Care Home: Bluebell Lodge Care Home

What the care home does well People who had moved into the home relatively recently considered they had been given good information to help them in their choice of home. The home`s assessments of prospective residents were detailed and objective, enabling the home to make a judgement about people`s dependency and the home`s ability to provide for individual needs. Care plans showed appreciation of `whole person` needs. As well as care plans for personal and physical care such as pressure area care and mobility, there was also consideration of people`s preferences in respect of recreational and spiritual needs. People had signed their care plans. Where people had specific medical conditions, these were reflected in their care plans. This meant staff had guidance on what it meant to have a particular condition, and what signs might indicate discomfort or deterioration. Records showed a high level of liaison with GP practices, and support to people to maintain appointments with consultants, opticians and clinics. Staff kept daily notes of care given. These gave a flavour of the quality of life people experienced, and showed that staff were aware each day of all the residents and of key care issues in the home. Staff gave a handover of information to staff coming on to the shift following them. Medicines were administered by members of staff who had undertaken appropriate training and been assessed as competent to administer. Elaine Andrews kept records of monthly medications audits that she carried out, which included observation of a medicines round and detailed checks on record-keeping and storage. People living in the home had many opportunities for stimulation and participation. Some people had recently been on local trips to a farm shop and a garden centre. Within the home there were visits by musicians and singers, and a `PAT` dog (pets as therapy). There was a visiting hairdresser, and a person commented on staff attention to helping people maintain and paint their nails if they wished. Members of staff encouraged people in games, such as dominoes and ball games. A link had been made with the local museum. There was evidence of support to people to maintain active involvement in chosen religious observance. The main meal of the day was lunch, for which there was a menu in the dining room. People told us they enjoyed their meals and our observation was that they did so. Service in the dining room was friendly and unobtrusive and it was a pleasant room. People received appropriate assistance to eat if they wished. During the afternoon there was a hot drinks round. This included the offer of fruit portions as well as cakes, which was popular. Elaine Andrews kept a log of complaints received since she became manager of the home in June 2008. There had been six, all of which had been addressed promptly. Each had been upheld, leading to corrective actions. Training and induction records showed all staff received abuse awareness training within the previous year. The home and garden presented well, with evidence of ongoing investment in fabric and decor. Furnishings were of good quality. Standards of cleaning were higheverywhere. The communal rooms were homely and included a quiet lounge where drink making facilities were maintained for use by visitors. People had personalised their bedrooms in various ways. The home benefited from a mainly stable staff team. Where new staff had been recruited, all necessary checks had been carried out to ensure they were safe to work with vulnerable people, before people commenced duties. The home had dismissed two staff discovered asleep on night duty, which showed effective monitoring and decisive action by the management. A group of care staff we spoke with presented as a close and motivated team. They were committed to training and development, all having NVQ (National Vocational Qualification) in care to level 2 or higher. One had obtained level 4, and two spoke of their hopes to go on to level 3. Ninety per cent of the total care staff team had obtained NVQ to level 2 or higher. A training matrix was used to plan training through the year, on the basis of needs established through regular individual supervision of staff. It showed all staff were kept up to date with mandatory training. The home had a health and safety policy and there was evidence to show how that was complied with by risk assessments, routine servicing of equipment and management monitoring. What has improved since the last inspection? The staffing rota provided for three care staff on duty throughout the day. This represented an increase on previous levels. The home had also created a new post (10 hours per week) of activities co-ordinator. Elaine Andrews had set up an annual questionnaire to obtain the views of residents and their supporters, which could be used to inform development planning. One issue this raised in 2008 was that some visitors experienced a lack of welcome at the home. This finding had led to the decision to provide refreshment facilities in the small sitting room. The home has addressed requirements made at the previous inspection, some of which had been repeated. Care plans were now being reviewed regularly. Where people`s hydration needed to be monitored, fluid charts were being kept and totalled, with one of the senior carers having specific responsibility for this. Risks of sustaining pressure ulcers were assessed using a recognised scoring system, and care plans were put in place in response. The monitoring of people`s weights was improved by obtaining scales suitable for people with mobility difficulties, as recommended at the previous inspection. Staff administering medications ensured they recorded medicines as taken, only after observing this to be so. What the care home could do better: We have recommended that any handwritten entries in the MAR charts should be counter-signed by a second member of staff to demonstrate they were checked for accuracy and thus to reduce risk of error. Medications requiring refrigeration were being stored in the kitchen refrigerator, which was not convenient to either care or kitchen staff. All medicines should be stored in one place by purchase of a smallrefrigerator specifically for