Care Home: Bracknell Nursing Home

What the care home does well Each resident is only admitted to the home following a comprehensive needs assessment to ensure that the home can meet the resident`s identified needs. Residents benefit from the management approach at the home providing an open, positive and inclusive atmosphere. From observations made on the day of this visit and from comments made on the staff survey forms it is clear that the home have an enthusiastic and happy staff team. Staff comments on the survey forms returned included: `If any problems the manager sorts the problem out as soon as possible`, `is a very friendly and happy place to work`, `we work as a team and the atmosphere is very friendly` and `there are friendly staff who respect one another and are happy in their work.` One relative commented on a survey form that `my relative has settled in well due to constant support. We are grateful!` Feedback received by the inspector from the expert by experience included: `The staff were welcoming and cheerful and the atmosphere was friendly. The residents looked well cared for and appropriately dressed. The staff were careful with their charges and dealt with them with dignity and sensitively.` The expert by experience also reported that all residents spoken to, when asked, were happy with the care provided by the staff. What has improved since the last inspection? The ongoing maintenance, redecoration and refurbishment programme provides residents with a comfortable and homely environment in which to live. A number of comments were received relating to improvements at the home since the last inspection. Staff comments included: `there is a big improvement in the home` and `since the new manager has been employed things have greatly improved. She is approachable and sorts problems out quickly and effectively`. Comments received from Care Managers included: `Since the arrival of the new manager (and whilst the temporary manager was present) standards and morale have improved a lot. Staff, residents and families now feel more included in day to day matters` and `have seen improvement in the service since new manager came into post`. What the care home could do better: Requirements have been made and the home must ensure that all residents have a written plan of care that sets out, in detail, actions staff need to take to ensure that all aspects of the residents` health, personal and social care needs are met and that identified goals and expected outcomes are realistic and achievable. This includes needs related to equality and diversity. Care plans need to be more person centred, need to promote independence and include residents` choices and preferences in how they would like their care delivered and their needs to be met. Where risks to the health and safety of residents are identified by risk assessments, care plans must include actions staff need to take to reduce and/or minimise the potential risks. It has been recommended that the provider review, with all nursing and care staff, the different stages of their new care planning system plus how the staff are expected to use the system in practice. Current recruitment practices are potentially placing residents at risk of harm and/or abuse. A requirement has been made and the provider must make sure that no person is employed to work at the home without all the required checks and documents having first been obtained. A system needs to be developed and implemented for monitoring that improvements, when introduced, are being followed by all staff and that the staff understand any new systems and new ways of working (such as the new care planning system). There also needs to be a system where known issues are more closely monitored until resolved. Although the registered provider may delegate various aspects of the management of the home to the manager, until the manager becomes registered with CQC accountability remains with the registered provider who should monitor practice and ensure that the requirements within regulations are understood and adhered to. The provider will be asked to provide an improvement plan setting out the methods by which, and the timetable to which, the registered person intends to improve the services provided in the care home. A copy of this plan should be made available to the people living at the home and/or their representatives. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Bracknell Nursing Home Crowthorne Road Bracknell Berkshire RG12 7DN     The quality rating for this care home is:   one star adequate 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: Denise Debieux     Date: 0 1 0 6 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 38 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 38 Information about the care home Name of care home: Address: Bracknell Nursing Home Crowthorne Road Bracknell Berkshire RG12 7DN 01344484584 01344429343 bracknell@fshc.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Tamaris (RAM) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) The registered provider is responsible for running the service care home 30 Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users to be accommodated is 30 The registered person may provide the following category 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 category; Old age, not falling within any other category (OP) Physical disability (PD) Date of last inspection 2 7 0 6 2 0 0 8 0 30 Over 65 30 0 Care Homes for Older People Page 4 of 38 Brief description of the care home Bracknell Nursing Home is situated close to the local shopping precinct in Easthampstead. Bracknell Town Centre is approximately one mile away and is accessible via local public transport. The home provides accommodation for up to thirty service users with nursing needs in a variety of single and dual occupancy bedrooms. The service users accommodation is on two levels with a passenger lift available between floors. There is a small garden to the rear of the property and parking to the front. Care Homes for Older People Page 5 of 38 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This unannounced visit formed part of a key inspection and was carried out by Denise Debieux, Regulation Inspector. The manager and a peripatetic manager were present as representatives for the establishment. It was a thorough look at how well the service is doing. It took into account detailed information provided by the manager and any information that CQC/CSCI has received about the service since the last inspection on 27th June 2008. Service users at this home prefer to be referred to as residents. For clarity and consistency this term will be used throughout this report. During this visit the inspector was also accompanied by an expert by experience, who spent four hours at the home between 10am and 2pm. An expert by experience is a Care Homes for Older People Page 6 of 38 person who has direct experience of using social care services, including