Care Home: Bon Accord

What the care home does well The service provides nursing care to up to forty one older people with mental health disorders. Residents appeared happy; and the majority of residents had full access to walk around the ground floor of the home and could be assisted to walk into the garden. An activities co-ordinator is employed by the home anda range of activities is offered which include occasional outings and residents being assisted to the shops or to a hairdressers outside the home. Some residents are assisted to attend religious worship in the local church and a minister visits the home. On the day of the inspection a local choir was singing to the residents. Residents appeared well groomed and it was evident that staff were taking a pride in ensuring resident`s appearance met their needs. Residents nursed in bed appeared comfortable. The home provides a nutritious and well balanced menu with choices at each meal. Menus with pictures of the meals to be served are on the tables; and tables and trays were attractively set out. Comments from resident surveys and comments received on the day included: " The home is very family orientated, all staff interact well with each other and with the residents, they are a very friendly team". " A caring and supportive staff, the home is usually clean and the food is good". " I think I am very well looked after, I like the meals and I like the staff, they are all my friends. The night staff always have a kind word for me and will sit and chat to me if I get worried about things, they make sure I am safe at night if I am scared". What has improved since the last inspection? There have been many improvements since the last inspection and many of the improvements seen at the last inspection have been sustained. The company is now investing in the home insomuch that there is new furniture including new profile beds and mattresses, equipment is maintained, new carpets purchased and redecoration of resident`s rooms is being undertaken. Staff now have regular formal supervision and recruitment systems are robust. Requirements made at the last inspection have been complied with. A relative of a resident who had concerns at an earlier inspection told us: " It is so much better here, the food is so much improved, equipment is provided, my (relative) is so much better cared for. Management is much better and we are very pleased with the home as it is now". Staff also said that improvements in the home were tangible and that it had made a difference to them to be able to ensure that the residents had the diet that they wanted and also that the equipment was kept in good order. What the care home could do better: Although some improvements in care planning and medication administration seen at the last inspection have been maintained, they have not been wholly sustained, and staff must ensure that the current needs of residents are clearly and accurately identified. The storage and recording of medication does not always safeguard residents, and senior staff are not yet ensuring that actions are recorded and taken for those residents who refuse food or drink. There is a concern that minor complaints are not being taken seriously, and that these may not always be recorded or acted upon. Staffing levels, specifically at some times of day, do not allow for the dependency of the residents and do not allow for extra housekeeping staff to be brought in if a member of staff is absent. Staff do not have time to visit residents nursed in their rooms at intervals other than the allotted time for giving care and are therefore unable to offer extra fluids or check on the specific residents, this means that residents in their rooms undergo a time of isolation and do not have contact. The home has no results of recent quality monitoring audits which have taken place in the past year and these were not available at the last inspection. These should be made available to residents and other stakeholders in the home. Not all staff have received mandatory training in the past twelve months. Requirements have been made around all these issues and the home will be expected to provide an action plan. Key inspection report Care homes for older people Name: Address: Bon Accord 79-81 New Church Road Hove East Sussex BN3 4BB     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: Elizabeth Dudley     Date: 1 1 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 36 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: Bon Accord 79-81 New Church Road Hove East Sussex BN3 4BB 01273721120 01273730983 bonaccord@schealthcare.co.uk leeminggarth@schealthcare.co.uk Southern Cross (Hamilton) Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Nicola Jayne Stevenson Type of registration: Number of places registered: care home 41 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users to be accommodated is 41. The registered person may provide the following category/ies of service: Care home with Nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Mental disorder, excluding learning disability or dementia (MD) Date of last inspection Brief description of the care home Bon Accord is a care home with nursing and is registered to provide nursing to 41 older people with mental health needs.It is owned by Southern Cross(Hamilton) Limited. 