Care Home: Barrington Lodge Nursing Home

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What the care home does well The home does use the support and expertise of several external health care professionals to help meet peoples health care needs and to access specialised equipment. Some people have their very particular choices and preferences met well. Everyone has a choice of what they wish to eat and special diets are provided for. The kitchen is well run and has been awarded four stars by the Food Safety Officer. The home now has a strong emphasis on stamping out abusive and poor practices and it liaises well with the appropriate agencies to achieve this. Any complaints and concerns are taken seriously and investigated thoroughly and appropriate action is then taken. The environment has been improved and is kept clean. Staff are now being well supervised and new staff receive good induction training and support to be able to carry out their job well. Peoples health and safety needs are considered and well planned for. What has improved since the last inspection? Certain areas of the service are being managed in a more robust and clear manner. What the care home could do better: The service needs to continue its plans to improve basic staff skills and to recruit more competent staff. Care planning and additional care assessments need to be kept up to date and records kept accurately of the care being delivered. Guidance within the care plans needs to be concise and not in conflict with other care documentation. Care needs to be delivered in a more person centred way and task orientated and institutional practices need to be successfully eradicated. Appropriate and accurate equipment needs to be put in place to monitor peoples weights. Arrangements need to be clarified and then organised for the correct application, administration and recording of creams and ointments applied to the skin. A better provision of social interaction and activities is needed for those people with cognitive impairment. Certain aspects of the recruitment process need some improvement to ensure all possible checks on peoples employment history are carried out where possible to help protect people from potential abuse or harm. Staff must adhere to the company`s policies, procedures and protocols. The company must reassure itself that its arrangements for quality review and auditing do actually trigger areas of concern successfully. Key inspection report Care homes for older people Name: Address: Barrington Lodge Nursing Home Cirencester Road Cheltenham Glos GL53 8DS     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: Janice Patrick1     Date: 2 4 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 40 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 40 Information about the care home Name of care home: Address: Barrington Lodge Nursing Home Cirencester Road Cheltenham Glos GL53 8DS 01242263434 01242260731 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd care home 37 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: 10 residential beds for the elderly (Cat I) included within total of 37 nursing beds. To accommodate one named service user aged 57 years of age. Date of last inspection Brief description of the care home This Home is part of the BUPA Group and is situated on the outskirts of Cheltenham Spa Town. Near to local bus routes and shops, it sits back off the main road with its own private parking and gardens. The Home provides 24 hour nursing care and personal care for those predominantly over the age of 65 years of age. Internal accommodation is offered over numerous floor levels. There is a passenger lift, stair lifts and sloped floors that aid access to these levels. There are a small group of bedrooms that can only be accessed by people that are able to walk, therefore admissions to these rooms is very selective. All bedrooms have ensuite facilities of some sort. Communal rooms are on the ground floor. The current fee range is £800.00 to £1,000 per week. The home does accept authority funded or health funded admissions. The home makes available information regarding previous inspections in a Care Homes for Older People Page 4 of 40 0 2 0 3 2 0 0 9 0 Over 65 37 Brief description of the care home folder in the main reception area. Care Homes for Older People Page 5 of 40 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: We looked at all the information that we have received, or asked for since the last key inspection or annual service review. This included the most recent Annual Quality Assurance Assessment, AQAA that was sent to us by the service. The AQAA is a self assessment completed annually by the service and forwarded to the Commission. It tells how well the service feels it is meeting peoples needs. It also tells us of improvements made to the quality of the services provided and the plans the service has for the next twelve months. It also gives us some numerical information about the service. We looked at any information that tells us how the service has managed any complaints, concerns and any staff investigations. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. Care Homes for Older People Page 6 of 40 We looked at the previous key inspection report and the results of any other visits that we have made to the service in the last 12 months. This included any outstanding requirements and how the service has told us how these have been met. In this case there were none made at the last inspection in January 2009. We have considered any relevant information from other organisations. We then visited the service over two days. On the first day between the hours of 10:10am and 8.45pm and on the second day between 7.45am and 10:50am. We looked in detail at the care of four people and observed interactions between several others and staff. We inspected care records, staff personnel files relating to their recruitment, supervision and training. We also inspected other records pertaining to the smooth running of the service and peoples health and safety. We looked at the arrangements for safeguarding people from abuse. We looked at the current arrangement for the management of the service, how the service measures the standards of its service provision and how it aims to improve this. We walked around the building, spoke to several service users, members of staff and spoke to one relative. Care Homes for Older People Page 7 of 40 What the care home does well: What has improved since the last inspection? What they could do better: The service needs to continue its plans to improve basic staff skills and to recruit more competent staff. Care planning and additional care assessments need to be kept up to date and records kept accurately of the care being delivered. Guidance within the care plans needs to be concise and not in conflict with other care documentation. Care needs to be delivered in a more person centred way and task orientated and institutional practices need to be successfully eradicated. Appropriate and accurate equipment needs to be put in place to monitor peoples weights. Arrangements need to be clarified and then organised for the correct application, administration and recording of creams and ointments applied to the skin. A better provision of social interaction and activities is needed for those people with cognitive impairment. Certain aspects of the recruitment process need some improvement to ensure all possible checks on peoples employment history are carried out where possible to help protect people from potential abuse or harm. Staff must adhere to the companys policies, procedures and protocols. The company must reassure itself that its arrangements for quality review and auditing Care Homes for Older People Page 8 of 40 do actually trigger areas of concern successfully. 