medicines. A residents` meeting had been used to remind people they could lock their bedrooms if they wished. We recommend people`s options should be made plain in the service`s statement of purpose, and individual wishes about use of locks and of safe keeping facilities for personal monies should be revisited as part of individual reviews. There was an ongoing concern in the home of how to improve access via a patio door to the gardens, because a step made this difficult for some people, yet rails and ramps might impede others. We suggested the opinion of an occupational therapist should be sought. It would also be worth beginning to plan how best to upgrade the kitchen over time, before surfaces and fittings begin to fail. Care staff availability remained reduced on Mondays and Tuesdays when they covered the chef`s absence by preparing the midday meal. When we spoke with staff they considered staffing numbers to be sufficient, other than when there were cooking duties to be undertaken. The addition of a part-time cook or kitchen assistant would both promote the professionalism of the kitchen, and provide flexibility in how meals are provided without impinging on the care task. Minutes of residents` meetings showed they were attended mainly by the same small group of residents. The activities co-ordinator may be well placed to follow up residents` meetings one-to-one with those who do not attend them, for whatever reason, to assist them to feel involved and to have their voice heard. This in turn would increase the influence residents may have on how their care service is provided to them. Some residents may also like to contribute to the newsletter sometimes. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Bluebell Lodge Care Home Forest Lane Chippenham Wiltshire SN15 3QU     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Roy Gregory     Date: 0 6 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 33 Information about the care home Name of care home: Address: Bluebell Lodge Care Home Forest Lane Chippenham Wiltshire SN15 3QU 01249443501 01249447506 bluebell.lodge@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Chippenham Limited care home 19 Number of places (if applicable): Under 65 Over 65 1 19 mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: 0 0 Not more than 1 service user aged 65 years and over with a mental disorder may be accommodated at any one time. Not more than 1 service user in the age range 50 - 64 years may be accommodated at any one time. This person may only occupy the accommodation referred to in the variation application dated 27 March 2004 for respite or intermediate care and for a period not exceeding 4 weeks (except by prior consultation with the Commission). This bedroom is numbered 19 and located on the first floor immediately next to the medication storage room. The room may not be used for any mental disorder placement. The maximum number of service users who may be accommodated in the home at any one time is 19. Date of last inspection Brief description of the care home Bluebell Lodge is situated in a quiet cul-de-sac, in a residential area of Chippenham that has some local amenities. The town centre, with high street shops and mainline Care Homes for Older People Page 4 of 33 Brief description of the care home railway station, is about a mile away. Parking is available to the front of the home. There are 17 single bedrooms and one twin room, although the latter is used currently for single occupancy. One room is reserved for respite (short stay) use only. Rooms are large enough for people to bring some of their own possessions with them if they wish, when they move into Bluebell Lodge. Many have televisions, radios and small pieces of furniture. All rooms have en-suite toilet or bathing facilities. Rooms are on both the ground and first floors, which are connected by a passenger lift and two stairways. The shared areas of the home consist of two sitting rooms and a separate dining room, plus pleasant garden areas outside. The home does not provide intermediate or nursing care. Some residents are funded by their local authority, with fees starting from £377 per week. Residents who pay their own fees pay from £525 to £700 per week, depending on the degree of dependency being provided for. Additional charges are made for services such as hairdressing. A brochure gives people good information and is available in large print and audio formats. Care Homes for Older People Page 5 of 33 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: two star good 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 visited Bluebell Lodge on Wednesday 6th May 2009, between 9:20 a.m. and 6:00 p.m., our inspector being Roy Gregory. During this visit we met with most residents, in the sitting rooms and by sharing lunch in the dining room with four people that live at the home. We had detailed conversations with six residents and saw two personal rooms with the agreement of their occupants. We also looked at the respite room, which was vacant at the time, and toured all areas of the home, including bathrooms, kitchen and laundry room. The registered manager, Elaine Andrews, was available during most of the day. We also spoke with a group of care staff, the chef and the housekeeper. We had private conversations with a visiting district nurse and with a person visiting their relative. Care Homes for Older People Page 6 of 33 Records examined during the inspection included care plans and records of care, medication records, evidence of activities provided, and records of staff training, recruitment and supervision. It was also possible to look at the results of the homes internal surveys of residents and relatives opinions, from May and October 2008. We checked health and safety documentation, such as records of equipment servicing and risk assessments. Elaine Andrews provided evidence of routine monitoring of service provision, by herself and Mr Mackey, the proprietor. Prior to the inspection visit, Elaine Andrews had returned the homes Annual Quality Assurance Assessment (AQAA), which gave some descriptive and numerical information. It indicated where the service had made improvements and their aspirations for further development. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visit to the home. They take into account the views and experiences of people who live there. Our previous inspection of Bluebell Lodge took place on 15th May 2008. What the care home does well: People who had moved into the home relatively recently considered they had been given good information to help them in their choice of home. The homes assessments of prospective residents were detailed and objective, enabling the home to make a judgement about peoples dependency and the homes ability to provide for individual needs. Care plans showed appreciation of whole person needs. As well as care plans for personal and physical care such as pressure area care and mobility, there was also consideration of peoples preferences in respect of recreational and spiritual needs. People had signed their care plans. Where people had specific medical conditions, these were reflected in their care plans. This meant staff had guidance on what it meant to have a particular condition, and what signs might indicate discomfort or deterioration. Records showed a high level of liaison with GP practices, and support to people to maintain appointments with consultants, opticians and clinics. Staff kept daily notes of care given. These gave a flavour of the quality of life people experienced, and showed that staff were aware each day of all the residents and of key care issues in the home. Staff gave a handover of information to staff coming on to the shift following them. Medicines were administered by members of staff who had undertaken appropriate training and been assessed as competent to administer. Elaine Andrews kept records of monthly medications audits that she carried out, which included observation of a medicines round and detailed checks on record-keeping and storage. People living in the home had many opportunities for stimulation and participation. Some people had recently been on local trips to a farm shop and a garden centre. Within the home there were visits by musicians and singers, and a PAT dog (pets as therapy). There was a visiting hairdresser, and a person commented on staff attention to helping people maintain and paint their nails if they wished. Members of staff encouraged people in games, such as dominoes and ball games. A link had been made with the local museum. There was evidence of support to people to maintain active involvement in chosen religious observance. The main meal of the day was lunch, for which there was a menu in the dining room. People told us they enjoyed their meals and our observation was that they did so. Service in the dining room was friendly and unobtrusive and it was a pleasant room. People received appropriate assistance to eat if they wished. During the afternoon there was a hot drinks round. This included the offer of fruit portions as well as cakes, which was popular. Elaine Andrews kept a log of complaints received since she became manager of the home in June 2008. There had been six, all of which had been addressed promptly. Each had been upheld, leading to corrective actions. Training and induction records showed all staff received abuse awareness training within the previous year. The home and garden presented well, with evidence of ongoing investment in fabric and decor. Furnishings were of good quality. Standards of cleaning were high Care Homes for Older People Page 8 of 33 everywhere. The communal rooms were homely and included a quiet lounge where drink making facilities were maintained for use by visitors. People had personalised their bedrooms in various ways. The home benefited from a mainly stable staff team. Where new staff had been recruited, all necessary checks had been carried out to ensure they were safe to work with vulnerable people, before people commenced duties. The home had dismissed two staff discovered asleep on night duty, which showed effective monitoring and decisive action by the management. A group of care staff we spoke with presented as a close and motivated team. They were committed to training and development, all having NVQ (National Vocational Qualification) in care to level 2 or higher. One had obtained level 4, and two spoke of their hopes to go on to level 3. Ninety per cent of the total care staff team had obtained NVQ to level 2 or higher. A training matrix was used to plan training through the year, on the basis of needs established through regular individual supervision of staff. It showed all staff were kept up to date with mandatory training. The home had a health and safety policy and there was evidence to show how that was complied with by risk assessments, routine servicing of equipment and management monitoring. What has improved since the last inspection? What they could do better: We have recommended that any handwritten entries in the MAR charts should be counter-signed by a second member of staff to demonstrate they were checked for accuracy and thus to reduce risk of error. Medications requiring refrigeration were being stored in the kitchen refrigerator, which was not convenient to either care or kitchen staff. All medicines should be stored in one place by purchase of a small Care Homes for Older People Page 9 of 33 refrigerator specifically for medicines. A residents meeting had been used to remind people they could lock their bedrooms if they wished. We recommend peoples options should be made plain in the services statement of purpose, and individual wishes about use of locks and of safe keeping facilities for personal monies should be revisited as part of individual reviews. There was an ongoing concern in the home of how to improve access via a patio door to the gardens, because a step made this difficult for some people, yet rails and ramps might impede others. We suggested the opinion of an occupational therapist should be sought. It would also be worth beginning to plan how best to upgrade the kitchen over time, before surfaces and fittings begin to fail. Care staff availability remained reduced on Mondays and Tuesdays when they covered the chefs absence by preparing the midday meal. When we spoke with staff they considered staffing numbers to be sufficient, other than when there were cooking duties to be undertaken. The addition of a part-time cook or kitchen assistant would both promote the professionalism of the kitchen, and provide flexibility in how meals are provided without impinging on the care task. Minutes of residents meetings showed they were attended mainly by the same small group of residents. The activities co-ordinator may be well placed to follow up residents meetings one-to-one with those who do not attend them, for whatever reason, to assist them to feel involved and to have their voice heard. This in turn would increase the influence residents may have on how their care service is provided to them. Some residents may also like to contribute to the newsletter sometimes. 