19 of these places are contracted to the local authority. Residents accommodation is spread over three floors and consists of thirty-five single Care Homes for Older People Page 4 of 36 Over 65 0 0 41 41 2 0 0 8 2 0 0 9 Brief description of the care home rooms and two shared double rooms. Twenty-one of the single rooms and three of the shared rooms have ensuite facilities consisting of a washbasin and wc.There are two assisted bathing facilities and three assisted shower facilities. All staircases and the front door have a secure keypad entrance system. A shaft lift serves all floors.Communal accommodation consists of three lounges and two dining rooms. There is access to a large rear garden. The home has a large garden at the front with limited parking facilities.The roads around the home are metered parking only but the home is served by public transport and there is a train station at Portslade, which is approximately twenty minutes walk from the home.The home maintains links with the local psychiatric hospitals and local General Practitioners and associated health care professionals visit the home. Current fees range between £624 and £850 per week. These do not include extra services such as hairdressing and chiropody and charges for these are available from the manager. The last key inspection took place on the 20th August 2009 Care Homes for Older People Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This key unannounced inspection took place on the 11th May 2010 from 10:00 to 17.30 and was facilitated by the registered manager and the manager from another Southern Cross home. Whilst all residents in the home were seen on this day, three residents, six visitors to the home and eight members of staff were involved in the inspection and gave their views on the home. Documentation, which included care plans, personnel files, medication charts, menus , training plans and health and safety files, was examined. All areas of the home, including residents personal accommodation were seen. Prior to the inspection surveys were sent out by the Care Quality Commission to residents and six were returned. Some of these had been filled out by relatives and Care Homes for Older People Page 6 of 36 representatives, but all surveys gave a valuable insight into the life at the home and information from these were used to inform the inspection. Ten surveys were sent out to members of staff and seven were returned. The Annual Quality Assurance Assessment, a document required by regulation in which the provider or manager tells us what they have achieved in the past twelve months and what they hope to achieve, was received when we asked for it and was used to inform the judgements in this report. The last key inspection took place on the 20th August 2009 Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? There have been many improvements since the last inspection and many of the improvements seen at the last inspection have been sustained. The company is now investing in the home insomuch that there is new furniture including new profile beds and mattresses, equipment is maintained, new carpets purchased and redecoration of residents rooms is being undertaken. Staff now have regular formal supervision and recruitment systems are robust. Requirements made at the last inspection have been complied with. A relative of a resident who had concerns at an earlier inspection told us: It is so much better here, the food is so much improved, equipment is provided, my (relative) is so much better cared for. Management is much better and we are very Care Homes for Older People Page 8 of 36 pleased with the home as it is now. Staff also said that improvements in the home were tangible and that it had made a difference to them to be able to ensure that the residents had the diet that they wanted and also that the equipment was kept in good order. 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. 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 36 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 36 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. There is sufficient information available to enable prospective residents or their representatives to make an informed decision about whether the home can meet their individual needs. The manager or another trained nurse assesses the psychological, health and social needs of the resident to determine whether the home is able to meet these needs. Evidence: Prospective residents are assessed by the manager or another registered nurse prior to admission to the home and to ensure that the home can meet their needs. Residents receive a brochure about the home and they, or their representatives are able to visit the home before deciding whether the facilities and services offered are suitable for individual requirements. Copies of preadmission assessments carried out for three residents who had been Care Homes for Older People Page 11 of 36 Evidence: recently admitted to the home were examined. These were sufficiently comprehensive to inform staff and to form the basis of the individuals care plan. All prospective residents are informed in writing about whether the home has the facilities and skills required in order to meet their needs. The home produces a Statement of Purpose and Service User Guide, both these documents have been reviewed recently and are made available to the prospective resident on their admission to the home, or prior to this should the resident wish to have this information before admission . All residents receive a copy of the homes Terms and Conditions of Residence on their admission to the home. The relative of one resident who recently come to live at the home confirmed that they were happy with the way that the admission process was carried out and that this had been done in a relaxed manner. The home admits residents for permanent, respite and continuing care, but not for transitional or intermediate care. Care Homes for Older People Page 12 of 36 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. The standard of care planning does not accurately support the care required to ensure residents current and ongoing nursing and health care needs will be met. The standard of medication storage and recording does not safeguard residents and may lead to the misappropriation