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 40 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 40 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has identified some fundamental shortfalls within how information is communicated and how necessary arrangements are made following a pre admission assessment. These are being robustly reviewed so that people in the future will have their needs comprehensively assessed and the necessary information will be communicated to staff who will then have the correct knowledge and confidence to make the appropriate arrangements. This will ensure that the person has a smooth transfer into the home and their needs will be fully met once they arrive. Evidence: In past inspections the service has always demonstrated that people have only been admitted following an assessment of their needs and these have always been recorded. A recent complaint highlighted some shortfalls in one persons pre admission arrangements and then in the care the person subsequently received immediately Care Homes for Older People Page 11 of 40 Evidence: following admission. This led to basic shortfalls being revealed in some staffs knowledge and in their professionalism. Subsequently certain areas of the services assessment process and care delivery has required review and alterations. This has also led to some staff leaving the service and others requiring further support and training. Following this the service made a decision not to take any new admissions for a period of time until these issues were resolved. This arrangement was still in place when we visited the service. We therefore looked at the pre admission assessment of one person who was admitted just prior to this decision being made. The assessment had been completed eight days before the person arrived and as with others we have seen in the past; recorded the persons health and care needs. The new Manager of the service is known to the Commission and we are confident that any future admissions to the service will follow a robust assessment process. A particular review of the arrangements required for meeting palliative care and end of life needs is being undertaken by the Manager. This includes improving the staffs knowledge in this area of care but also includes ensuring that the right arrangements are in place with local, external health care professionals so that when the service requires specialised support it is available. We have been told that people who require this level of care will not be admitted until the service is confident everything is in place to acheive this. As explained above, following the complaint investigation it was apparent that the knowledge required within the staff team to both plan for peoples needs prior to their admission and to fully meet them once they were admitted was not in place. Areas of individual weakness have been addressed and a full programme of supervision and training has been commenced. A new manager in place who is supported by a competent Deputy Manager. The nursing team are short of permanent staff but competent and regular interim staff are supporting the main team During this inspection these staff were able to demonstrate that they had the required knowledge to meet peoples current needs. Further details on management of the service and staffing can be found within the Staffing and Administration and Management outcomes of this report. Care Homes for Older People Page 12 of 40 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. Some peoples needs have not been consistently met and in some areas of care the service is still struggling to demonstrate that peoples needs are being correctly met. However, the shortfalls in care practices have been robustly identified and arrangements are in place to ensure these continue to improve. The people that are now taking a lead within the home are competent and there is some evidence of individualised care. Evidence: The AQAA tells us that person centred care is delivered and that care plans are devised to give appropriate guidance to staff on how to meet peoples specific needs. It also tells us that staff are trained correctly to meet these needs. This has not always been the case and we are still not confident that it is something that the home do well as yet. The AQAA does however recognise that there needs to be a reintroduction of BUPAs initiative Personal Best which helps staff to focus on delivering their care in a person centred way. It also recognises that the care plans need to be written in a more person centred way and that there needs to be more relative and representative involvement in this where it is appropriate. Care Homes for Older People Page 13 of 40 Evidence: During our visit we inspected the care records of four people in detail. We spoke to seven people who use the service about their care and we spoke to one relative who visits on a regular basis. We also made several observations. We considered the content of the complaint referred to in the above outcome and BUPAs investigation findings. This was relevant because along with other investigations carried out by BUPA, shortfalls in several areas of staff practice have been revealed. The investigations have also shown that the attitude of some staff was not benefiting the people who live in the home. It is these concerns that have triggered this inspection. Although shortfalls have clearly been identified in some peoples care, this clearly has not been everyones experience and several positive comments were received by us during our visit. We are also aware that the new Manager and her Deputy are actively addressing these issues with the support of senior BUPA Managers. Some of the identified shortfalls did mean that some people had been put at risk and for others it meant that the outcomes for them had not been as good as they should have been. Once identified, the new Manager with BUPAs support has taken robust action and significantly reduced any risks to those living in the home. The services arrangements for safeguarding people from abuse and harm and dealing with complaints is reported on in more detail within the Complaints and Protection outcome of this report. Staff responsible for the more serious shortfalls no longer work for the service. In order for the service to be confident that the care being currently delivered is to a high standard and is meeting peoples needs; a full quality review has been