Care Home: Bluebell Court

What the care home does well Residents are happy living at Bluebell Court. They speak well of the staff team and about the care that they receive. Comments include `I am so much better now than when I arrived at the home`, `the staff always do their best to make sure I am comfortable` and `the staff are kind and caring`. Residents are also happy with the food provided and think that the activities and entertainment provided are also good. The home has good facilities, with large bedrooms, en suites and a choice of lounges on each unit. The home is clean and well maintained. The management team have an open and objective approach to any concerns or complaints. Staff are recruited properly to the home and a high percentage of them have achieved an NVQ qualification in care. What has improved since the last inspection? Since we last visited the home a new permanent manager has been employed and there is some steady progress. Care plans and records are improving and overall the team at the home are more resident led and are providing a more person centred approach to care. Some records have been reviewed and updated, such as the Service User Guide and the pre-admission assessment. The level of staff with an NVQ qualification has risen significantly and the turnover of staff has decreased and less agency staff are used. What the care home could do better: Whilst it is clear that the home has improved overall, there are still areas for work and/or continued development. Progression in some areas has been limited and it is likely that this has been affected by the lack of a consistent manager. The care records have improved but more work is needed on developing a person centred approach, management also needs to ensure that plans are up to date and the required risk assessments are completed. The prevention of pressure sores in the home needs to improve along with manager`s monitoring of such issues. Medication administration is generally sound but staff need to tighten up their practice. Entertainment in the home is good but the team need to work on developing meaningful one to one or small group activities that would help residents retain skills, feel valuable and improve their self worth and independence. There are gaps in the staff training that need addressing and we are aware that management are taking action. However the number of staff trained in the specialist care of people with dementia is still lacking and potentially affecting outcomes for residents with those needs. Bluebell Court is a large home that is registered for three different resident groups. The management of the home needs to be robust and work needs to be done with the new manager to ensure that systems are in place that keep her up to date with key information, so she can take action where required. Key inspection report Care homes for older people Name: Address: Bluebell Court Stanley Road Grays Thurrock Essex RM17 6QY     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: Diane Roberts     Date: 1 9 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 35 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 35 Information about the care home Name of care home: Address: Bluebell Court Stanley Road Grays Thurrock Essex RM17 6QY 01375369318 01375369346 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Primrose Care Home Limited care home 80 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home Bluebell Court is a purpose built three storey care home with Nursing for older people who have physical disabilities and dementia and is registered with Commission for Social Care for the continuing care of 80 residents in total. The Home is located centrally in the town of Grays within walking distance of local amenities. The M25, the A13 and Grays railway station are in close proximity. The building has been adapted to provide three purpose built floors, to provide a homely atmosphere for the service users and families. Trained nursing staff and carers are available for the provision of personal and nursing care. Parking is available to the front of the building. The home was registered in July 2006. At the time of the site visit the manager confirmed that the fees ranged from £395.43 to £575.00 per week. Care Homes for Older People Page 4 of 35 Over 65 30 80 10 0 0 0 1 6 0 4 2 0 0 9 Brief description of the care home Care Homes for Older People Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The site visit was undertaken over a 7 hour period with two inspecting officers, as part of the routine key inspection. It was possible to meet with two senior managers from the company who are having regular input at the home and the new manager who commenced work in June 2009. The manager completed an Annual Quality Assurance Assessment, as required by law, that details their own assessment of what they feel they do well, what could be done better and what needs improving. Prior to the site visit we sent surveys to the residents and staff at the home and got a good response. We also contacted the visiting district nursing team to the home for their input. Comments and responses are throughout this report. During the visit to the home, it was possible to speak to 6 residents and 4 staff in addition to the management team. It was also possible to speak to one relative. A tour of the home was undertaken and a range of records relating to the home and the services offered were reviewed. Care Homes for Older People Page 6 of 35 Care Homes for Older People Page 7 of 35 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. Care Homes for Older People Page 8 of 35 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 35 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can generally be assured that their needs will be properly assessed prior to coming into the home and that they will have sufficient information on which to base a decision. Evidence: Since we last visited the home the management team have reviewed and updated the service user guide. Efforts have been made to make it pictorial