of medication in the home. Evidence: Whilst residents appeared to be cared for and comfortable, the standard of care planning which informs the staff over the care required and includes essential information, has not improved to any significant degree since the last inspection. Consequently information in some care plans was not compatible to the care required. Four care plans were examined and these belonged to both new residents and those who had been in the home for a longer period. Staff have been undertaking monthly reviews and evaluation of the care plans, however there was evidence in one care plan that this had not been done in a Care Homes for Older People Page 13 of 36 Evidence: thoughtful manner which related to changes in the residents condition since the original care plan dated 3/07/08. It would appear that the staff have just copied the relevant chart from one month to another. In this case it showed that a resident was at a low level risk of pressure damage when observation of this resident and their presenting health conditions showed that in reality this resident was at a very high risk of pressure damage. Further more the same chart had been filled in twice each month with the same or slightly different outcomes. Out of the three care plans examined, all showed that any changes in the residents needs detailed in the monthly reviews had not been added to the main body of the care plans or had adequate instructions to staff on how to address the changes. Likewise all the main bodies of the care plans were dated as being formed in April, July or August 2008 and little change made to them. Two of the care plans stated updated July 2009 but no changes at all made to the care plans although monthly reviews showed that there were changes. Another part of a care plan instructed staff to maintain blood glucose to within normal ranges but did not include what the normal ranges for this specific resident were. Other information not present in care plans included information about night care, what were the residents preferred times of rising and retiring, how often they would need care or fluids during the night and were there any specific problems staff should be aware of. Continence care plans were not personalised, social care plans incomplete and no outcomes of visits from other health care professionals were shown which may have changed care needs. There were no oral care plans in place. Information about the required pressure of pressure mattresses for the individuals were not present in care plans although evidence that these had been checked were in the individual rooms. There was misleading information regarding one resident which stated that nutritionally this resident was not at risk whereas discussion with staff and evidence from food and fluid charts showed that this resident would often refuse food and fluids. This was evident on the day of the inspection and charts compiled on the day prior to the inspection showed that the person had only taken in 200mls of fluid- this was not recorded in the care plans or the daily records therefore action had not been taken. It was evident on talking to registered nurses that that they were aware of this situation but had not addressed this or ensured that it was reported in the daily records. Care Homes for Older People Page 14 of 36 Evidence: Risk assessments had not been reviewed monthly and there was insufficient documentation to show how risks would be avoided around some areas ie the use of profiling beds, and where residents were at risk of falling out of bed, appropriate action had been taken but lack of of documentation would prevent staff unfamiliar with the resident to have knowledge of these actions.. Wound care planning was not of the standard that would be expected, and whilst the Wound Care Specialist Nurse had undertaken a mattress audit and the parent company has been proactive in speedily replacing these mattresses, the specialist nurse also identified that staff were in need of wound care and pressure damage prevention training. The only policy in the home relevant to pressure ulcer management was the generic company policy dated 6/01/2006, this will be out of date in relation to current good practice, research and up to date advice from wound care specialists. Other issues in care planning were found and discussed with the manager. It was noted that the level of personal care of the residents had improved with staff ensuring that residents were well groomed and taking a pride in their work. However the majority of people spoken with said that more staff were needed at specific times of day whilst a resident survey said more staff were needed in the afternoons. All residents in their rooms had call bells appropriately placed although the abilities of some residents would mean they were unable to use these. This was also confirmed by staff who also said that they did not have time offer drinks to residents who stayed in their rooms other than at designated meals or beverage times. We do not have time to pop in and make sure people are alright and offer them drinks and some of them cannot manage to use their bells. Staff had received training in ensuring residents dignity is maintained and the home has a specific member of staff Dignity Champion who is responsible for maintaining these standards throughout the home. Relatives spoken with and surveys received said : I am happy to leave my (relative) knowing that she is in good hands and that she will receive the considerable care and attention that her condition demands. Care Homes for Older People Page 15 of 36 Evidence: Staff have a lot of patience with everyone in their care. Much improved over the past year, they look after my resident well. Very good staff, they are always busy but they really try. Registered