completed by BUPA on all care systems, documentation and staff training and an action plan has been devised. How the services quality of care additional services are monitored and improved on is reported on in the Administration and Management Outcome of this report. During our case tracking (reading peoples care records and cross referencing these with the care people are receiving) we were not therefore surprised that there were times when we could not always successfully evidence that peoples needs had been appropriately met. The shortfalls we identified appeared to be predominantly between April and September of this year. These related to one persons wound care, one persons pressure relief care, in the monitoring of people generally who are nutritionally at risk and in the services ability to identify mental health needs that require specialist assessment. We are aware that some peoples continence care has Care Homes for Older People Page 14 of 40 Evidence: not always been sufficiently met and that end of life care requires improvement. Current records show that people who are nutritionally at risk are now being weighed at appropriate intervals, however recordings are showing some unexpected changes in weights for some people. The Deputy Manager had already started to pick this up and was currently asking for some weights to be repeated. We were not able to ascertain during our visit when the sit on scales, which were being used to weigh most people, had last been checked or serviced (calibrated). We were also advised that these were not practical for every service user. This needs resolving and if necessary a different style of scales should be purchased so that an accurate record of peoples weights can be achieved. We observed one person refuse most of the food that was put in front of them over a span of a day. The care records identified that the person could be at risk of not eating well and that they required support and help. The care records identified that the persons apetite had been poor for the last couple of days and the current care plan gave clear guidance to staff on how to manage this. The records showed that the person had lost weight between April and September of this year but we were unable to see what had been done about this. We also saw the same senario for one other person who appeared to have lost twelve kilograms in six months, but again there was no documented evidence to say what had been done about this. The Deputy Manager agreed that some people had lost weight and the risk assessment tool should have triggered weekly weights but the weights had remained at monthly. This was not now the case. We did witnessed staff throughout the day dedicate periods of time to the person that was refusing their food to try and encourage small amounts of food and drink to be accepted. They were also able to describe what intervention the person would accept and what they did not like. We felt this was a very good example of the current staff knowing the person well and delivering the appropriate individualised care. During our visit there was still confusion regarding one persons pressure relief care. This related to how often the person should have their position altered to relieve pressure. Depending on which piece of care documentation you were reading this varied from two hourly, three hourly or four hourly. When we inspected the persons turn chart to see what staff were actually doing, this showed gaps of beyond four hours and on one occasion beyond five hours. The record keeping was also not of a good standard. We spoke to one night nurse who said he would expect the person to be turned at least three to four hourly so as not to disturb the persons sleep too much. Records showed that night turns were completed regularly at 2am and 6am. We also spoke to one night carer who gave us the times of when night rounds are Care Homes for Older People Page 15 of 40 Evidence: completed and these were 2am and 6am. The carer also said that additional two hourly checks are completed on all service users unless they specifically say they do not want this to happen. Although we could see specialised pressure relief equipment in place for this person, we observed folded towels between certain areas of the persons body to prevent, we presume, friction between the skins surfaces. These however were rough and were placed in areas that then defeated any benefit being achieved from the specialised mattress. The Deputy Manager agreed that this was not beneficial and all though well meaning, it demonstrated a lack of updated knowledge. Arrangements were made to stop the practice and to ensure the correct equipment was used to protect the skin between the persons knees. One nurses hand over meeting discussed the needs of one service user. These needs were predominantly caused by the persons mental state. On inspection of the care records a fairly substantial period of time had obviously gone by where this person was expressing very clear needs that this service is not registered to meet. Although there had been reviews carried out by the General Practitioner (GP) there had been no previous request from Registered Nurses in the home for the person to be referred to the Mental Health Team for assessment. On the day of our visit the GP was contacted and over the phone prescribed double the amount of the persons medication to be given. The new Manager has a qualification and recent experience in caring for this type of illness and up to this point had been unaware of the issues. She did not believe this to be a satisfactory review and would arrange for a referral to be made to the Mental Health Team as soon as possible. Whether the GP agrees with this request or not the new Manager has demonstrated that she has taken the correct action in circumstances where the persons needs are outside of the homes registered category and where a specialised assessment is required. We also pointed out to the Deputy Manager that although this persons records say they are eating well; they had in fact dropped from 52 kilograms in weight to 48 kilograms in a month. This was recorded on the persons nutritional assessment but the review comment on the relevant care plan said no changes. We could see from some peoples records that external health care professionals are involved in and are used by the service to help meet peoples health and equipment needs. We could also see that people were receiving Chiropody (foot care) and visiting the Ophthalmologist (eyes) if needed. We spoke to the two interim agency nurses on duty who confirmed that the current nursing team had updated fifteen peoples care files so far. Care Homes for Older People Page 16 of 40 Evidence: One of the main issues raised within the recent complaint was the poor and disorgansied care of someone at the end of their life. We were informed that both of the interim nurses, including one of the permanent Registered Nurses and the Deputy Manager were all updated in the use of a syringe driver. The Manager confirmed that the home has now purchased their own so that in the event of someone requiring medication