management stating Staff changed at management level should be reduced if possible. Other surveys from staff commented upon staffing levels: There is a great need to address staff shortages.. as this leads to stretching of the abilities of care staff most times More staff levels, work in harmony and less pressure, More help downstairs required (Night staff). From discussions with staff, morale has improved since the last inspection, however, three staff members spoken with all felt that staffing levels needed to increase to enable staff to meet more than basic care needs of the people who live within the nursing unit and on night shifts. As identified by the pharmacy inspection, management of medication must improve to ensure that the correct medicine is administered to the correct person at the correct dose and time as prescribed and records reflect practice. Information provided by the manager in the pre-inspection questionnaire indicates that relevant Health and Safety checks and maintenance are being carried out at the home. A number of Health and Safety records were checked, including the fire safety log. These records showed that health and safety matters are well managed. A gas landlord certificate was seen and was up to date. Care Homes for Older People Page 28 of 34 Evidence: A system for evaluating the quality of the service provided is being introduced and includes consultation with residents. The manager recently carried out a questionnaire survey with residents which included feedback from some relatives. The home is waiting for the return of questionnaires so information can be collated and an action plan devise to address areas of improvements. The manager confirmed that they do not hold any monies for people living in the home. When discussing supervision with staff it was noted that annual appraisals have not taken place in the past but the home has recently started to ensure that formal supervision system is in place. Regulation 26 visits are being carried as required by the home operations manager. A record of each visit is kept, including details of area of the homes looked at during the visit. This complies with the law that says providers must make a monthly, unannounced visit to the service. At the visit, they need to check on the quality of service provided at the home. The provider needs to keep a copy of the report so that it can be inspected at the next key inspection. Staff spoken to were complimentary of the home, one stated Provides a homely atmosphere, generally quiet and relaxed. Excellent and regular activities, approachable manager. Another stated Good care practice, fantastic activities. There is adequate equipment for moving and handling purposes. Care Homes for Older People Page 29 of 34 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 30 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 12 Care plans must state actions to be taken to minimise risk for those individuals who have been assessed as being at risk. This includes challenging behaviour management. This will ensure that all staff are fully aware of the risks and actions to take to minimise the risk. 08/01/2010 2 9 13 The medicine chart must be 25/12/2009 referred to before the preparation of peoples medicines and be signed directly after the transaction and accurately record what has occurred. This is to ensure that the correct medicine is administered to the correct person at the correct dose and time as prescribed and records reflect practice. Care Homes for Older People Page 31 of 34 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 3 31 9 The manager must submit 31/12/2009 an application to become the registered manager of the service. This is to ensure the manager takes action to comply with Section 11 Care Standards Act 2000. This is ensure people are confident someone suitably confident manages the service. 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 3 The home should ensure that all prospective residents and their families receive information about the service prior to moving in to ensure they are making an informed decision. People should be provided with contracts by the home detailing the terms and conditions of their stay at the home and what they can expect to receive for their money. This is necessary so that everyone is clear about what they have to pay for and so that their rights may be upheld. Care plans for the people at the home could be improved to demonstrate a person centred approach to care planning. The home should take action to ensure there is appropriate levels of staff available at all times to provide support to those who need it. This is to ensure people are supported to maintain all aspects of their personal care. It is advised that the care plans include all the clinical conditions of the service users so the staff have full information to support their clinical needs. It is recommended that full medication reviews are sought 2 5 3 4 7 8 5 8 6 9 Care Homes for Older People Page 32 of 34 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 to reduce the reliance on anti psychotic medication 7 8 15 30 Action should be taken by the home to review all people who are currently having food supplements. 50 of staff should be qualified to NVQ level two to ensure people are supported by staff who have the competencies and qualities required to meet their needs. The home must ensure that the Annual Quality Assurance Assessment is completed and returned to the Commission within the required timescales. This would demonstrate that the home is being managed in peoples best interests. All staff should have annual appraisals to help in staff development and ensure staff have the appropriate knowledge and skills to carry out their jobs. 9 33 10 36 Care Homes for Older People Page 33 of 34 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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