carers, and visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The expert by experience spent her time speaking with residents, their visiting relatives and some on duty staff members. Observations fed back to the inspector by the expert by experience have been included in this report. On the day of this visit the inspector spoke with four of the residents and six on duty staff. Prior to the inspection, survey forms were sent to residents, staff employed at the home, healthcare professionals, GPs and care managers. Survey forms were returned by eight residents, eight members of staff and four care managers. These comment cards were correlated and the results were shared with the manager during the inspection. Comments made on the survey forms, both positive and negative, were included in the correlation and shared with the manager. Care was taken to exclude any comments that could identify the writer. The manager demonstrated a very pro active attitude to the results of our survey and plans to explore any concerns raised further as part of the homes quality assurance process. Some of the comments made to the inspector and made on the survey forms are quoted in this report. The manager had completed an annual quality assurance assessment (AQAA) and residents care plans, staff recruitment and training records, menus, health and safety check lists, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Fees range from 557.88 to 750 pounds per week. This information was provided on 1st June 2009. The inspector would like to thank the residents, their relatives and staff for their time, assistance and hospitality during this visit and the residents, staff and care managers who participated in the surveys. What the care home does well: What has improved since the last inspection? What they could do better: Requirements have been made and the home must ensure that all residents have a written plan of care that sets out, in detail, actions staff need to take to ensure that all aspects of the residents health, personal and social care needs are met and that identified goals and expected outcomes are realistic and achievable. This includes needs related to equality and diversity. Care plans need to be more person centred, need to promote independence and include residents choices and preferences in how they would like their care delivered and their needs to be met. Where risks to the health and safety of residents are identified by risk assessments, care plans must include actions staff need to take to reduce and/or minimise the potential risks. It has been recommended that the provider review, with all nursing and care staff, the different stages of their new care planning system plus how the staff are expected to use the system in practice. Care Homes for Older People Page 8 of 38 Current recruitment practices are potentially placing residents at risk of harm and/or abuse. A requirement has been made and the provider must make sure that no person is employed to work at the home without all the required checks and documents having first been obtained. A system needs to be developed and implemented for monitoring that improvements, when introduced, are being followed by all staff and that the staff understand any new systems and new ways of working (such as the new care planning system). There also needs to be a system where known issues are more closely monitored until resolved. Although the registered provider may delegate various aspects of the management of the home to the manager, until the manager becomes registered with CQC accountability remains with the registered provider who should monitor practice and ensure that the requirements within regulations are understood and adhered to. The provider will be asked to provide an improvement plan setting out the methods by which, and the timetable to which, the registered person intends to improve the services provided in the care home. A copy of this plan should be made available to the people living at the home and/or their representatives. 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 9 of 38 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 38 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. Each resident is only admitted to the home following a comprehensive needs assessment to ensure that the home can meet the residents identified needs. This home does not offer intermediate care. Evidence: In the AQAA, to demonstrate what the home does well, the manager stated that: Following a general enquiry the manager ensures that a brochure is sent and the prospective resident or the relatives are invited to view the home. Where possible the manager takes the personal responsibility to meet up with the families to ensure they are well informed before they make any decision. Residents and visitors are also invited to spend a day at the home or even join us for a meal or activities allowing them to have a true feel of how it is to be a resident at Bracknell care home. The Company has introduced a new assessment tool CHAP (Care And Health Assessment Profile) which covers all the activities of daily living as well as mental capacity. This statement is supported by the findings on the day of this inspection. Care Homes for Older People Page 11 of 38 Evidence: On the day of this inspection three sets of relatives visited to have a preliminary tour of the home. Two of these visits had been arranged in advance and one person came unannounced. All were welcomed and members of staff were allocated to show the people round and answer questions. Written information about the home was provided to all the visitors for them to take away. Two care plans, for people who had recently moved to the home, were sampled during this visit. For both people, comprehensive pre admission assessments had been carried out to ensure that the home could meet the residents identified needs. The organisation uses an in depth pre admission form that covers all areas of a persons health, personal and social care needs, including associated risk assessments. In the files sampled the manager had carried out both assessments, prior to offering the people a place at the home. It was also seen in one file that, where there was a potential that the home could not meet an identified need, the manager had obtained additional information before offering the person a place at the home. These forms also include assessments designed to identify any individual needs a person may have related to equality and diversity. The home also work with residents and their relatives and draw up life histories with each resident after they have moved in to the home. These life histories also provide detailed information about the residents previous hobbies, interests and pastimes that could be used when planning an individualised activity care plan with the resident. Of the four care managers who returned survey forms, one said that the homes assessment arrangements always ensure that