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 set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 33 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 33 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. Efforts are made to ensure that as much information as possible is gained about prospective residents to ensure their needs can be met. People and their families are encouraged to visit to see for themselves what is being offered. Good information is made available to help people make a decision about pursuing a placement at the home. Evidence: The homes statement of purpose had been re-written in line with the requirement made at the previous inspection. In addition, the home had produced a new brochure that gave accessible information, and was also available in large print and as an audio version. One resident told us how they had planned for admission to the home, on the basis of information provided, visiting the home, and receiving an assessment visit at their home. However, their plans had been overtaken by a hospitalisation, from which they had been discharged to Bluebell Lodge, as their continued residence in their own Care Homes for Older People Page 12 of 33 Evidence: home had become non-viable. The person felt that the way admission planning had proceeded, both initially and in response to their changed circumstances, had helped them move in with full awareness and a minimum of disruption. They considered the written information provided was also helpful to the process. Assessment records for another person recently admitted showed they were subject of a full assessment, in which a significant relative was also involved. Some aspects of the assessment were scored, which enabled the manager to be sure the service could meet the persons needs and assisted staff in knowing the degree of support that would be provided. Detailed assessments for aspects of care, such as moving and handling needs and nutrition screening, were carried out as part of the pre-admission assessment. Hospital discharge reports were also incorporated into initial assessment. The management of the home had given consideration to developing an additional room as intermediate care provision, but this was not being pursued and the related National Minimum Standard is therefore not relevant to this service. One bedroom was designated for use as a respite (short-stay) place and had just been made ready for occupation. Mrs Andrews confirmed that people staying short-term would be assessed in the same way as people being considered for long-term placements. Care Homes for Older People Page 13 of 33 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual care plans direct how care is to be provided and they receive regular review. There is prompt awareness of and response to health needs, including good liaison with health professionals and emergency services. People are protected by the homes policies and procedures for the safe handling of medication, subject to improved storage. The approach to the care task is based on respect for diversity and privacy. Evidence: All care plans followed a consistent and logical format. They included personal profiles and assessments of dependency levels. There was evident appreciation of whole person needs. As well as care plans for personal care and physical issues such as pressure area care and mobility, there was also consideration of recreational and spiritual needs, and peoples preferences in respect of sleeping, and eating meals. People had signed their care plans, and there was evidence of monthly review by the manager, which ensured plans were up to date. Full reviews were held six-monthly. This level of review practice was in contrast to that seen at previous inspections, when we had to make requirements for improvement. Care Homes for Older People Page 14 of 33 Evidence: A person described what they considered their major care needs were at the present time, and what the home provided to support those needs. Their account correlated closely with the recorded content of a recent full review of their care plan. Elaine Andrews said that for people part-funded by local authorities, the home was experiencing good co-operation by care managers in the review process. Where people had specific medical conditions, these were reflected in their care plans. This meant staff had guidance on what it meant to have a particular condition, and what signs might indicate discomfort or deterioration. Records showed a high level of liaison with GP practices, and support to people to maintain appointments with consultants, opticians and clinics. A persons close relative told us the home had always obtained medical attention quickly when necessary, and kept the family informed of developments. We saw a recently recorded example of a person being admitted to hospital for investigation. It was possible to track events from the initial record of concern by a night carer, to handover to a senior carer and a request for a GP visit. There was then liaison between the home and the hospital regarding the persons return to Bluebell Lodge. Care plans were complemented by individual risk assessments, for example covering risk of falls. An example of a falls risk assessment described why the person was assessed as being at heightened risk, and the particular factors to be reduced. Risks of pressure ulcer formation were assessed using a recognised scoring system and any observed marks were recorded on body maps. This meant our requirements from the previous two inspections, regarding pressure area risk assessment, were met. Where it was part of the care plan to turn