but overall the documents are still wordy and not very user friendly, for the different resident groups in the home. However it is available in large print and in an audio version. The manager in her AQAA said we would like to review the format of our service user guide so they are more user friendly. We did not see the guide freely available around the home and this should be reviewed to ensure that residents have access to this information at their leisure. Residents and families who commented on our surveys felt that they have received enough information prior to their admission to the home. Care Homes for Older People Page 11 of 35 Evidence: The manager or key senior staff at the home undertake pre-admission assessments for prospective new residents. Two recently completed assessments were reviewed. Overall these were sufficiently detailed to enable the team to make a decision as to whether they would be able to meet the new residents needs. The assessments contained some person centred information regarding residents preferences and abilities but this was not consistent and limited in some areas, for example, with personal care. Whilst this assessment tool has developed since our last visit to the home, it may be of value to review the form further, in order to prompt the assessor to seek more person centred information. The home is registered to care for people with dementia. The information provided in the assessments was limited on how a persons dementia actually affected them, for example, what they are able to do and if there are any behavior management needs that could potentially be challenging. The team need to evidence that they are aware of and have considered this information before accepting a resident rather than just stating end stage dementia. Residents who we spoke to who had recently moved into the home said that they had settled in well. They said when I came in the staff showed me around and introduced me to people, they are all very friendly here, I was a bit nervous but I soon settled in and everything is good, they could not do anymore for you. Care Homes for Older People Page 12 of 35 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect to have their basic care needs met in quite a person centred way but some aspects of their health care may not always be fully taken into account. Evidence: We reviewed care planning and management in the home and in doing this looked at 6 care plans from the nursing, residential and dementia units. Overall the care planning continues to improve in the home although there are still areas for work. On the whole the residents had the care plans that they needed in place, following a full assessment of need. However, more work is needed with staff to ensure that they do not overlook, for example, planning the ongoing care and support for residents who are bereaved and how this may be affecting them and those who require pain management. The care plans in place were generally detailed enough in order to guide staff and in some cases they contained some good person centred information, for example, residents choices and the way they wanted their care delivered had been noted. Overall, this continues to need development by the care team in order to bring more of the resident into the care plan, showing their preferences and abilities etc. as this is not consistent across all care plans. Care Homes for Older People Page 13 of 35 Evidence: Care plans from the dementia floor were on the whole more person centred than others and gave some good detail on the individual. On discussion with the care staff, they knew the residents care needs quite well. They could give some detailed person centred information, which was not evident in the care plan, for example, residents preferences on who they liked to care for them and food preferences. This information should be recorded to ensure that all staff are made aware. Staff did demonstrate a limited knowledge of residents with regard to their life history and them as an individual, before coming into the home. Information regarding this was seen in the care plans and staff should ensure they read it, so it can help them to relate to the residents more. Overall the assessment of social care needs was weak, giving more statements of fact rather than an actual assessment. Some were only partially completed and the subsequent care plans were either not in place or contained limited information. This is discussed more in Section 3 of this report. Care plans on the residential and dementia units were up to date. However, on the nursing unit, it was noted that some had not been reviewed for three months, bringing into question whether they reflected the current needs of the resident. We observed that reviews do take place with relatives, where residents are unable to have input and this is good practice. However this was approached as a quick exercise, with limited detail, rather than a more meaningful discussion of the resident, their needs and the continued placement at the home. The carer was observed to be writing down the review before the relative had had chance to speak or consider things. However it was clear that the relative was happy with the care provided. It was also noted that the reviews carried out with relatives and residents are not preplanned, therefore not giving any party real time to consider the review. We feel that this would be of value considering some reviews with relatives had not been completed for well over one year. The manager in her AQAA said care plans are reviewed monthly by the staff team and we do 6 monthly reviews with care managers, relatives etc. We would not fully agree that this is consistently in place. The management team are currently introducing a deprivation of liberties checklist for all residents in the home. The daily notes that care staff record have improved since our last visit and they generally are now more reflective of the care provided and the resident themselves, although some staff still need guidance in this area, for example, staff