accurate information is gathered and that the right service is planned for people, two answered usually and the fourth said they were unable to comment. Six of the eight residents who returned survey forms said they had received enough information prior to moving in to help them decide if the home was the right place for them. All residents who returned survey forms stated that they had been given written information about the homes terms and conditions. Care Homes for Older People Page 12 of 38 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. Personal and healthcare support and assistance was seen to be provided in a respectful and sensitive manner, but individual care plans do not include all personal, health and social care needs or detail the residents preferences and choices in how they would like their care delivered. Care plans need to be more person centred and include individual needs related to equality and diversity. Residents are protected by the policies, procedures and practices in place to ensure the safe administration of medication. Evidence: The new assessment and care planning system developed by the provider is an in depth system that begins with a preadmission assessment, as described in the previous section of this report. The second step the staff should follow is to draw up care plans with the resident, shortly after admission, using the information on assessed needs identified during the pre admission assessment, the inspector was advised that at this stage the residents choices and preferences on how they would like their care delivered should be established and added to the care plans. To accompany the care plans are a number of risk assessment forms, e.g. skin, nutrition, Care Homes for Older People Page 13 of 38 Evidence: manual handling, falls, where these risk assessments identify that the resident is at risk, staff are required to draw up a specific risk reduction care plan. When completed, the resident is asked to sign to indicate they have understood and agreed to their care plan. The final part of the care planning system is a recording sheet where staff are required to record daily and should relate their recordings to a specific care plan to evidence that staff are following the care plans and that the identified goals or outcomes are being met, in the way preferred by the resident. Three care plans were sampled during this inspection, one for the resident who had most recently moved to the home. The files sampled did not evidence that the staff drawing up the care plans were following the care planning system as designed or that they had used the information contained in the residents pre admission assessment or life history as a basis for the care plan. In each care plan it was seen that a number of needs, identified on the assessment forms and risk assessment forms, had not been carried forward to the care plans and there was no evidence to show these needs were being addressed, no resident had an individualised activity plan. In the daily records sampled, staff had not related their recordings to specific care plans as required. For example, all three people had been assessed as at risk for developing pressure sores, yet there were no preventative care plans in place. The manager advised that there are no residents at the home with pressure sores at this time and that preventative measures are always taken when skin integrity risks are identified, e.g. provision of pressure relieving mattresses etc., but acknowledged that staff should be opening care plans and recording actions for staff to take to minimise risk. On another assessment, a residents anxiety relating to their concerns about being able to get to the toilet in time had been identified, there was a care plan to deal with the anxiety when it occurred but no care plan relating to the potential for incontinence i.e. the care plans in place dealt with the symptoms of anxiety but not the cause of the anxiety. One resident was assessed as being at high risk of falls, there was a care plan in place which was discussed with the manager. The goal for this care plan had been identified as to prevent falls, and one action for staff to follow was to remind the person to call for assistance when mobilising. When explored further the manager said that the resident has had a number of falls and does not realise that they need assistance with mobility. In the monthly care plan review notes, there was no evidence that staff had recognised that the goal of preventing falls was unachievable or that the planned intervention was not working as the resident continues to try to stand without assistance at times when staff are not present to remind the resident to use the call bell. However, staff had consulted with and referred the resident to the local falls clinic and measures had been put in place to reduce the risk of injury if the resident should fall, e.g. hip protectors had been provided and there was a note in the care plan that the resident should wear them. There was an internal quality audit of Care Homes for Older People Page 14 of 38 Evidence: care plans carried out in March of this year where it had been identified that a number of goals, on the care plans sampled at that time, were not achievable as written but there was no evidence to show the actions that had been taken to address this with the staff. Equality and diversity needs, although identified at assessment, were not always carried forward to the care plans. In two of the files sampled the assessment identified that English was the persons second language. There were no care plans opened to address this area of need and no guidance for staff to refer to. The manager advised that with one resident, there were staff members who were of the same nationality and were able to chat with the resident. There was no evidence that further information had been sought to establish if there were any other cultural differences that could be catered for, e.g. specific national celebrations. One resident had a hearing impairment and there was a care plan that identified that the resident needed to wear a hearing aid. However, the care plan did not include any information for staff on what times of day the resident wears the hearing aid or how best to communicate with them when they were not wearing the hearing aid, e.g. at night and first thing in the morning. It was also recorded in the file that the hearing aid had been broken and was not repaired for approximately six weeks. Staff had clearly documented their efforts to get the aid repaired as quickly as possible but there had been no amendments or additions made to the care plan to show how to communicate with the resident in the interim, the care plan had remained the same and continued to instruct staff that the resident should wear the hearing aid. Another resident was assessed with a visual impairment but there was no care plan that addressed their associated needs. The third care plan sampled