a person regularly as a precaution against pressure ulceration, turn charts showed evidence of compliance with the plan, and also showed that the person was offered fluids each time they were attended. A senior carer had responsibility for weekly totalling of fluid charts, where these were in use for individuals, and passed on to the manager any concerns arising. This was in line with a previous requirement. Peoples weights were monitored regularly, unless they had indicated they did not wish for this to happen. The home had obtained weighing scales suitable for use with people who cannot weight-bear, as we recommended. A visiting district nurse said she found Bluebell Lodge a good home to work with. Staff were knowledgeable about all residents and wanted to understand issues from the nurses perspective in order to complement the care they gave. Referrals to the nursing service were appropriate, and advice given was followed. The nurse told us she had never seen anything to suggest people were not well cared for. We joined a handover from one care shift to another, it was matter-of-fact but Care Homes for Older People Page 15 of 33 Evidence: sufficient to ensure care staff coming on duty were aware of peoples state of wellbeing and of priorities for meeting peoples needs. Staff kept daily notes of care given, these gave a flavour of the quality of life people experienced, and showed that staff were aware each day of all the residents and of key care issues in the home. People living at the home told us they found their privacy and dignity were respected. They made choices during the day about using communal rooms and the garden, or being in their bedrooms. For less mobile people, staff asked about and facilitated such preferences. We saw that staff asked permission before entering peoples rooms. One person required the assistance of three staff to use the bath, but their care plan stated that once in the bath, only one person was to stay with them until they wished to get out again. Where necessary, there were communication care plans to ensure staff had guidance on effective communication, these included consideration with the person of their needs and preferences concerning vision and hearing aids. The home has one double room, but this was being used as a single room as it was considered a small room to share, unless by two people who definitely wished to share. No residents were self-medicating, apart from one person who had a reliever medication in respect of a specific condition and had been risk assessed as competent to retain responsibility for this. Medicines were administered by members of staff who had undertaken appropriate training and been assessed as competent to administer. Individual competency was checked annually and records showed all were currently in date. Elaine Andrews kept records of monthly medications audits, which included observation of a medicines round and detailed checks on record-keeping and storage. This meant medicines that were expired or no longer needed were returned promptly to the pharmacy, and the medicines administration records (MARs) were checked for accuracy. We recommended that any handwritten entries in the MAR charts should be counter-signed by a second member of staff to demonstrate they were checked for accuracy and thus to reduce risk of error. Where people were prescribed medicines to be taken as needed there was guidance in individual care plans about how these should be made available to people, and this was reflected in the record kept in the MAR. Storage of medicines was safe, and was being improved by an up to date controlled drugs cabinet, which was on order (there were no such medicines in use at the home at the time). However, medications requiring refrigeration were being stored in the kitchen refrigerator, which was not convenient to either care or kitchen staff, neither of whom could be considered fully responsible for the safety of the items. All medicines could be stored in one place by purchase of a small refrigerator specifically for medicines. Care Homes for Older People Page 16 of 33 Care Homes for Older People Page 17 of 33 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home seeks to identify and meet peoples social, religious and recreational needs. There are no barriers to contact with family and friends, and people are able to make some decisions about every day life. People are offered a choice of good quality meals, which take account of dietary needs and preferences and are served in a pleasant environment. Evidence: Activity records showed people living in the home had many opportunities for stimulation and participation. Some people had recently been on local trips to a farm shop and a garden centre. Within the home there were visits by musicians and singers, and a PAT dog (pets as therapy). There was a visiting hairdresser, and a person commented on staff attention to helping people maintain and paint their nails. Members of staff encouraged people in games, such as dominoes and ball games. A link had been made with the local museum. A person from there had visited the home with exhibits on different themes, such as toys and holidays, to give talks and lead conversations with a reminiscence theme. There was evidence of support to people to maintain active involvement in chosen religious observance. Care Homes for Older People Page 18 of 33 Evidence: A visitor said they viewed everyday life in the home as based on encouragement and participation, whilst also respecting peoples wishes for quiet or privacy. Their relative enjoyed alternating between using their television and CD player in their private room, and joining with others in the main sitting room. Another resident said they liked to go to the dining room or small sitting room for a change from the main sitting room or their own room, whilst others liked to use the garden sometimes. A resident talked about helping with tasks in the garden. The small sitting room provided a private alternative to receiving visitors in bedrooms or the large central sitting room. This room was provided with hot water and drink-making facilities for visitors to use at any time. Activity provision in the home had recently been boosted by the addition of an activities