via this route; it can be provided immediately. The services access to this type of end of life medication and external support is also important. The home currently liaises with numerous surgeries and relies on support from many different sources and it is the wish of the new Manager to bring more structure to this and to have a good working relationship with one local surgery. The Deputy Manager has also confirmed that a small stock of continence aids (pads) are now being kept by the service. In order for people to receive continence aids/pads after admission the home has to organise an assessment by the local Primary Heathcare Trusts Continence Adviser and then the appropriate aid/pad has to be ordered. The above arrangement will avoid any personal discomfort in the time it takes for this to be completed. We were informed that all the staff are aware of this arrangement. During our visit we observed a selection of medication being administered and inspected a selection of medicine administration records (MARs). The nurses practice was correct and the trolley was made safe each time she moved away from it. The MARs that we inspected did not contain any signature gaps. The medication fridge in the treatment room was correctly locked and fridge temperatures were being consistently recorded. We visited various bedrooms with the Deputy Manager and found various prescribed creams with either no date of opening on them or in one room a new container of the same cream without the old one having been discarded and still with no date of opening. One person had cream in their room that they were using that had been dated but which was several months out of date. Creams and ointments were also not being signed for by the person applying it and there was currently no other record to tell us who had completed this task. We suggested that an audit of all creams in all rooms was carried out, that a system be started where old stock is collected before new stock is distributed and that staff understand that all topical medicines/creams should be dated on opening. We also explained that we would get the Commissions Pharmacy Inspector to provide advice regarding the correct recording of topical applications. We did not observe any interaction or observe any practices, at the time of this visit, that indicated peoples dignity and privacy were being compromised. We saw such Care Homes for Older People Page 17 of 40 Evidence: things as staff knocking on bedroom doors before entering, staff addressing people by their name and practices such as covering service users legs when moving them in a hoist in the main lounge. People were also asked at mealtimes if they wanted a covering put on their fronts; it was not just presumed that they did and where staff knew this was needed it was done in a dignified manner after explaining to the person what it was they were going to do. Care Homes for Older People Page 18 of 40 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people are having individualised choices and preferences met very well and others require more support to achieve this. The staffs knowledge and awareness is not such at the moment to always allow this to be achieved but measures have been introduced that will improve this over time. Evidence: The service employs a dedicated person for 30 hours per week to organise and lead activities. The AQAA tells us that this person has received training to do this and that the service plans to provide more structured activities at the weekend. We were informed that activities ideally involve small groups of service users; usually in the lounge area doing group or one to one activities of individual choice. This can also involve taking people outside for some fresh air or just having a chat. On the day of our visit one lady was flower arranging, another person had enjoyed a long chat with the activities coordinator. Another person was being taken out in the afternoon, which they explained was a regular outing with the coordinator, if the weather was fine. We did then wonder what happened to the rest of the people in the home at this point as apart from care staff talking to people we did not observe any specific activity taking place. Care Homes for Older People Page 19 of 40 Evidence: Despite the AQAA explaining that activities are provided on an individual basis when we looked at the activity records they did not show a consistent provision of this. We understand that for various reasons the activities have not been consistently provided and that some people are not getting the stimulation they need or that would be appropriate for them. For example one persons records recorded very brief comments in January and February of this year and then nothing until October. It may have been that this person refused any involvement for the seven months but the records did not tell us if this opportunity had been provided. We met several people during our visit that said they prefer not to join in organised activities, but we also observed others that clearly would benefit from more interaction. The new Manager has specialist experience and qualifications in caring for people with dementia and associated health problems and has identified that the people with less cognitive ability in the home do require more social input specific to their needs. This is something that she plans to develop. Some people are clearly able to express their choices clearly and we spoke to three people who were able to talk to us about these. All three had very specific preferences; one person also had a very set routine that they like to adhere to. We could see that items in this persons bedroom were stored in a way that would not be to everyones liking but it was how this person wanted it to be. This person had very specific preferences as to when various care tasks were carried out and in what they ate and when they ate it. They explained that they were generally very happy with their care but that there are times when their meals arrive despite them having expressed they would like this later. Another person finds it more comfortable to remain in bed and prefers their own company. The surrounding area around the bed was very personalised with pictures and personal items in reach. This person explained that the company of a cat, that was sleeping on their bed at the time of our visit, was very important to them. They said that some staff agree with this and others do not like it and make this known. The third person had been given the opportunity of moving to their current room when it became vacant specifically because they preferred a view of the garden. We observed one person sitting in their bedroom who told us that they had rung their call bell to be taken upstairs to the lounge. The call bell had been answered and they were now waiting for the staff to return. We noticed this person still sitting in their room thirty- five minutes later. Once in the lounge the person explained that it can take staff a while to come back once they have answered their bell initially but they realise they are busy. We also spoke to another person who said