was for a resident with a physical disability. The home was seen to be accessible to people dependent on a wheelchair for mobility and it was seen that time and thought had gone into the arrangement of furniture etc in the communal rooms and corridors so as not to hamper mobility for these residents. However, the care plans did not identify or address ways that staff could enable this resident to maintain maximum independence in all areas of their life at the home. None of the care plans sampled, when relating to personal care, included in depth details of the individual residents personal choices or preferences, e.g. preferred times of getting up and going to bed, the care plans mostly covered what assistance people needed when going to bed or getting up, but not their preferred times. The expert by experience reported that a number of residents said they were put to bed at 7pm. This was not always appreciated by the residents but they were resigned to the fact. The night staff did a continence check at 7am. The residents were served breakfast in their rooms and got up as and when staff became available. It is important that residents choices are explored and documented in more detail in the Care Homes for Older People Page 15 of 38 Evidence: care plans so that their choices are supported by the staff and form part of the care they receive. It is also important that the manager has this information available when determining staffing levels at the home at different times of the day. At present the staffing levels reduce at 8pm from one registered nurse and four care assistants, to one registered nurse and two care assistants. Without knowing how many residents would prefer to go to bed after 8pm, given the choice, it is not possible to ascertain whether the staffing levels during the early part of the night shift are sufficient and are not restricting peoples right to choose. This concern is addressed further in the Staffing section of this report. Feedback received by the inspector from the expert by experience included: The staff were welcoming and cheerful and the atmosphere was friendly. The residents looked well cared for and appropriately dressed. The staff were careful with their charges and dealt with them with dignity and sensitively. The expert by experience also reported that all residents spoken to, when asked, were happy with the care provided by the staff. Of the eight residents who returned survey forms, five said they always receive the care and support they need, two answered usually and one answered sometimes. Additional comments made on the survey forms included: All staff are very caring and helpful, very friendly. My relative is well looked after, when I come away after visiting I dont have to worry as I know she is being well looked after. and Generally quite good with care but are sometimes short staffed. In the AQAA, to demonstrate what the home does well, the manager stated that: The manager or the deputy takes the personal responsibility to carry out preadmission assessments. Then an individually tailor made care plan is drawn up and reviewed regularly to ensure that the resident needs are met. Residents are encouraged to a have a direct say in the type off care they receive. Individualised care plans. This statement is not fully supported by the findings at this inspection. The home needs to ensure that care plans for all residents include all areas of assessed health, personal and social care needs, including needs relating to equality and diversity. Where indicated by risk assessments, care plans must include actions needed to be taken to reduce and minimise the potential risks. Care plans need to be more person centred, need to promote independence and include residents choices and preferences in how they would like their care delivered and their needs to be met. Requirements have been made. Part of the midday medication round was observed and the medication administration records, medication storage, policies and procedures were all sampled and all found to Care Homes for Older People Page 16 of 38 Evidence: be in order. During this visit, staff were observed to always knock before entering the residents bedrooms and all interactions observed between staff and residents were seen to be caring and respectful. Care Homes for Older People Page 17 of 38 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recent employment of an activities coordinator and the ongoing development of the homes activity provision is a positive step towards ensuring that each resident will be enabled to participate in meaningful activities of their choice that meet their preferences, expectations and needs. Meals are well balanced and varied with individual choices and preferences catered for. Evidence: As mentioned in the previous section of this report the staff need to identify, and include in the care plans, individual residents choices and preferences related to their own routines of daily living, e.g. preferred times of getting up and going to bed, how they would like their personal care delivered etc. In the AQAA, to demonstrate what the home does well, the manager stated that: The home has managed to employ a dedicated activity organiser who is readily available Monday to Friday, 10am to 3pm Monday to Thursday then 2pm to 7.30 on Friday. Activities are now varied and more interesting to residents as they do choose what they want to do, eliminating the risk of individual isolation. New home magazine in place (stories and jokes input by the residents themselves). The home has introduced Care Homes for Older People Page 18 of 38 Evidence: the happy hour which has proved to be popular with residents every Wednesday and Friday 6 to 7pm. All our residents have a say in the day to day life of the home, ranging from who works there and the type of activities they want to do. Bracknell has managed to maintain a homely happy environment. A wide range of activities is provided throughout the month ranging from one on one to group activities, indoor and outdoor activities. Family events are celebrated in the home, as well as residents are encouraged and assisted to celebrate special events for their loved ones. e.g. they make home made cards for birthdays or anniversaries. Six of the eight residents surveyed stated that there were always activities they could participate in, with one answering usually and one that they didnt know. Comments received from residents varied in relation to activities at the home, these comments included: Activities are very good, No one is left out when activities are going on and They could take us out more for social, leisure or even shopping. Feedback received by the inspector from the expert by experience included: During the morning, there were between 11 and 16 residents in the lounge. They were asked if they would like the TV on and if they would like music (on the day of my visit, the choice was TV on low and music.) The residents were mainly seated