co-ordinator to the staff team, for ten hours per week. Whilst this person had some specific performance skills, he saw his role as getting to know individuals to ensure they received the kinds of interactions they wanted at a one-to-one as well as group level. During our visit the co-ordinator led bingo and quiz sessions in the sitting room. He said he looked forward to direct involvement in care planning as far as peoples social and occupational needs were concerned. He intended targeting his attention on those who had few visitors or who did not join group activities for whatever reason. We saw in a care plan review that a person had been noted by staff as spending increasing time in their room, and less time pursuing their usual interests. This had led to a care plan direction to staff to remind the person about activities that were provided, and to ask the activities co-ordinator to offer one-to-one engagement. At a residents meeting in April 2009, it had been stressed that the activities coordinator would concentrate on individual wishes, and would not replace any of the trips and entertainments that people were already used to. We heard positive feedback from people living at the home about their initial experiences of the activities coordinators role in the home. Care plans showed that peoples preferences about food were gathered at assessment and passed to the chef on admission. Lists in the kitchen showed individual preferences and dislikes as well as information about medical constraints on diets. The main meal of the day was lunch, for which there was a menu in the dining room. There was no choice of alternative main courses, but because of the small size of home, individuals were invited to choose an alternative if the main meal was known to be unsuitable for them, for example, one resident disliked fish. There was a choice of sweets, and of breakfasts. People told us they enjoyed their meals and our observation was that they did so. Service in the dining room was friendly and unobtrusive. Where a person needed assistance to eat, this was provided with a sensitive approach, and it was recorded in the persons care plan that some assistance had become necessary. Another person was asked at table if they would like assistance and the staff accepted Care Homes for Older People Page 19 of 33 Evidence: readily that the person preferred to eat unaided. The staff helped to create a good atmosphere in the dining room. Some people by choice or necessity received meals in their rooms. As in the dining room, meals were portioned to match peoples appetites and tastes. During the afternoon there was a hot drinks round, this included the offer of fruit portions as well as cakes, which was good practice and was popular. The chef worked five days per week, including every weekend. She was enthusiastic and saw it as part of her job to have plentiful interaction with the residents, in order to maintain direct feedback from them. One resident liked to assist with some kitchen tasks, such as peeling vegetables. Menu planning was geared to the preferences of the resident group and to the season. There was also some taking account of the fact that in the chefs absence, care staff had to prepare the midday meal as well as breakfast and tea. Care Homes for Older People Page 20 of 33 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. There is good provision for receipt of and response to complaints. Staff and management understand and exercise responsibilities in respect of keeping residents safe. Evidence: Elaine Andrews kept a log of complaints received since she became manager of the home in June 2008. There had been five complaints from residents and one from a relative. All had been addressed promptly and each had been upheld, leading to corrective actions. Openness of communication, by way of residents meetings, staff meetings and unrestricted visiting, appeared to produce a climate of confidence for people to raise issues as they arose. People we spoke to knew of the option to make any issue a formal complaint if necessary. Training and induction records showed all staff received abuse awareness training within the previous year, and there was provision to ensure this was renewed twoyearly. Staff members were given the No Secrets abbreviated guide to local safeguarding procedures. Elaine Andrews has experience from a previous post of working with these procedures. In response to suspicions raised within the home, Elaine Andrews had visited Bluebell Lodge by night to check on the working practices of two night staff. Both had been Care Homes for Older People Page 21 of 33 Evidence: found sleeping and this was regarded by management of the service as a major protection issue, resulting in the two staff being dismissed and referred for inclusion on the POVA (Protection of Vulnerable Adults) List, which would prevent them working in future in a care capacity. Residents had lockable cabinets within their rooms. A recent residents meeting had considered the issue of locks on bedroom doors. Residents were reminded they could have a key if they wished to use one. Downstairs rooms did not in fact have locks, but Elaine Andrews said they could be fitted for anyone that wanted one. It would be preferable to establish with each individual, at initial assessment and on review, their current wishes and abilities concerning use of locks. The statement of purpose should also be clear about how this issue is to be addressed for individuals. Care Homes for Older People Page 22 of 33 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 live in a safe, well-maintained and homely environment. Personal accommodation is excellent. Communal and private areas are kept clean and hygienic to a high standard. Evidence: Records of the proprietors regular visits to the home showed close attention was paid to environmental issues, with quick responses to rectify any identified shortfalls. Five resident rooms had been redecorated over a three month period. A persons care plan review showed they had requested redecoration of their room, and they had subsequently been invited to choose a colour scheme. All rooms had en suite toilets. The two rooms we saw in detail were attractive and personalised. A persons visiting relative said