nurses were observed undertaking medication rounds and this was done in a manner which ensured the safety of the residents. The controlled drug cupboard was being used for the storage of medication that does not need this level of security, it was noted that these had been signed into the Controlled Drug records and checked but then not signed out when disposed of, giving the impression that supplies of drugs were in the home. Likewise there were supplies of drugs which do not need to be treated as controlled drugs in this cupboard which were not accounted for. It was noted that according to the controlled drug records the home should still have Temazepam elixir 300mls in the cupboard as this ( which has to be treated as a Controlled Drug) had not been signed out when disposed of. The AQAA stated that regular drug audits were taking place, but this had not been addressed on any drug audit. A bottle of Diazepam syrup 2mg/5ml was found in the trolley this had obviously been prescribed for a resident but had the label taken off and was being used for general use neither did it have the date of opening on it. A bottle of Senna Liquid 100ml prescribed for a resident no longer in the home had the 100ml amount crossed out and 200ml written on it and the name of the resident for whom it was prescribed was crossed out. A bottle of Paracetamol Suspension also prescribed for someone had the label torn off it and was being used for general use. The home has not commenced care plans to be kept in the medication records for the use of as required medication although this was discussed with the manager at the last inspection. A requirement will be made. There was no evidence that the suction machine had been tested at regular intervals or cleaned and suction catheters were lying on the work surface which could lead to Care Homes for Older People Page 16 of 36 Evidence: their paper covers being damaged and therefore the catheters unhygienic to use. Eye drops, insulin and liquid medicines did not have the dates of commencement of use on them. The drug trolleys and the clinic in general were in need of cleaning and staff should ensure that this room is kept in a clean condition at all times to minimise infection control risks The manager said that she is now in the process of arranging for staff to have end of life care training, and all registered nurses have had training in administering pain relief through syringe drivers and are about to update their skills in this procedure. Residents wishes for end of life care and any interventions they wish to have are now in place in the care plans. Letters received by the home from relatives of former residents praising the care given by the home were seen. Care Homes for Older People Page 17 of 36 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. Leisure activities provided by the home ensure that the majority of the residents are able to participate in activities which are reflect the individuals abilities and needs. Menus provided offer residents choices at all meals and ensure that finger foods are available throughout the day. Evidence: The home realises the importance of ensuring that the residents who live there are enabled to pursue leisure activities which they find interesting and are suitable for individual abilities. The activities programme showed a variety of activities including outings to local shops and hairdressers, art sessions, visiting musical entertainers and one to one activities. An activities coordinator works at the home on a full time basis and as much as possible the home aims to have some leisure activities on offer each day during the seven day week. The manager has stated her intention of training some care staff to coordinate activities when the cooridinator is off duty. A reflexologist also visits the home, this is not included in the fees and therefore is Care Homes for Older People Page 18 of 36 Evidence: available only to those residents able to pay for this, residents receiving reflexology on this day appeared to be enjoying the experience. In order to maintain residents dignity any treatments such as reflexology should be taking place in the residents room or a similar place of privacy and this was discussed with the manager. It is appreciated in some instances that the specific resident will be reluctant to leave the lounge area. Discussions were held with the activities coordinator around ensuring that people who cannot leave their rooms were included in one to one activity sessions.These are people who are likely to lack contact and stimulation due to the geography of the home. Records of residents participation in activities are in place but these should be recorded in the social care planning part of the report as part of the holistic care plans. Visitors to the home, those residents able to do so and staff confirmed that residents have full choices in the activities of daily living including their times of rising and retiring, which clothes they wish to wear and how they spend their day. Visitors are welcome at any time of day and are encouraged to participate in the life of the home including activities and meals. There is a lunch club and a breakfast club in progress which residents can attend, with different groups of residents attending each session. The home has relatives meetings and also has a Friends of Bon Accord group which enables relatives and friends of past and present residents to meet up and be kept informed of what is going on in the home and to visit the home. Comments received from visitors on the day and surveys received prior to the inspection included: Activities have improved for some service users. Events such as mothers day are addressed and celebrated. The home has made a sensory garden, which will include a water feature and have intentions of