round the outside of the lounge with the TV at one end. I did not observe any staff one to one activity. Other than a pub lunch outing, there appeared to be no activities although some of the residents were reading a paper and one was attempting a jigsaw. None of the residents I spoke to had been involved in planning or suggesting activities. Many just did not want to take part regardless, particularly those who were independently minded. In discussion with the manager it was clear that improving the activities at the home has been one of her goals since taking up her managers position in December last year. The home have made progress, all residents now have a life history and a dedicated activity coordinator was employed at the beginning of March. The focus to date has been to introduce new activities that would benefit a number of residents and the improvement has been noted on the survey forms with one care manager commenting Activities have improved and another that The new range of activities look very interesting. At present, none of the care plans sampled included individualised activity care plans and the manager confirmed that, apart from taking the life histories, activities are not included in the written care plans. The inspector was advised that the activity coordinator keeps her own records and, at present, the work of the activity coordinator is seen as separate to that of the care staff. It is important that Care Homes for Older People Page 19 of 38 Evidence: meaningful daily activity is seen as part of the residents whole care and ways for residents to continue previous pastimes and hobbies within the home need to be explored. For example on one residents life history it was seen that she had enjoyed baking cakes, another resident had enjoyed painting in watercolours until having a stroke. From the results of our survey and the comments made by residents on the day of this visit it is apparent that a number of the residents do not want to be involved in the organised activities available at the home at present. However, having worked with the residents on developing their life histories, the staff need to now take this information to the next stage and explore with each resident what their individual needs are related to their own preferred activities. This information should be documented in their care plans together with any support needed from staff to carry out that activity or to enable the resident to continue an activity that is important to them, e.g. cooking, gardening, painting, reading. Particular attention should be paid to addressing any special needs related to any disability or sensory/cognitive impairment that the person may have. There are a number of specialist organisations that can provide additional information and guidance. The inspector left details of the National Association for Providers of Activities for older people (NAPA). The need for social care to be included in care plans has been addressed in the previous section of this report and included in the requirement made under that outcome group. Menus sampled showed that the home offers a varied and well balanced menu, with residents able to choose alternatives if they do not want the dish that is on the menu on the day. The lunchtime meal was taking place during this visit, the food was well presented, the atmosphere in the dining room was pleasant and relaxed and there were ample staff available to offer help and assistance as needed. In the AQAA, to demonstrate what the home does well, the manager stated that: Meal times are calm and unrushed, all members of staff concentrate on serving meals and no medication is given during this time unless indicated. Feedback received by the inspector from the expert by experience included: The residents did have a choice as to whether they sat at a table for four, a chair in the lounge, outside, or had their meal in their room. There were four care staff providing assistance if they needed. The meal looked appetising and residents did say that the food was good. Suitably modified utensils were used by those with severe arthritis. One resident said she had her meals in her room and said that her choice was asked Care Homes for Older People Page 20 of 38 Evidence: for the day before and an alternative if she did not like the choice on offer. Not all the residents were eating in on the day I visited as some had elected to have a pub lunch at the local hostelry. Residents I spoke to appeared to have enjoyed their lunch and had no complaints. Of the eight residents surveyed, three said that they always liked the meals at the home and five answered usually. Care Homes for Older People Page 21 of 38 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. The home has a clear and accessible complaints procedure which includes timescales for the process. Policies and procedures are in place to protect residents from potential harm or abuse. Evidence: The home has a complaints procedure in place that is available to all residents and their relatives and is also included in the homes service users guide. Of the eight residents surveyed, seven said there was someone at the home they could talk to informally if they were not happy and that they knew how to make a formal complaint, with one relative commenting that: I have no problem finding someone to talk to about my relative if I need to and another that: All our concerns have been answered promptly and efficiently. Of the four care managers who returned survey forms, one said that the home always responded appropriately when concerns were raised and three answered usually. There is a whistle blowing policy in place and the home have a copy of the latest Berkshire Safeguarding Adults Policy and Procedure. Training in safeguarding adults is included in the homes staff induction and all staff surveyed confirmed that they knew what to do if someone has concerns about the home. The manager is aware of the requirements of the Mental Capacity Act and the new Deprivation of Liberties legislation, which have been taken into account in the companys new care planning system. Care Homes for Older People Page 22 of 38 Evidence: In the AQAA, to demonstrate what the home does well, the manager stated that: Home manager is available at all times and encourages residents and relatives to air out their complaints. Open door policy. Complaints are dealt with promptly and effectively according to the Four Seasons Health Care policy. Home has an in house POVA (protection of vulnerable adults) trainer, allowing all staff to be kept updated. Care Homes for Older People Page 23 of 38 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. The location and layout of the home and gardens are suitable for their stated purpose. An ongoing maintenance and redecoration programme provides the residents with clean, pleasant and homely surroundings in which to live. Evidence: Residents spoken with expressed their satisfaction with the accommodation