they appreciated the amount of storage available in their relatives room. They had been able to bring in a lot of personal possessions. We also saw a room recently refurbished to provide a short-stay facility. This was spacious, but a shortage of natural light, and some restricted headroom, would make the room unsuitable for long-term occupation. The communal rooms were homely in character. People appreciated the choice of sitting rooms, both for themselves and as providing options for meeting with visitors. The main sitting room was large enough for the television at one end not to interfere Care Homes for Older People Page 23 of 33 Evidence: with the ambience at the other end, which lent itself to conversation and quiet pastimes. Furnishings were of good quality. Baths in en suites were unsuited to the needs of most residents, but there were sufficient assisted bathing facilities, which included a newly purchased hoist. There was an ongoing concern of how to improve access via a patio door to the gardens, because a step made this difficult for some people, yet rails and ramps might impede others. We suggested the opinion of an occupational therapist should be sought. The kitchen was just coping with the demands made of it, in terms both of size and the nature of surfaces, as it was essentially a domestic rather than commercial scale of kitchen. It also has the disadvantage that care staff have to use part of the kitchen as a through route at all times of day. It would be worth beginning to plan how best to upgrade the kitchen over time, before surfaces and fittings begin to fail. The laundry was also a cramped room, but worked for the size of home. The garden was being used as a drying area, as a new tumble drier was awaited. Care staff undertook laundry tasks, and night staff saw to ironing and labelling clothes. A housekeeper was employed for five days per week. She showed the cleaning schedule she worked to, which included regular deep cleaning of residents rooms. The schedule was flexible to allow for specific needs or requests arising. There was regular monitoring of cleaning standards, which we found to be high throughout the home. There were no unpleasant odours anywhere. Paper towel dispensers had been installed, as recommended at the previous inspection. All staff received training about infection control, and hand gel was available around the home. The housekeeper had been trained in infection control and food hygiene, and had received specific input about MRSA. Care Homes for Older People Page 24 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have support from competent staff who are provided in numbers sufficient to maintain essential care. People are protected by sound recruitment practices that ensure nobody works at the home until checks on their background are complete. The service invests in the development of staff, to maintain a trained and mainly qualified team. Evidence: The staffing rota provided for three care staff on duty through the day and evening and two staff awake through the night. This represented an increase on previous levels. A complaint from a resident in 2008 about call bell response times during afternoon shifts led to a review of staffing levels, and an increase from two to three care staff at those times. Some staff had also raised the issue of staff numbers through individual supervision. Care staff availability remained reduced on Mondays and Tuesdays when they prepared the midday meal as those were the chefs days off. When we spoke with staff they considered staffing numbers to be sufficient, other than when there were cooking duties to be undertaken. The chef was about to take two weeks holiday, and Elaine Andrews had prepared for this by increasing morning care staff to four over that period, so one of them could undertake kitchen duties without affecting staff availability to residents. However, the addition of a part-time cook or kitchen assistant would both promote the professionalism of the kitchen, and provide Care Homes for Older People Page 25 of 33 Evidence: flexibility in how meals are provided without impinging on the care task. The group of care staff we spoke with presented as a close and motivated team. They were committed to training and development, all having NVQ (National Vocational Qualification) in care to level 2 or higher. One had obtained level 4, and two spoke of their hopes to go on to level 3. 90 per cent of the total care staff team had obtained NVQ to level 2 or higher. Training was well organised. For each member of staff there was a training record that showed training updates that were due and that had been completed. There had been recent training inputs on care of the dying, and manual handling. A training matrix was used to plan training through the year, on the basis of needs established through individual supervision of staff. It showed all staff were kept up to date with mandatory training. The activities co-ordinator expressed an intention to be included in the staff training programme. Apart from the two staff dismissed earlier in 2009, there was a largely stable staff team. In respect of a person who had been recently recruited, they had completed an application form and there was a record of interview, showing their aptitude was fully considered. Their employment history had been considered in full, as required following the previouis inspection. They had not been employed until after receipt of two references, a CRB (Criminal Records Bureau) disclosure and check against the POVA list. We saw that for another recently recruited member of staff, a second reference and CRB disclosure were being awaited before setting a start date. Care Homes for Older People Page 26 of 33 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home benefits from an effective chain of management. The views of people living in the home, and their supporters, are sought and acted on to ensure the home is run in their best interests. The care people receive is enhanced by regular supervision of staff. People are safeguarded by the arrangements made for handling their finances. The environment is safe for residents and staff because of sound health and safety policies and practices. Evidence: Elaine Andrews, had been managing