are writing resident maintained in a safe environment, which is not reflective of the resident, their abilities or the support given. The manager in her AQAA said residents care plans are more person centred and the information contained within this is in depth and comprehensive. We would generally concur with this statement. The manager says that they plan to provide more training on care planning. Care Homes for Older People Page 14 of 35 Evidence: Residents we spoke to said they always give me an extra pillow to rest my arm on, they always ask me if I am warm enough at night and they come and check on me, I feel a lot better than I did when I first came into the home, I am very well now, they look after your dignity when they are helping you with a bath, my independence is encouraged but staff are about in case they are needed, I like to look presentable and they look after my clothes. Residents who commented in surveys felt that they always had the care and support that they needed and staff listened to them. Comments included I am well looked after, my laundry is done well and they do their utmost to make me comfortable. Residents had a range of risk assessments in place. Generally those requiring to be in place were completed well but there were still some omissions. For example, one resident who required help with feeding and was on nutritional supplements, did not have a nutritional screening tool completed. It was noted that the risk assessments had more omissions and were less likely to have been reviewed on the nursing floor of the home. Wound assessments and treatment plans were in place on the nursing floor and these were sufficiently detailed but did require dates so that they could be evaluated properly. Since our last visit to the home, the team have developed the bed rail risk assessment tool so that it now more robust and shows whether the rails are suitable for use with residents. Records showed that residents weights were being consistently monitored and that were any concerns were noted, these were referred on to the doctor and/or dietitian. When we visited the home in May 2009, we looked at the prevention and management of pressure sores in the home. Whilst there was a home acquired sore at the time that was a concern, overall the team were preventing and managing pressure sores well, especially as residents were coming in from home and the hospital with them. On review this time, it was noted that there were some residents who had developed low grade sores from sitting in the same position. Some of these had healed and on observation there was plenty of pressure relieving equipment about. On the residential floors, the team needs to be more proactive in assessing risks and obtaining equipment from the community services so that sores do not develop in the first place. The manager of the home also needs to have clear and up to date information on any residents with or who have a potential pressure sore in the home, as at the time of our visit the manager was unsure. On discussion with staff from the visiting district nursing team, they would concur with this assessment. Records showed that residents health care needs were being met and that they were having the appropriate input from doctors, physiotherapists, district nurses, Care Homes for Older People Page 15 of 35 Evidence: chiropodists etc. It was noted that all the residents are on fluid intake monitoring charts. These are not in place on a needs assessed basis and this practice could be reviewed. Those fluid charts check were up to date and gave a good picture of the intake of the resident. On touring the home it was noted that more support needs to be given to residents with regard to their personal care, for example with hair brushing in the mornings. It was also noted that staff need to be more aware of what residents are saying and wanting, especially on the dementia unit, where whilst staff interactions were caring, they were not always listening to residents and missing what was really needed. For example a resident was wandering with a cup and this was filled up when she said she did not want it and staff did not attend to the fact her nose was running. Another staff member was noted to give a resident a drink whilst standing over her rather than sitting with her. Observing staff around the home there are many examples of good practice but equally example of practice that shows that staff needs more support/training and ongoing management/guidance to ensure that residents receive care in a person centred way. From the records, of the 27 staff covering the unit that cares for people with dementia, only six have received training on caring for people with dementia. This is a concern and was an agenda item at the last key inspection. It is of particular concern that none of the senior staff taking charge of the night shift have training in this subject. The administration of medication was reviewed on two floors. The management team complete a weekly audit of medications on each floor and the results of these were seen. Overall the administration of medical in the home was generally sound although there is some tightening up on practice to be done. Shortfalls noted, but these were not consistent over the two units checked, were for example, the dates of opening on liquid medications and eye drops were not always recorded, which would not aid an audit if required or help to ensure items were disposed of at the correct time. It was also noted that staff were using omissions codes but they were not always defining why a medication had been omitted. Where residents are not taking medications at night because they are asleep, staff need to be more proactive with the residents doctor to see if this can be administered at another time. For example, one resident had not had a required tablet four nights in a row. Other evidence showed that where staff were concerned about medications, they had contacted the doctor for advice and/or a review. Staff need to sign any transcribed hand written prescriptions