provided at the home. Of the eight residents who returned survey forms, five said that the home was always fresh and clean and three answered usually. Feedback received by the inspector from the expert by experience included: The entrance hall is small but welcoming. The residents are housed on two floors with lift and stairs access. There was one large lounge which doubled up as a dining room. This room was partially divided so as to have a quite area either for themselves or if they had visitors, a quiet place to chat. The staff were welcoming and cheerful and the atmosphere was friendly. The domestic did a good job to keep the place clean and sweet smelling. During this visit the inspector was shown around the home, all internal and external communal areas were seen, as well as the bathrooms, laundry, kitchen and the clinical/medication room. The furniture and furnishings were seen to be of a good quality and personal bedrooms were seen to be personalised to the individual Care Homes for Older People Page 24 of 38 Evidence: residents wishes. The maintenance and redecoration programme for the home was seen to be ongoing. Laundry facilities are sited on the ground floor with washing machines suitable for the needs of the residents at the home. In the AQAA, to demonstrate what the home does well, and what improvements have been made in the last twelve months the manager stated that: All equipment is regularly serviced to ensure maximum safety for those who use them. Staff are continually reminded that this is the residents home and not their work place creating a homely environment. Managed to eliminate some of the shared rooms. Created an allocated hair dressing space upstairs, enhancing infection control. Bathrooms redecorated to enhance a homely feel as they were too clinical. The findings on the day of this visit supported this statement. On the day of this visit the home was found to be warm and bright with a homely atmosphere and a good standard of housekeeping apparent. Care Homes for Older People Page 25 of 38 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. Current staff recruitment practices are potentially placing residents at risk and staffing levels need to take into account individual residents needs, preferences and choices. The home has a staff training programme which is designed to ensure, as far as reasonably possible, that residents are in safe hands at all times. Evidence: The care staff team comprises the manager, a deputy manager, seven registered nurses, two senior care assistants and sixteen care assistants. There are three shifts worked at the home, the morning (8am to 2pm) shift is covered by one registered nurse and five care assistants, one registered nurse and four care assistants cover the afternoon/evening shift (2pm to 8pm) and the night staff consists of one registered nurse and two care assistants. Of the eight residents surveyed, four stated that staff are always available when they need them, three answered usually and one answered sometimes. Comments received on survey forms from residents/relatives included: Staff are all approachable and caring, Lots of interaction between staff and residents, Generally quite good with care but are sometimes short staffed, Possibly more staff on duty at any one time. Possible quicker response to alarms and one relative, in response to the survey form question What could the home do better replied: The only thing I can think of is if the carers had a little more time to spend with the residents. Care Homes for Older People Page 26 of 38 Evidence: Of the eight care staff who returned survey forms, three said there were always enough staff to meet the individual needs of all residents at the home, four answered usually and one answered sometimes. These survey results and comments were discussed with the manager, together with other findings at this inspection (as discussed earlier in this report) that could potentially relate to staffing levels, e.g. the need to establish residents preferences on times of getting up and going to bed and to then ensure that staffing levels are sufficient to ensure their choices can be accommodated and the need to identify and include social care in residents care plans for all residents so that their social care needs can be met as well as their personal and health care needs. At present, staffing levels are calculated based on the occupancy at the home, with additional staff provided (particularly at night) if a resident is ill and needs additional staff to make sure their health care needs are met. However, the home needs to implement a system for determining staffing levels that is based on meeting the assessed personal, health and social care needs of individual residents living at the home at any one time. In the AQAA, to demonstrate what the home does well, the manager stated that: The home has managed to build a strong and motivated team as well as recruit more carers, reducing the agency usage, allowing continuity in care. The survey results from this inspection demonstrate an improvement in the outcomes for the residents, for example the number of residents stating that there were always enough staff available has increased from 20 last year to 50 this year, which is a positive result and potentially shows that improvements have been made. The manager plans to explore this area further with each resident to establish where further improvements can be made. At the last inspection a requirement was made relating to ensuring staff are available at all times to ensure that positive quality of life outcomes are not limited by a lack of staff. The staffing levels have not changed since the last inspection and the survey forms received indicate there has been an improvement, however it was not possible for the inspector to assess whether or not this requirement has been met due to the need for the residents individual needs to first be fully identified. The requirement has been removed from this report and it is expected that, once the home has met the requirements made under earlier sections of this report (e.g. established residents preferences and choices in their daily routine and identified staff support needed to ensure that each resident has the opportunity to participate in meaningful activities of their choice), the manager will review staffing levels on each shift to ensure that they Care Homes for Older People Page 27 of 38 Evidence: are sufficient. This will also need to be an ongoing process when residents leave the home and new residents move in. Of the eighteen care staff, ten hold a National Vocational Qualification (NVQ) level 2 or above in care, with a further three currently undertaking NVQ level 2. During this visit the files of three recently recruited members of staff were sampled. All files were seen to contain proof of identity, two references, a completed application form and an enhanced Criminal Record Bureau (CRB) certificate, including a Protection of Vulnerable