they do sometimes have to wait for a while for staff to come back and finish off small care tasks usually Care Homes for Older People Page 20 of 40 Evidence: first thing in the morning. We did look specifically at a selection of call bells response times because if people are generally having to wait unreasonable lengths of time for staff to respond, then this would have an impact on peoples quality of life and how the service enable peoples preferences to be met. These appeared to be predominantly responded to under five minutes and certainly less at times however, there were some which showed it had taken eight, nine and ten minutes. We identified that where the one service user could not remember staff visiting them first thing in the morning, they evidently were as the print out showed the call bell being activated and responded to several times during this period. We did ask the Deputy Manager however to ascertain if this persons requests and needs were being met in a way that fully satisfied them. We asked the Manager if she always has enough staff on duty to ensure that call bell response times did not get any longer and at the same time ensure the lounge area was supervised (refer to Complaints and Protection outcome for details). She admitted that she has to keep to a certain staffing level and to achieve this she cannot go under this. How the home is staffed is reported on within the Staffing outcome of this report. The service offers a choice of food each day and at lunch time and tea time we saw a variety of meals being provided. The cook was also able to confirm that various people have a cooked option for breakfast. We spoke to several people about the food and all said they always enjoyed what is provided and that it is always tasty. We observed staff treating people who needed support with feeding, with dignity and in an unrushed manner. We did note that the housekeeper met the needs of those in the dining room when care staff were busy attending to those who required more support. The one relative we spoke to said that they visit on a regular basis and that another member of the family also visits frequently; they indicated that there appeared to be no restrictions on when they could visit. The managers still feel that some staff are working in an institutionalised and task orientated manner and they are very keen to abolish this and establish personalised care throughout the twenty four hours. We feel that the odd comments made to us during the inspection process would indicate that this is probably the case and we recognise that this shift in culture does not happen over night. This is also one of the reasons the Deputy Manager is being given dedicated time to concentrate on taking a lead in supervising care practice and altering some of the working systems. As reported on in the previous outcome the reintroduction of BUPAs Personal Best will help with this. There did not appear to be any obvious guidance for people living in the home on Care Homes for Older People Page 21 of 40 Evidence: advocacy support. The Manager however was aware that this can be accessed through Age Concern and would make sure that appropriate guidance was made available. Care Homes for Older People Page 22 of 40 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. Peoples concerns and complaints are listened to and taken seriously. They are investigated and robustly addressed. People have been placed at risk through poor practices but the service have taken appropraite and swift action once the shortfalls have been identified. Evidence: The service adheres to the companys policy and procedures for complaints and the procedure is made available to all who move into the home; their representatives and is displayed within the reception area. We asked to see the services complaint file and spoke to the Manager and Deputy Manager about a recent complaint and the companys subsequent findings. Altogther the complaint file indicated that there have been three other complaints since January of this year in addition to the most recent received in August of this year. This corresponds with the information given to us within the services AQAA which also tells us that all complaints have been upheld. All of the complaints were investigated and the issues have either been addressed or are still in the process of being addressed as part of the services longer term improvement strategy. The most recent complaint was responded to within the companys stated time frame but has taken longer than the stated twenty-eight days to fully investigate. The Commission have been appropriatetly updated throughout this process and the complainant has been responded to. Where it has been appropriate the new Manager has correctly shared information with Care Homes for Older People Page 23 of 40 Evidence: the local Safeguarding Adults Team. The AQAA tells us that the service has made three safeguarding referrals to the local Safeguarding Team in the last twelve months and this is correct. The company have therefore demonstrated that their policy regarding this has been adhered to. The company have also shown good practice in taking robust action against staff who have put people at risk. In response to these shortfalls various staff trainings and quality reviews have taken place. All staff have received further updates on what constitutes an abusive act, in how to identify abuse and what to do if they witness or suspect it. We spoke to one member of the night team who was able to demonstrate a clear understanding of what potential abuse maybe, what they should do and why certain protocols are in place to protect vulnerable people. Staff are also aware of the companys Whistleblowing policy and have used this. One element of the most recent complaint was that staff were not present in the lounge area; late afternoon and early evening and therefore service user needs were not being met and people were not receiving adequate supervision. This concern has been raised before in this service so we were specifically keen to evidence how the service is now making sure this is addressed. During our visit we witnessed staff organising and making sure this did happen, but also when speaking to them it was very clear that the importance of this had been emphasised to the staff team by the current management team. Another issue that was raised in one of the complaints was one persons lack of access to a call bell. It is thought in this case that the call bell was within reach but that the lead had partially diconnected itself from the junction box. There are now regular checks in place to try and avoid this from happening again. The AQAA tells us that the companys Safeguarding Adults policy was last reviewed and updated in 2006. The new Manager has also identified a need for service users relatives and representatives to have a better understanding of the staffs limitations when service users refuse to do something. This stems from situations where staff have respected a service users right to refuse but family members have then expected them to make their relative; for example have a bath, get