and they need to evidence that as and when medications have been offered of considered for residents. The safe storage and administration of controlled medications was checked and found to be in good order. It was noted that residents had a range of topical creams available and on discussion with staff, there was no consistent approach or rational for use. Their use was also not Care Homes for Older People Page 16 of 35 Evidence: always reflected in the care plan. This requires review to ensure that residents are getting the required care that has been planned and evaluated. Care Homes for Older People Page 17 of 35 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Outcomes for residents are generally good with regard to mealtimes, activities and choice in their daily routines. Evidence: On discussion with staff and residents and from the records, it is clear that the routines of the day are generally quite resident led. Residents that we spoke to said They ask me what time I want to go to bed and they come and help when I want to go, They ask me if I wanted to get up early and I do so, they come about 6.30 to 7 a.m, which suits me, if you are asleep they will leave you alone and you can please yourself in this home. Staff spoken to gave examples of giving residents choices, promoting their independence and showed an appreciation of residents rights. The activities officer keeps a social profile on each resident. These contained some good information on residents preferences and how much they like to participate in the activities offered. Aims and objectives were limited and tended to give more general statements such as get more involved with social events and get to communicate with other residents more. In addition to this, some residents had life histories completed whilst others did not, even though they had relatives who regularly visited them at the home. Some of the life histories contained a good level of Care Homes for Older People Page 18 of 35 Evidence: detail which is valuable to the staff team to read. Residents need a social care assessment in place that outlines their needs so a care plan care be developed that guides staff on the support needed to ensure that residents take part in meaningful activities as well as having opportunities for entertainment. At the current time there is no evidence that residents completed are encouraged and supported to take part in activities of daily living such as dusting, laundry, table laying etc. This needs to be explored. Staff spoken to felt that activities was an area that could be improved in the home as they felt that residents needs were very different and they found it difficult to cater for them all. They did see that they had a role in the provision of activities, which is positive. Records showed that activities included films, entertainers, trips out the local community and shops, quizzes, exercises, church services, fish and chips and fancy dress, harvest festival, sing a longs etc. The records tended to reflect what had been going on in the home rather than if the resident had taken part. The records contained limited evidence of one to one time, which can often benefit the resident to retain their independence/skills and promote their self worth. From discussion, it is clear that their are quite good opportunities for entertainment and group activities but the development of one to one time and therapeutic individual time needs more work. Residents enjoyed a staff member bringing a small puppy into the home and those with dementia were particularly positive. It is positive to see that the local scout group are due to come and help put up the Christmas decorations in the home this year, helping to integrate the home more into the local community. Residents we spoke to said I have been offered trips outs, we have a lot of entertainment here, we all come downstairs and do exercises, its good, we have a knitting afternoon which I enjoy, we are not just left, the activities people are very good, I have been out to Tescos today, I enjoy the exercise class and the coffee mornings we have, I dont have any one to one time with the activities officer but she is very helpful, if I want to go out the staff take me or they will buy me things I want when they are off duty, the entertainers are good and the staff get me crosswords if I want them. The majority of residents who commented on our surveys said that there was always activities for them to take part in although some said usually or sometimes there was. The management team said that they plan to recruit another activities officer in the near future. It was noted from records that the company only provide a £25.00 a month activity budget for a home of over 80 people. We observed the lunchtime routine on all three floors. Lunch is served at approximately 12.30 to 13.00. Many of the residents are still eating at 13.30. We noted later that tea is then served at 16.15, which is very early and does not give Care Homes for Older People Page 19 of 35 Evidence: sufficient times between meals. It could also mean that residents, who choose to go to bed early may not have anything to eat or drink for over 15/16 hours till breakfast the next morning. This was discussed with the management team, who agreed that this needed a review. Supper is served later on and toasted teacakes or crumpets are popular. Records show that some residents do choose this option during the evening. Over lunch residents were being sensitively assisted by the care staff. Some floors did not have condiments available to the residents and more could be done to promote their independence and choice during mealtimes, for example, self serving drinks, gravy etc. Some residents choose to eat in their rooms and they were served appropriately. The menus are reviewed with input from the chef, who regularly talks to residents and the manager. They are checked by a nutritional specialist. The chef uses low calorie sweeteners for all items in order to cater for diabetic residents, but in turn was still serving