making a seaside garden for residents. I must complement them on arrangements for entertainment which I find outstanding. Care Homes for Older People Page 19 of 36 Evidence: What a difference over the past year, food has improved and residents seem more alert and look well cared for. Menus in the home were nutritionally balanced and offering two choices at each meal. Management has tried to make residents aware of the choices available. Finger foods are being offered in between meals, although the home is not providing a fruit platter as often as previously, there were bowls of fruit in each lounge. The chef and manager said that residents who were nursed in their rooms could ask for fruit: it is doubted that they would have the ability to do this and therefore may benefit from fruit being offere The kitchen attained five stars in the Environmental Health Authoritys Scores on Doors initiative. The time of breakfast is in line with individual residents preferences and the chef said that if they wished for a cooked breakfast he would ensure that this was provided. All residents spoken with said that they enjoyed the food and a visitor to the home said that the meals had improved considerably in the past year. Care Homes for Older People Page 20 of 36 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A concern relayed by us to the manager was not dealt with in the manner which would have been anticipated, therefore raising some questions about the homes manner of addressing minor complaints. Staff were aware of what constitutes an adult safeguarding issue and how they should address this, and information received by the commission shows that the home is addressing adult safeguarding issues appropriately. Neither the manager or all of the staff have received adult safeguarding training through an accredited source. Evidence: The complaints policy is clearly displayed in the home and included in the Service User Guide. Visitors to the home were aware of to whom to address a complaint. Few of the residents currently in the home would be able to use this procedure but one resident said that they would speak to the nurse should it be necessary. The home has received one complaint since the last inspection which was unfounded, this was available to be seen in the homes records. The manager stated that records are kept of minor concerns, although this was not seen at the inspection. The commission has not received any complaints about the home since the last Care Homes for Older People Page 21 of 36 Evidence: inspection, however during the day we received one concern regarding care of a resident, this was relayed to the manager. The managers response indicated that she did not take the concern as seriously as would be expected neither did she confirm that this would be added to the records of complaints and concerns, therefore raising doubts that the home is adding all concerns raised to the records. There have been 16 adult safeguarding referrals since the last inspection, these have related to residents challenging behaviours and have not involved staff. The home has taken appropriate measures to try to prevent recurrence of the individual issues and has informed the Care Quality Commission of each event and its outcome. The records in the home show that 81 of the staff have had recent adult safeguarding training. Although records were not available to show when the remaining 19 had received their training, the manager should make it a matter of priority to ensure that all staff are fully up to date with this and therefore fully conversant with their responsibilities towards those in their care and the correct reporting procedures to be used in the event of a safeguarding issue. Staff spoken with and information received from the home shows that staff are aware of how to report a safeguarding issue and were aware of their responsibilities to the residents in the home. The adult safeguarding training provided in the home has not yet been accredited with the local authority and this should be made a priority. The manager has not yet attended adult safeguarding training with the local authority although she said that training has been arranged. Care Homes for Older People Page 22 of 36 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. Improvements over the past year in maintenance and refurbishment of the service have resulted in a pleasant home for the people who live there Evidence: There have been several improvements made in the home over the past year, including provision of new carpets in some areas and redecorating of rooms. The company has invested in new pressure relieving mattresses and some variable height profiling beds, and plans are in place to replace all the beds in the home. A sensory garden has been added to the rear garden and there are plans to include a water feature and a sea side. garden. The rear garden is accessible to all residents and is used in the summer for outdoor activities and garden fetes. Residents accommodation was comfortable and residents are able to bring in their own possessions if required. Where residents are able to manage these, they are provided with a lockable drawer for their personal possessions. All windows have restricted opening and records of the hot water temperatures in residents outlets showed that these were being regularly monitored and were within recommended parameters. Care Homes for Older People Page 23 of 36 Evidence: Staff said that all bathrooms were now functional and able to be used. A recent breakdown of an assisted bath was repaired promptly and staff said that repairs required to equipment were now generally undertaken in a prompt manner. Areas of the home with the exception of the clinic room, were clean. The stairs leading up to the first floor corridor and one area of the second