Adult (POVA) list check. However, two of the three CRB certificates did not match the name of the applicant on their proof of identity; reasons for leaving previous employment with vulnerable adults had not been verified for two people; full employment histories had not been obtained and some gaps in employment had not been explained or explored. One file had dates of employment on the application form that did not agree with the dates given on the reference from the previous employer and in one file the references gave conflicting information that should have been clarified. The amended Schedule 2 of The Care Homes Regulations 2001 was reviewed with the peripatetic manager during this inspection and the home were referred to the CQC guidance documents available on our website: Criminal Records Bureau Checks and the associated annex 2 which set out the changes to regulations and explain the latest recruitment requirements. It is positive to note that, following this inspection the manager and peripatetic manager took prompt action to ensure the safety of the residents. The inspector was contacted the day after the inspection via email and advised that a full audit of all staff files had been completed, that any missing information, incorrect documents and information that needed to be clarified or verified had been identified. Information was also provided on the interim measures put in place by the provider until all correct recruitment documentation and information has been obtained. The manager was not present at the home while recruitment files were being sampled so it was not possible to ascertain what training had been provided before she had been given the responsibility for recruitment at the home by the provider. Whilst organisations may delegate various aspects of the recruitment and vetting process, accountability remains with the registered persons who should ensure that the requirements within regulations issued under the Care Standards Act, and those arising from other legislation, are adhered to. A requirement has been made that the provider must ensure that all staff involved in recruitment understand and adhere to Care Homes for Older People Page 28 of 38 Evidence: the requirements of legislation and ensure that no person is employed to work at the home without all the required checks and documents having first been obtained. Whilst legislation allows that new staff may start working at a care home in exceptional circumstances and following the receipt of a clear POVAfirst check but pending a full CRB certificate, this is subject to a number of conditions. It was identified that two new members of staff are currently working on the basis of a POVAfirst but the arrangements for an appointed staff member were not in place and there was no documentation that detailed what the exceptional circumstances had been. Staff induction is in line with the new, mandatory Skills for Care common induction standards and the training log sampled evidenced that staff receive mandatory health and safety training and updates as required. The manager is aware that role specific training needs to be identified and provided to the new activity coordinator and the peripatetic manager plans to contact the training department for this to be arranged. The Care Homes Regulations also require an appointed staff member, with similar conditions to those set out above, until a new worker has completed their induction. These arrangements were not in place for two new workers still in their induction period. In the email received on the day following this inspection the peripatetic manager confirmed that staff that are working on a POVAfirst and staff that had not completed their induction will be supervised at all times and have appointed mentors. It was also confirmed that the manager and peripatetic manager had downloaded and read both the CQC guidance and Four Seasons Health Care Policies and that the manager now felt confident with all aspects of the recruitment process. Of the eight staff members that returned survey forms, all felt they are being given training which is relevant to their role. Seven felt that they are being given training which helps them understand and meet the individual needs of residents, with one person answering no and six felt that they are being given training that keeps them up to date with new ways of working, with two people leaving this question blank. One staff member added the comment that: The manager makes sure everyone has the opportunity to take courses to help improve their careers and knowledge of health and safety and everything that is relevant to the working environment and the safety of the residents. Of the eight residents surveyed, six said that the staff always listened to them and Care Homes for Older People Page 29 of 38 Evidence: acted on what they said, one answered usually and one answered sometimes. Five said they always receive the care and support they need, two answered usually and one answered sometimes. All interactions observed between staff and residents during this inspection were friendly, caring and respectful and residents and relatives spoken with were complimentary and happy with the staff team and the personal care provided. Care Homes for Older People Page 30 of 38 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. Residents benefit from the management approach at the home providing an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the residents. Policies and procedures are in place to protect residents financial interests. All other policies and procedures are in place to ensure, so far as is reasonably practicable, the health, safety and welfare of residents and staff but a system needs to be implemented to monitor that all staff at the home understand and adhere to these policies. Evidence: Since the last inspection there have been a number of management changes at the home, the previous registered manager left at the end of September 2008 and a temporary manager was put in place until the present new manager took up position at the beginning of December 2008. The new manager is a registered nurse and has her Registered Managers Award qualification. Her management style is inclusive and Care Homes for Older People Page 31 of 38 Evidence: the residents benefit from the ethos, leadership and new management approach at the home. The manager is in the process of obtaining the required documentation so that she can file an application with CQC to become the registered manager for the home. The home has a quality assurance and monitoring system in place that is based on seeking the views of the residents and their relatives and monthly visits from a representative of the provider take place as required. The inspector was advised that the home carry out yearly resident and relative surveys, correlate the responses and then formulate an action plan to address any issues that are raised. In the AQAA, to demonstrate what the home