some processed foods that contained sugar. This should be reviewed. Fresh fruit was available and the chef makes home made cakes every day. More attention should be given to providing more snack type meals on the unit for people with dementia and also more specific options for individuals with weight loss, rather than the chef just putting more food on the trolley. Records show that residents do have some flexibility with the menu and the chef does his best to accommodate preferences and alternatives. It was noted that residents are still using coloured plastic beakers for drinks which are not seen as age appropriate and this should be reviewed as it was stated that these are used because of the risk of breakage with glass. It was noted that residents are using china cups etc. On this visit, residents had much better access to drinks, such as squash, between the more formal drinks rounds. Residents we spoke to about the food said whatever I have I enjoy, there is choice and they bring fruit around, oranges, apples, bananas, when we are in the lounge, I dont find the food too bad, you can ask for something else, the food is always hot enough, the food is very good and if there was something on the menu I did not like then an alternative would be offered and you can have food and drinks anytime of day or night, I often ask for tea during the night and they get me a cup straight away. Residents who commented on the surveys gave variable responses to the meals at the home saying that they always, usually or sometimes like the food provided. Care Homes for Older People Page 20 of 35 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that any concerns they have would be listened to and acted upon and generally they would be protected in the home. Evidence: Notices around the home show that the manager holds a surgery for relatives once a week, for them to come and discuss any matters with her, including any concerns they may have. The manager confirmed that these are ongoing. Residents we spoke to said they say if you have any complaints, just tell them and they will sort it out for you and I would tell people immediately if I had any concerns or complaints. Of the residents who commented on surveys, nearly all said that they knew how to raise any concerns. Since we last visited the home the manager has dealt with nine complaints and one is ongoing. Complaints related to staffing, laundry and the care of residents personal items. Communication with relatives and external bodies was also raised. Records showed that the management team had dealt with these in a timely manner and objectively. Records showed the actions taken in response to the matters raised. The manager in her AQAA said we learn from the outcomes of our complaints and we have a robust policy in place for dealing with complaints. Staff spoken to showed a good understanding of adult protection matters and where appropriate the management team had notified the appropriate authorities of any Care Homes for Older People Page 21 of 35 Evidence: concerns. The manager in her AQAA said we now have more emphasis on adult protection within the staff supervision process. Training records show that out of a team of 95 staff, 39 do not have up to date training in adult protection. On discussion with the management team, they had recently been let down with a booking for training sessions and this has left them with a significant shortfall which they are currently addressing. Care Homes for Older People Page 22 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a clean, safe and well maintained home but their specialist needs could be better met. Evidence: We undertook a partial tour of the home with the manager. We visited all three floors and saw bedrooms, lounges, dining rooms and bathrooms. Overall the home was seen to be very clean. Occasional odours were noted but these were limited to individual rooms. In some cases they may be requiring more attention from the domestic team. Relatives who commented said the home is always kept clean and residents we spoke to said the home is very clean and my room is kept very clean and tidy. Those who commented in our surveys said the home was primarily always clean and fresh with only a few saying it was usually clean and fresh and comments included the home is clean and comfortable. The home has good facilities and the bedrooms are large with en-suites. Bathrooms are large and each unit has two separate lounges and dining room facilities with a small kitchenette. The home provides a room for residents who smoke. The smell of cigarette smoke was very evident outside this room, without us opening the door. This could affect the quality of life for the residents in the adjacent rooms and the installation of an Care Homes for Older People Page 23 of 35 Evidence: extractor fan should be considered, especially in light of recent smoking legislation. Since we last visited the Memory unit for people with dementia there has been an improvement with the amount of interactive and textural items displayed on the walls. However, residents still do not have names or other prompts on their bedroom doors to promote their independence and apart from the items on the walls there was little else seen to stimulate the residents. We recommended that residents had their names put on their bedroom doors in November 2008. Since we last visited the home a gardener has been employed and the grounds are very pleasant. Residents were seen to be accessing the garden with staff and relatives. The manager had an up to date fire safety risk assessment in place. Regular checks are made on the fire safety systems and equipment in the home including specialist maintenance. Records show that staff attend regular fire drills. The maintenance man checks equipment and systems in the home on a regular basis and keeps records of such. The manager in her AQAA says that she walks around the home on a daily basis and actions any items or issues that need attention. We noted that there was plenty of protective clothing around for