the home since May 2008. She was committed to the My Home Life project in Wiltshire, which has a remit of promoting person-centred and forward-looking care practices. She had introduced an improved care planning system to the home with related documentation. All administrative records were in logical order and easy to access. There was evidence of keeping up to date with current publications. Elaine Andrews worked some care shifts, including evenings and weekends, which made her accessible to people and kept her in touch with how the Care Homes for Older People Page 27 of 33 Evidence: home was running. She clearly had a good knowledge of all the resident group. We are aware at the time of compiling this report that there is to be a change of manager during 2009. The manager was supported by monthly visits from the provider, Mr Mackey. Records of those visits showed they always included direct contact with residents and staff as well as supervisory and discussion time with the manager. There was evidence of monitoring of matters such as complaints handling and environmental standards. Elaine Andrews had set up an annual questionnaire to obtain the views of residents and their supporters, which could be used to inform development planning. One issue this raised in 2008 was that some visitors experienced a lack of welcome at the home. This finding had led to the decision to provide refreshment facilities in the small sitting room. Residents meetings provided another avenue of two-way feedback between residents and management. Two residents confirmed their involvement in these. For example, one said a request he had made in the meeting for some trellis in the garden had been passed on, and Mr Mackey had confirmed to him that it had been bought. However, minutes of the meetings showed they were attended mainly by the same small group of residents. The activities co-ordinator may be well placed to follow up residents meetings one-to-one with those who do not attend them, for whatever reason, to assist them to feel involved and to have their voice heard. A monthly newsletter was distributed to residents, and copies were left in the entrance hall for visitors to take. A visiting relative said they appreciated these, and took extra copies to send to relatives that were unable to visit. The visitor described the home as constantly accessible and open. It may be that some residents would like to contribute to the newsletter as well as being recipients of it. Earlier in 2008, the newsletter carried pictures of different options for a water feature in the garden, to enable a majority decision on which was to be bought. The majority of residents chose to have a small cash float kept in safe keeping in the office. Individual monies were kept separately within this system, with receipts kept along with a running record of monies received and paid out. Elaine Andrews signed the records regularly to show she had checked them against balances held. For additional security of all concerned it would be appropriate to confirm the wishes of residents, or their advocates, concerning safe keeping arrangements by way of a signed agreement. This could then be revisited at reviews to ensure arrangements were still regarded as satisfactory. Staff meetings were held bi-monthly. Minutes of the most recent showed it was attended by all but three of the staff. Elaine Andrews was undertaking all individual Care Homes for Older People Page 28 of 33 Evidence: staff supervision, but intended the three senior carers would take on more of this task. They might benefit from some specific training in this role. A supervision matrix on the office wall showed planning to ensure that staff would receive individual supervision six times per year. Supervision records showed staff had the opportunity to discuss their work with residents, how their work was organised, training aspirations and personal issues. The home had a health and safety policy and there was evidence to show how that was complied with. There were good arrangements for the use and storage of substances potentially hazardous to health. Unused water outlets were routinely flushed to ensure no build-up of conditions for legionella to develop. There was an upto-date range of environmental risk assessments, including for waste disposal. There were individual risk assessments for evacuation of residents in the case of fire, and also for each organised trip from the home. All care staff received emergency aid training, whilst senior carers were trained in first aid to appointed person level. The staff group were up to date with training in moving and handling, and food hygiene. There was evidence of recent servicing of the passenger lift, emergency call bell system and fire precautions. Care Homes for Older People Page 29 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 30 of 33 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 9 13 A suitableregfrigerator must be provided for storage of medications that require refrigeration. All medicines need to be stored in one secure location, and with no compromise to the storage needs associated with the kitchen. 31/07/2009 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 9 18 Handwritten entries in the Medicines Administration Record should be checked and signed by a second member of staff. The statement of purpose should include options for residents about locking personal rooms, and individual wishes should be established and revisited periodically. Commence planning for upgrading the kitchen to commercial standards. Seek the advice of an occupational therapist on how best to provide safe access from the home to the garden. 3 4 19 20 Care Homes for Older People Page 31 of 33 5 6 33 35 Consider how to widen resident participation in residents meetings. Ask residents or their advocates to sign agreement to arrangements for safekeeping of personal monies, and keep these arrangements under review. Staff who are to provide individual supervision to other staff should be provided with appropriate training to do so. 7 36 Care Homes for Older People Page 32 of 33 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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. 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