does to ensure that the views of residents are promoted and incorporated into what they do the manager stated: monthly residents meetings; annual customer survey; regulation 26 (monthly provider visits); remedial action plan; home manager open door policy; complaints investigation outcomes; involve residents in staff selection and interviews; comments and suggestion book in reception. Policies and procedures are in place to protect residents financial interests. Records are audited once a week by the manager and monthly by the regional administrative support team. The manager stated that the home does not handle the financial affairs for residents. Health and safety monitoring check sheets were sampled and found to be mostly well maintained and up to date. On the temperature recording sheets for the kitchen it was seen that fridge/freezer and hot food temperature columns are being left blank at the weekends, although completed during the week. The inspector was advised that the person responsible has been spoken with about this omission before and that the manager will take this issue up with the person concerned again. All staff have received required safe working practice training and updates. Staff were observed to be mostly following appropriate health and safety practices as they went about their work, although one member of staff was observed by the expert by experience to be handing biscuits to residents straight from a biscuit tin using bare hands. This information was passed to the manager to deal with. Since starting in post it is apparent that the manager has worked, and is working, hard to introduce improvements at the home, it is recognised that this is an ongoing process and a number of the improvements are in the early stages and not fully implemented yet. The manager expressed a commitment to making improvements so that current and future residents can be confident that the home is run in their best Care Homes for Older People Page 32 of 38 Evidence: interest. However, a system needs to be developed and implemented for monitoring that improvements, when introduced, are being followed by all staff and that the staff understand any new systems and new ways of working (such as the new care planning system). There also needs to be a system where known issues are more closely monitored until resolved, e.g. the recognised problem with food safety checks not being carried out at weekends, the issue identified in March with goals in care plans not always achievable. As stated above, the new manager is not yet registered with CQC and, although the registered provider may delegate various aspects of the management of the home to the manager, accountability remains with the registered provider who should monitor practice and ensure that the requirements within regulations issued under the Care Standards Act, and those arising from other legislation, are understood and adhered to (e.g. staff recruitment, staff supervision while working on a POVAfirst check and during induction, safe food handling etc.) A total of eight care staff survey forms were received prior to this inspection. From observations made on the day and from comments made on the staff survey forms it is clear that the home have an enthusiastic and happy staff team. Staff comments on the survey forms returned included: If any problems the manager sorts the problem out as soon as possible, is a very friendly and happy place to work, we work as a team and the atmosphere is very friendly and there are friendly staff who respect one another and are happy in their work. A number of comments were also received relating to improvements at the home since the last inspection. Staff comments included: there is a big improvement in the home and since the new manager has been employed things have greatly improved. She is approachable and sorts problems out quickly and effectively. Comments received from Care Managers included: Since the arrival of the new manager (and whilst the temporary manager was present) standards and morale have improved a lot. Staff, residents and families now feel more included in day to day matters and have seen improvement in the service since new manager came into post. Care Homes for Older People Page 33 of 38 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 34 of 38 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 The registered person must 01/09/2009 ensure that all residents have a written plan of care that sets out, in detail, actions staff need to take to ensure that all aspects of the residents health, personal and social care needs are met and that identified goals and expected outcomes are realistic and achievable. This includes needs related to equality and diversity. (This requirement also refers to national minimum standards 8 and 12.) In order that residents can be confident that the home can meet all their identified health, personal and social care needs. 2 7 12 The registered person must, 01/09/2009 so far as practicable, enable residents to make decisions with respect to the care they Page 35 of 38 Care Homes for Older People 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 are to receive and ascertain and take into account their wishes and feelings. Care plans need to be more person centred, need to promote independence and include residents choices and preferences in how they would like their care delivered and their needs to be met. In order that residents can be confident that they will be involved in decisions about their life and be enabled to play an active role in planning the care and support they receive. 3 8 13 The registered person must ensure that unnecessary risks to the health and safety of residents are identified and so far as possible eliminated. Where indicated by risk assessments, care plans must include actions staff need to take to reduce and/or minimise the potential risks. In order that residents can be confident that any risks related to their health and welfare are identified and, 01/09/2009 Care Homes for Older People Page 36 of 38 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 as far as possible, minimised by the home. 4 29 19 The registered person must ensure that no person is employed to work at the home without all the required checks and documents having first been obtained and that all staff involved in recruitment are fully aware of, and adhere to, the requirements of the Care Homes Regulations 2001 as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004. In order to protect the residents from the potential risk of harm or abuse. 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 01/07/2009 1 7 It is recommended that the provider review, with all nursing and care staff, the different stages of their new care planning system plus how the staff are expected to use the system in practice. Care Homes for Older People Page 37 of 38 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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