floor corridor were malodorous, although staff said that the carpets are regularly cleaned. On this day there was only one member of housekeeping staff on duty and this was apparently due to a member of staff being on leave. The home is comprised of single rooms and covers a large area and therefore one member of housekeeping staff was struggling to maintain the standard of cleanliness seen in the home. The home has an infection control Champion who has undertaken specialised training with the Health Protection Agency, and is responsible for maintaining links with the agency and ensuring that the home is following the policies and guidance set out by them. Care Homes for Older People Page 24 of 36 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. Observation and information received shows that there are insufficient staff to meet the needs of the service users at specific times of day. Recruitment processes safeguard the residents. Evidence: Observations in the home and evidence from duty rotas, surveys and talking to staff and residents, showed that there are insufficient care staff working in the home at specific times of day, and insufficient house keeping staff on duty when a member of the housekeeping staff is absent. Discussion with the manager intimated that she was assessing the amount of staff required by the numbers of residents in the home as opposed to monitoring dependency and needs of the residents. The manager said Ive kept the staffing numbers up to the same amount even though we have two vacancies. Surveys and discussions with staff showed us that the staff deficit affected the home particularly in the afternoons although on speaking to staff they also said that mornings were often affected depending on the behavioural needs of the residents. Staff told us that: Care Homes for Older People Page 25 of 36 Evidence: We do not have time to go and see residents in their rooms or give them extra fluids apart from when its their time to be turned. I know that we should be giving extra fluids and snacks to those residents in their rooms and that we should go in and make sure they are alright, especially as some of them cant use the call bell, but we just dont have time. The housekeeping staff have so much washing as many of the residents need changing a lot and its a lot for the staff to manage, and its a big home for one person to keep clean when housekeepers are on holiday. Staff were seen to be very busy all day and visits to the conservatory lounge where there are more dependent residents showed that only rarely were any staff in there. The numbers of adult safeguarding issues reported, all of which showed the reason to be residents challenging behaviour, may point to insufficient staff being available to adequately supervise the residents in the home. Observations at meal times showed that the home has many residents who require assistance with meals. At a previous inspection enforcement action was taken against the home by the Care Quality Commission, following which there was an improvement in the staffing levels. At the last inspection the area manager gave assurances that an extra member of staff would be on duty in the afternoon. It is clear at this inspection that staffing is not being adjusted according to the dependency levels and the needs of the residents. New staff receive an induction course which is comparable to the nationally recognised skills for care and are encouraged to attain the National Vocational Qualification in Care following this. Currently 73 of the care staff have attained this qualification at level 2 or above. Whilst staff are having ongoing training, both in house and from external trainers, the CQC has received information that some of the training relevant to care needs (ie nutrition) is being delivered to registered nurses by care staff. As registered nurses form a supervisory and teaching role in the home alongside their care role, and also have the need to have information about care matters at a more in depth level than normally given to care staff. Not all staff have received mandatory training in the past twelve months and no staff Care Homes for Older People Page 26 of 36 Evidence: other than the manager and the deputy manager have received training in Deprivation of Liberty Safeguarding and the Mental Capacity Act. Staff personnel files belonging to three new, and one long term staff members were examined, these show that all checks and information as required by regulation were in place. Care Homes for Older People Page 27 of 36 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 there have been improvements within the home in the past twelve months, some management systems in the home do not fully support the requirements of the home and the health and safety of the residents. Evidence: The manager is a registered general nurse and has been in post in the home for twelve months, she is registered with the Care Quality Commission and has the necessary qualifications to manage the home. The manager and the deputy manager have both attended training in the Deprivation of Liberty Safeguarding and the Mental Capacity Act, no residents have yet been assessed under Deprivation of Liberty Safeguards in relation to the key pads around the home and the manager must ensure that no resident in the home are in need of this. The AQAA was received when we asked for it and generally reflected what is Care Homes for Older People Page 28 of 36 Evidence: happening in the home. Whilst the manager informed us that the company has undertaken the annual quality monitoring audit which also considers the views of residents or their representatives, she said that the audit had not yet been consolidated or received by the home - this has not been available at the last inspection either so no evidence that