staff to wear and nearly half the staff team have attended training in infection control. Care Homes for Older People Page 24 of 35 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a stable staff team, who need more training in some areas to ensure that they can fully meet their needs. Evidence: Agency use at the home is minimal and the management team said that they only have 3 care staff vacancies at the current time along with the vacancy for the activities officer. At the time of our visit, the deputy manager was also on extended leave and the clinical lead post was about to become vacant. The manager said that they planned to advertise this post soon. The management team review the staffing levels based upon a dependency tool that they use in the home. At the current time the staffing level are 1 senior and 5 care staff in the mornings and 1 senior and 4 care staff in the afternoon on the unit for people with dementia and at night there is 1 senior and 2 care staff. On the nursing unit there is an RGN, 1 senior and 5 care staff on in the morning reduced by one carer in the afternoon and at night there is an RGN and 2 care staff. On the residential floor there is 1 senior and 3 care staff in the morning and afternoon and at night this reduces to 1 senior and 1 carer. On reviewing the rotas the records showed us that the on the unit for people with dementia, they were regularly not achieving the current levels that the manager said were in place, often being down by one carer on each shift. This was also evident on the nursing unit. Staffing levels on the residential unit are maintained. Records of staff Care Homes for Older People Page 25 of 35 Evidence: meetings show that the management team try to address unacceptable sickness levels amongst staff. The manager needs to liaise with staff and review cover and address why there are shortfalls especially as the vacancy levels at the home are relatively low. Residents we spoke to said the staff are very good to us, they are kind and they stop and chat, if you buzz, they are here very quickly, my call bell is always available and the staff respond very quickly, nice carers, the staff are all very good and there are not any that are not nice, day and night staff, and the staff are very nice and very good to me. Records show that the care team now have over the 50 desired NVQ qualified level and some of the care staff have achieved an NVQ level 4 in care management. This is a good progression. Staff files were reviewed in order to check the robustness of the recruitment procedures. Staff files were found to be in good order with all the required checks and documentation in place. Qualified nurses registrations were checked and found to be in good order. There was evidence of the induction of new staff and this included care practice observations. Staff spoken to confirmed that they had undertaken induction training. Training records show that there are still gaps in staff training, for example with manual handling and fire safety and other updates. When we visited in November 2008, the teams training also had significant gaps. The management team explained to us that they had been let down by a training company with whom they had booked training sessions and this resulted in the current gaps. They were able to evidence that these had been re-booked with other companies. The management team have booked some train the trainer sessions for key subjects in early 2010 and this may help them in the future to avoid such situations and to keep on top of the training requirements of such a large staff team. Records also show that staff are attending training on the management on challenging behavior and the managers AQAA says that 37 staff have attended infection control training. Some staff have attended odd courses or days on specific subjects such as skin assessment and palliative care etc. but this is minimal and needs to develop in order to ensure that the staff team understand the conditions associated with old age and especially dementia. Whilst we understand and accept that the home have been let down, this does not account for all training in the home and it is disappointing that this remains an area for development that the management team must address and that we shall be monitoring closely. Staff confirmed that they had attended training sessions and were undertaking NVQ Care Homes for Older People Page 26 of 35 Evidence: qualifications. Care practice competencies are undertaken and there was evidence of this on the staff files, for example, for manual handling and the safe administration of medication. This is used as an addition to the staff supervision programme. Care Homes for Older People Page 27 of 35 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst the management team at the home aim to ensure that it is run in the best interests of the residents, gaps in management mean that outcomes may not always be positive. Evidence: The manager has been in post at the home since June 2009 and this is her second management role. She is a qualified nurse with additional qualifications in teaching and assessing, the care of the elderly and she confirmed that she is up to date with all her required training such as manual handling etc. Since we last visited the home, the day to day manager of the home has changed twice and this has not helped with the overall progression of the home, despite support from the providers management team. This is reflected in this report. However, the home is steadily improving but there remain areas for work. On discussion with the manager, it was evident that she needs to have more Care Homes for Older People Page 28 of 35 Evidence: management monitoring systems in place in order to provide her with the up to date information that she needs to help ensure that the home runs smoothly and that residents needs are met. We felt that the manager should be more aware of, for example, the number of residents with pressure sores in the home and why these had developed and also more information on accidents