out of bed, eat or take part in activities. This topic is therefore going to be discussed in future resident and relative meetings. New staff do receive awareness training on the complaints policy and procedures but the AQAA tells us that this is to be reinforced. Staff also receive initial training on abuse issues and we have been informed that this has recently been reinforced with Care Homes for Older People Page 24 of 40 Evidence: all staff. We did not inspect each persons training file but we did inspect the training matrix and saw that most staff had been updated. Any gaps for various people were explained, for example they may be a bank member of staff who has not worked in the home for sometime. We also saw that one new member of staff had completed this training and another was due to complete this soon. Care Homes for Older People Page 25 of 40 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 benefit from living in an environment that is able to meet their needs and which is kept clean and domestic in charactor. Evidence: An extensive programme of refurbishment has taken place and we felt the environment looked much improved. The AQAA tells us that there are plans to improve the access to the garden and improve the garden generally. We complimented the housekeeper on the cleanliness of the home; there were no offensive odours and communal areas had less clutter. A seating area had been made around a fire surround instead of the previous storage of walking frames and wheelchairs we saw during one of the previous inspections. Although there are usually three domestics on duty each week day there is currently no domestic cover at the weekend so the new Manager is making arrangements to resolve this by recruiting a weekend cleaner. The laundry is covered separately and is also covered at least one day each weekend. There is a system in place for the segregation of soiled washing. The housekeeper confirmed that the same cleaning processes are in place as were in place during the last inspection. There are arrangements in place to promote good infection control. We also saw staff wearing protective clothing such as disposable gloves and aprons when carrying out certain care tasks and when dealing with food. Care Homes for Older People Page 26 of 40 Evidence: These systems were also colour coded as is the cleaning equipment. We observed staff hand washing and saw alcohol hand gels available for use by staff and visitors. We know that an Inspector from the Health and Safety Excutive, HSE gave the service a notice to improve the checks and risk assessments associated with Legionella. We asked to see compliance of this and were shown confirmation that this had been achieved in October of this year. We saw a variety of equipment including specialised beds and moving equipment to help make the care of those in the home more comfortable and safe. If specialised equipment, above and beyond what the service can provide, is required to meet a persons needs then appropriate assessments and support is arranged. The Manager spoke to one service user when we were present about a specialised wheelchair and how this could be arranged but the service user themselves have been reluctant for this to be done. Many of the bedrooms were personalised and people are obviously encouraged to bring in treasured items and pictures that will help them feel more at home. On the day of our visit the heating suddenly went down including the light in the lift. Immediate action was taken and a portable heater was placed in the lounge area and extra knee blankets found. An emergency torch was placed in the lift and external contractors called. It was resolved on the same day and later found to have been caused by a delivery lorry backing into one of the external electricity boxes, which inturn fused the electricity feeding the boilers and lift light. Care Homes for Older People Page 27 of 40 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. Although the service does not have a complete and permanent team in place as yet and there is still a need to improve the staffs collective skills. Alot of work has been done to improve the culture within the team and managers are actively addressing the shortfalls so peoples care needs can be met by staff who have the skills and interest to do this well. Evidence: On the days of our visit there were twenty four service users living in the home. It was explained that the home is currently staffed with six care staff in the morning and two Registered Nurses. In the afternoons there are predominantly five care staff on duty with two Registered Nurses. We were told that these numbers can sometimes drop if staff go off sick at the last minute. At night there are, as there were in our last inspection, three care staff and one Registered Nurse on duty. On the second day of this inspection a carer who was supposed to work from 8am until 8pm went off sick. The home therefore managed with five care staff until 10am when an agency carer arrived. We spoke to one carer and one night nurse who both agreed that currently the night staffing was adequate. We were particularly interested to have this confirmed as one service user, previously discussed in the Health and Personal Care outcome of this report has required alot of support and care from the night staff over a long period of time. One member of staff said this has been more Care Homes for Older People Page 28 of 40 Evidence: manageable lately because there have generally been less people living in the home and because the persons nights have been less active. The new Manager explained that any drop in what she knows to be an ideal number of staff to meet peoples needs has an impact on what the staff can achieve so she will try to avoid this whenever its within her means to do so. The Manager works Monday to Friday and is in addition to these numbers. Currently, because there are areas that require particular supervision and support and there are not the permanent staff to provide this on a day to day basis, the Deputy Manager is also in addition to these numbers and will be for the next forceeable few months. It is also planned that she will work some nights to audit care practices and identify training needs. The new Manager is currently going through an active recruitment process to rebuild a permanent and competent team. It is also planned to introduce a tier of senior carers who will lead groups of staff in the daily provision of personal care. These staff will be trained and initually supervised by staff within BUPA who are already successful senior carers. The new Manager was able to confirm that the services reliance on agancy staff has reduced. When staff are recruited it is explained that it is BUPAs expectation that all staff undertake an induction training which will then progress onto studies for the National Vocational Qualification, NVQ in care. We saw the learning portfolios for two people who had just started work at the home, which demonstrated they had commenced induction training. The training needs of the service are coorodinated and delivered by one Registered Nurse