it is actually been done. Whilst relatives and staff generally thought that the atmosphere in the home had improved, and that many very positive changes had taken place, staff in general were worried about making their views known in case of repercussions. Some surveys received from staff also stated that there was a lack of communication between senior staff and other grades. There was evidence that the manager is failing to monitor the dependency of the residents and has allowed staffing levels to fall below the level to meet the holistic needs of the residents in the home. Staff meetings are taking place as are relatives meetings and minutes of these were seen. Relatives and residents are encouraged to make their views known and the home tries to act on any suggestions made. Staff supervision is taking place at the intervals directed by the National Minimum Standards; and Regulation 26 visits (monthly visits by the provider or their representative required by regulation) are taking place with reports available in the home. Reports examined showed evidence of involving residents and staff and also that any problems found in the home were being identified and addressed. The majority of the companys policies and procedures have not been reviewed since 2006, this includes clinical policies. All policies need to be reviewed on a regular basis and as this home has no local policies it relies on the company policies to give an up to date overview of recent research, changes in legislation and local authority policy. The formation of local policies relating to clinical care was discussed with the manager. The company keeps personal money for residents in a separate bank account and records of any spending. These were examined and appeared robust. The AQAA told us that all the equipment and utilities used in the home were regularly serviced therefore these records were not examined on this occasion. Care Homes for Older People Page 29 of 36 Evidence: Risk assessments in residents care plans needed more information and details around minimising the risks involved. Risk assessments for the home in general addressed the risk and actions required. The manager is responsible for ensuring that all staff have received mandatory training. However the homes training records showed that only 83 of the staff had received fire training or fire drills in the past twelve months and 81 of the staff had received safeguarding training within this timescale. This must be addressed. Care Homes for Older People Page 30 of 36 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 31 of 36 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Care plans must accurately reflect the current and changing needs of the service user and the actions to be taken to meet these needs. All parts of the care plan must be contemporaneous In order that service users receive the care appropriate to their needs 14/07/2010 2 7 15 That registered nurses must ensure that there is sufficient directions in the care plans for the staff to fulfil the oral care needs of the residents To ensure the holistic care of the service users. 30/06/2010 3 8 16 That the registered nurses 30/06/2010 ensure that accurate records are kept and actions taken to ensure that all service users receive sufficient fluids Care Homes for Older People Page 32 of 36 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 over a twenty four hour period. To ensure the health of the service users in the home 4 9 13 Complete and accurate records must be kept in the controlled drugs records. Medications must not be used for any service user other than the person for whom they are prescribed. Care plans which reflect the specific condition for which the individual requires administration of as required medication must be in place and available to staff administering medication. To avoid any misappropriation of medication and to ensure that service users are safeguarded and receive their medication as required. 5 16 22 The registered person ensures that any complaints or concerns received are recorded and addressed under the companys complaints procedure. 30/06/2010 29/06/2010 Care Homes for Older People Page 33 of 36 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 To ensure that service users are fully protected and their holistic and personal needs are met 6 27 18 The registered person must ensure that there are sufficient staff on duty to meet the holistic needs of the service users over the twenty four hour period. To ensure that the needs of the service users are met 7 31 18 That training in Deprivation of Liberty Safeguarding and the Mental Capacity Act is extended to all staff, specifically those with a responsibility for care planning. To enable all service users that require this are suitably assessed regarding their mental capacity and to ensure that none are deprived of their liberty. 8 33 24 That quality monitoring 30/08/2010 takes place and the results are available in the home and extended to service users and other stakeholders in the home. That company policies and procedures specifically those relating to the delivery of 01/09/2010 30/06/2010 Care Homes for Older People Page 34 of 36 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 care are assessed at regular intervals. To enable service users and other stakeholders to determine the quality of the services offered and that these individuals know that staff are following up to date policies which reflect researched care practice. 9 38 13 That the manager ensures that all staff receive mandatory training at regular intervals To ensure the safety of staff and service users in the home. 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 30/08/2010 Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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