to evidence that these had been reviewed and followed up. It is felt that this may be compounded by the lack of deputy manager at the current time. The management team at the home have an on call system in place that includes senior management if required. The management of the home have a quality assurance system in place. This comprises of a range of internal audits, for example, medication administration and obtaining feedback from residents and relatives etc. This has recently been undertaken using feedback questionnaires for residents and the results are being collated. An action plan would then be developed. The manager meets regularly with residents and relatives. Minutes are available and show that a range of subjects are discussed and residents and relatives are kept up to date with planned changes within the home. Relatives we spoke to were very happy with the care their relatives received. They said good food and good carers who are lovely, I visit every other day and I am always happy with what is going on in the home. Residents who commented said I am happy here and I think the staff are lovely and helpful. The home do hold personal monies on behalf of residents. The manager confirmed that there is a double signatory system in place and that there are weekly audits undertaken to check the accounts. There is also a residents social fund account that is supported by relatives. The manager has completed appraisals for staff but acknowledged that the supervising system was not consistent at the current time and was still developing. Review meetings for new staff were inconsistent and not in line with the management policy. This in particular needs to be addressed to ensure that new staff are properly supported and that the care that they provide is acceptable. The manager holds regular meetings with the staff teams but the minutes do not always evidence the views of the staff team and generally just list the subjects discussed. There is some evidence that issues raised, such as concerns over hairdressing and food are dealt with. The manager has held a health and safety meeting. The minutes showed that any items identified had been dealt with appropriately and that staff were observant in Care Homes for Older People Page 29 of 35 Evidence: raising issues. This may be a good forum in which to review and discuss accident statistics, patterns in the home, having a more multi-disciplinary approach to the review. Accident records were checked and found to be recorded appropriately and notified to us when appropriate. The manager confirmed that they seek advice from the falls prevention team when needed and are also reported to the residents doctor. They also plan to work with the district nursing team to undertake a pilot study on falls. Accident records are audited, primarily in relation to the time of the accident. This could be developed further in order to give them more valuable information about the nature of accidents in the home to help them with planning any work that could be undertaken in order to reduce risks. For example, the number of unobserved accidents to help with staff deployment. It was also noted that the manager was not regularly monitoring accident records completed by staff and was not aware of an incident that caused unexplained bruising to a resident. Care Homes for Older People Page 30 of 35 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 30 18 The staff team at the home 31/07/2009 must be appropriately trained for the work they are expected to undertake, with particular emphasis on the care of people with dementia. So that residents are cared for by a competent staff team who understand their needs. Care Homes for Older People Page 31 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 12 Improve outcomes for residents health in relation to the prevention of pressure sores. So that outcomes for residents are good in this respect. 14/01/2010 2 8 12 Ensure that residents have 31/01/2010 all the risk assessments that they require in place and that they are kept up to date. So that any risks to residents are properly managed and reduce wherever possible. 3 12 16 Residents individual social care needs must be assessed and planned for. So that their needs are met, promoting their independence, the retention of skills and feelings of self worth. 14/02/2010 Care Homes for Older People Page 32 of 35 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 4 18 13 Ensure that all staff have up to date training in the protection of vulnerable adults. So that as far as possible, residents are protected. 14/02/2010 5 31 12 The manager at the home needs to put in place robust management monitoring systems. So that the health and welfare of the residents is protected. 14/01/2010 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 2 3 1 7 9 Continue to develop the service user guide to make it more user friendly and freely available around the home. Continue to develop the care plans in a person centred way. Review medication practice with the staff who administer medications so they attend to the shortfalls noted and ensure that these are monitored within the homes own auditing system. Review the provision of food in relation to specialist diets and additional items for individual residents, such as those with weight loss etc. Signage for residents with dementia need to improve in order to promote independence and the retention of skills. Consider the installation of an extractor fan for the smoking room. 4 15 5 6 19 19 Care Homes for Older People Page 33 of 35 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 7 36 The staff supervision programme needs to be fully implemented and maintained and new staff should be appropriately supervised. Accident records should be sufficiently monitored by the manager to ensure that where required the appropriate investigations are undertaken and/or followed up. 8 38 Care Homes for Older People Page 34 of 35 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. 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