who works twelve hours a week and who is specifically employed to do this. One of the vacant bedrooms in a corridor of only three rooms, which are all currently vacant, is being used as a training room. The new Manager said the home is doing alot of staff training at the moment so the dedicated space for this has been invaluable. The AQAA tells us that the service plan to utilise the skills and resources of external healthcare professionals in developing its own staff skills. This has always happened but the new Manager wants to access external training to a greater degree than has been done in the past. We spoke to two staff members; one on days and one on nights who confirmed recent updates in various trainings. We were informed of various additional trainings that have taken place and these have included, for some staff, continence aids/pad training, an update by the Speech and Care Homes for Older People Page 29 of 40 Evidence: Language Therapist, an update on nutrition and nutritional risk assessing by the Dietician, a session by a wound care and dressings company representative and training on the use of a specific type of pressure relief mattress. Staff are also soon to receive training on how to care for and fit various hearing aids. This training will be attended by a relative of a service user as well. More specific training is going to be organised for Registered Nurses and senior carers (once in place) on pressure care, wound care and foot care. The Deputy Manager is also trying to organise training from the Specialist Parkinsons Nurse employed by the Primary Healthcare Trust, PCT. Some training has been provided on dementia care by BUPA but the new Manager who has a wealth of experience in this area of care wants to develop this further and plans to provide additional in house training. We looked at the recruitment files of three people. All had checks initiated with the Criminal Records Beauru, CRB. One persons start date was recorded as before the return of the CRB clearence. We were assured that this person had not started work in the home and that two weeks of this time had been spent entirely in the training room. This is normal practice in care homes where they need to urgently recruit. The fact that arrangements had been met for this person not to be working with vulverable adults before their CRB clearence was received means that the service has complied with the Care Home Regulations 2001. All had two satisfactory references. One person had been made redundant from a job that involved working with vulnerable adults and there was no recorded reason as to why this was. We said that this needed to be followed up. One application form consistently only had the year of employment recorded; no specific dates so it would have been impossible to establish any clear gaps in their employment. Generally the recruitment records showed good practices in recruitment but there were areas that required more attention and follow up. At the time of this inspection there were twelve permanent care staff on days and six working nights. Six staff in total hold a NVQ award and three are currently studying for the award at Level 2. There are no care staff with Level 3 NVQ. We are aware that BUPA have stopped the fast track NVQ training preferring people to be provided with a good standard of training. This means that the service does not currently meet the national minimum standard of 50 of care staff holding an NVQ award, but we are also aware that the services priority at the moment is to reestablish a full team. Care Homes for Older People Page 30 of 40 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will benefit from the current management which will ensure an improvement in some aspects of their safety and will ensure that the service is run in their best interest. Evidence: The new Manager of the service was a well established Registered Manager of another BUPA care Home up until she moved to Barrington Lodge. She is therefore known to the Commission as being competent to carry out the role and is well aware of BUPAs protocols and expectations. She is currently applying to the Commission to be the Registered Manager of this service. She is a Registered Nurse, specialising in the care of those with mental health issues and dementia, but she also has extensive experience in the care of the elderly. She is supported by a Deputy Manager who is also a Registered Nurse and qualified in general nursing and also experienced in the care of the elderly. Both are being supported by BUPAs various specialised departments and the local Care Homes for Older People Page 31 of 40 Evidence: Operations Manager to rebuild the services care team and improve the quality of the services being provided. Both of these managers are effective communicators and show strong leadership qualities. Therefore a clear message is being communicated as to the standard of care and service provision they expect to see. We are aware that the new Manager has a proven track record of zero tolerance when it comes to issues of abuse and poor practice and that she communicates this strongly. A team meeting has already been held where her expectations in relation to care practices, staff training and supervsion were discussed. We also witnessed the new Manager encouraging and praising staff who deserved this. We are aware of the companys action plan and it has and continues to address the shortfalls that were identified. The new Manager liases well with the Commission and other relevant agencies when she feels it is relevant to do so or when it is required such as notifying us of events under Regulation 37 of the Care Homes Regulations 2001. As reported in the Staffing outcome of this report the services priority is the recruitment of permanent staff and the development of a strong staff team. There is evidence that staff are being supervised appropriatetly and this system will further strengthen as senior carers and permanent Registered Nurses start to form a new team. The new Manager has already identified some members of staff who she feels may well make good senior carers and we again witnessed her encouragement towards these staff. The morale of some staff is low and they appeared to appreciate this support BUPA have various quality review methods to ensure that the quality of care and other services remain at a high standard. These include the Early Warning Audit Tool, EWAT. These systems clearly failed to identify a shift in staff culture and care practice within the home prior to the new Manager arriving. We discussed the ongoing EWAT with the new Manager and its various audits. We did not inspect the electronic records held in relation to service users personal allowences during this inspection but we understand the system has not altered. No individual amounts of money are kept but the service runs a separate account that people can pay in to and then bills such as haridressing, chiropody, toiletries and sundries can be payed from this. Service users can have access to small amounts of cash if they wish or manage their own personal monies if they prefer. A monthly invoice then shows what has been used as well as an individual rate of accumulated interest. We have not received any information that would alert us to any problems with the financial arraingements for peoples personal monies. Care Homes for Older People Page 32 of 40 Evidence: We did not examine all the records pertaining to the extensive health and safety checks that are carried out either daily, weekly or monthly by the maintanence peson. These are in line with BUPAs policies and procedures and we know from past inspections that these are audited regularly by BUPA. We did see evidence that all moving and handling equipment is checked and serviced by a specialist external contractor. The AQAA also tells us that all the main utilities have service contracts which are up to date. We saw relevant records and certificates that demonstrated that the lift is regularly serviced and is fit for use. We inspected records pertaining to fire safety checks and fire drills carried out by the service. Various safety checks are recorded in relation to fire safety and the fire alarm and equipment is serviced by a specialist external contractor. The last fire drill was carried out on 26th September and was recorded as a failure. This we understand was predominantly due to the trained staff at the time not knowing how to take the necessary lead. Staff are being retrained in fire safety and the maintanence person will carry out further safety drills with all staff so they are confident in knowing what to do. We found two doors that were clearly marked as fire doors propped open with pieces of furniture. Although we were informed that specialised fire closures had been ordered this practice demonstrates that staff are still not understanding the basics of fire saftey. This was reported back to the Manager at the time of this inspection. BUPA have various protocols that they expect staff to follow in order to ensure peoples safety. One of these is to take and record the temperature of the bath water before someone is bathed. We saw a record in a bathroom that we established is still used regularly for service user baths and it had not been completed since April of this year. We asked the Deputy Manager if these were being recorded anywhere else; they were not. She was aware of this and explained it was being addressed with staff. Again it is a practice that has been previously allowed to lapse. We did observe staff moving people safely when using using hoists in the lounge and we have been told that all staff are up to date with safe moving and handling training. We did not check each individual file but did note that new staff had received this training. We were informed that all staff had completed training on the Mental Capacity Act, although we did not inspect individual records of this. Staff have yet to complete training on the Deprevarion of Liberty, DOLs Guidelines that are part of this Act. The Care Homes for Older People Page 33 of 40 Evidence: Manager has completed a more indepth training on both subjects and the Deputy Manager is due to attend the Implementation of DOLs training soon. We did not identify anyone who is being unlawfully deprived of their liberty and the new Manager has confirmed that no one had been referred under the guidance on this basis. The DOLs training will further help staff think about their practices and what is acceptable and what is seen as an infringement on peoples rights and liberty. Care Homes for Older People Page 34 of 40 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 35 of 40 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 The Registered Person must 30/01/2010 ensure that peoples needs are fully identified prior to their admission and that necessary arrangements are made to ensure these needs are reviewed as needed and that they are met once the person is admitted. This is so that the service can be sure that they can meet the identified needs before they make a decision to admit. And: So that any required arrangements can be made prior to the person arriving. So that the persons needs are fully and appropriately met once they have been admitted. 2 4 12 The Registered Person must make sure the home is 30/01/2010 Care Homes for Older People Page 36 of 40 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 conducted in a manner that will ensure proper provision for peoples health, care, welfare, treatment and supervision. This refers to the homes present staff skills and practice and to any new staff and their future deployment within the home. This is so that peoples needs are fully met and that they remain safe once within the home. 3 7 15 The Registered Person must 18/01/2010 ensure that care plans and related care documentation give clear and consistent instructions to staff as to how someones need is to be met. This is in relation to one persons pressure relief care. This is so that the staff have a reference point that explains how consistent pressure relief care is to be given to this person, which also follows best practice and updated guidance. This is so that the persons Care Homes for Older People Page 37 of 40 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 risk of developing pressure sores is reduced or avoided. 4 9 13 The Registered Person must 18/01/2010 make appropriate arrangements to ensure the correct use of, correct administration of and correct recording of prescribed creams or ointments. This is so that the service make sure people are being treated with, or having applied products that are still effective and which are not past their shelf live and that they have received the treatment as it has been prescribed by a responsible individual. 5 29 19 The Registered Person must make sure that all gaps in peoples employment history have been explored. And that any reasons that are not clearly explained as to why someone left a previous employment, certainly if it was working with vulnerable adults, are fully explored. This is so the service can demonstrate that it has taken every measure possible to ensure that the 18/01/2010 Care Homes for Older People Page 38 of 40 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 people in the home are protected from people who may abuse or harm them. 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 8 The Commission suggest that a review is made of the current arrangements for ensuring people are weighed correctly and if needed additional or alternative equipment is put in place to achieve this. The Commission suggests that the activity coordinator be given support and further training if required to provide activities and social interaction for those with impaired cognitive ability. The Commission suggests that BUPAs own leaflets on Advocacy are placed in a prominent position for people to see. The Commission would suggest that the company review some aspects of its quality audit system to ensure that it is able to effectively trigger shortfalls that effect peoples care outcomes. 2 12 3 14 4 33 Care Homes for Older People Page 39 of 40 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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