Care Home: Bredon View

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What the care home does well Bredon View provides a homely and welcoming atmosphere for its residents and visitors. Residents are admitted to Bredon View on the basis of an assessment of their individual needs, and have access to information about the home and its services. Prospective residents and their families are able to visit the home to view its facilities and services prior to coming in here. Upon admission each has their own personal documented plan of care, which addresses their particular health and social needs, whilst taking into account any risks to their individual health and safety. Respect and consideration is shown towards residents` personal choices and levels of independence. Residents and visitors spoke favourably about the care they experienced in the home, with some commenting on the sense of freedom that the home afforded them. Residents are able to manage their own medications if they wish and are able. A satisfactory standard of food is provided here, and residents spoke positively to us about it. A range of snacks was readily available for between meals if wanted. The home has an adequately robust complaints` policy, and residents` views, suggestions and opinions are sought as part of the quality monitoring systems. Staff are encouraged to develop professionally, and have access to training opportunities that include the National Vocational Qualification (NVQ) training programme, although the numbers of NVQ qualified staff are currently quite low. However there is a clear commitment to getting as many staff qualified to this level as possible. Issues of unacceptable practice by any staff are addressed through the disciplinary procedures for the protection of residents, and staff receive regular supervision and support. The garden is well planted and attractive for residents. What has improved since the last inspection? The home has had a new manager since the last inspection, and she clearly demonstrates a commitment to improving standards in the home, and shares a good rapport with the residents. A new pre-admission assessment tool has been devised, which is now being implemented. This will provide better opportunities for the home`s assessor to gain and record a more in depth understanding about prospective residents` needs before they come into the home. Key-worker sessions have been introduced, so that residents have more opportunity to have better quality individual time with a particularly familiar member of the staff team, and also so that a better understanding of person-centred care planning can develop for the benefit of the resident. There is an ongoing maintenance and redecoration programme. Two regular housekeeping staff have been employed and the home is now becoming cleaner and more hygienic, although there is still more to do in this area. There have been some challenges to overcome within the staff group, but the manager and her deputy share a very positive working relationship, and are working together to resolve these. An evacuation plan has been implemented for the event of fire. What the care home could do better: Generally the systems for managing medications are satisfactory, however a degree of review would help clarify the directions for the use of certain items, particularly analgesia. Also, despite the home taking all the appropriate measures to ensure secure storage of medications, there has been a recent breach of security beyond the home`s control that has resulted in the medication store cupboards being damaged and requiring replacement. Residents` advanced wishes regarding the care and arrangements they would choose at the end of their lives have not been consistently recorded, but this is an area that is being looked at more closely, with more staff training planned. A social activities programme is offered at Bredon View, however the programme could be increased and made more varied for residents. Some of the cooking and serving containers used for residents` food are old, very tarnished and in very poor condition and should be replaced. The home provides the minimum of staff. Also carers are regularly removed from direct care because they are expected to carry out non-care duties, such as catering and laundry. We have strongly recommended that two waking night staff are provided here. The staff recruitment procedures have not been consistently applied, and we have required an improvement here to promote the protection of vulnerable residents. Despite the delivery of training to staff in safeguarding vulnerable residents from abuse, some of them have not clearly understood what they have been taught, appearing not to have retained the information. There are certain aspects of the environment where we have required some improvement in terms of health and safety for residents. Despite some good quality monitoring systems the home`s policies and procedures have not been reviewed for some time. Key inspection report Care homes for older people Name: Address: Bredon View 24-26 Libertus Road Cheltenham Glos GL51 7EL     The quality rating for this care home is:   two star good 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: Ruth Wilcox     Date: 0 6 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 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) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: Bredon View 24-26 Libertus Road Cheltenham Glos GL51 7EL 01242525087 01242525087 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): CTCH Ltd Name of registered manager (if applicable) Miss Fiona McRoberts Type of registration: Number of places registered: care home 26 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Bredon View is a care home converted from two semi-detached older properties. It provides personal care for 26 older people, and is located in a residential area of Cheltenham, close to the railway station and local bus routes. It is part of the CTCH Ltd group of homes. Accommodation is on two floors, the first floor being accessed by a shaft lift and stair lift. All bedrooms have en-suite facilities; some have the addition of a bath or shower. The communal area consists of 2 lounges, dining room and a conservatory at the front of the property. There is a level access to the landscaped gardens at the rear of the home via a patio door from the lounges. Care staff are on duty twenty-four hours each day, and if nursing services are required, these are accessed from the community, and residents can register with the local General Practitioner of their choice. Information about the home is available to prospective residents and interested parties in the printed Service User Guide, and a copy of the Care Homes for Older People Page 4 of 36 0 Over 65 26 Brief description of the care home most recent inspection report is available in the front entrance hall for anyone to read. The charges for Bredon View range from 544 pounds at the private rate, with just one particular room being charged at 599 pounds. The home also provides care and accommodation at the local authority rate of funding. Hairdressing, chiropody, toiletries and newspapers are charged as extra costs. 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: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One Regulatory Inspector carried out this inspection over two days in October 2009. The last Key Inspection of this service was carried out on the 26th October 2007. Care records were inspected, with the care of four residents being closely looked at in particular. The arrangements to manage residents medications were inspected. We met and spoke to a number of residents and visitors in order to gauge their views and experiences of the services and care provided at Bredon View. Some of the staff were interviewed. Care Homes for Older People Page 6 of 36 Survey forms were also issued to a number of residents, staff and visiting health care professionals to complete and return to us if they wished. Only two out of ten residents to whom we sent surveys returned them to us, and four out of five staff responded to us. Some of their comments feature in this report. None of the visiting healthcare professionals to whom we sent surveys responded to us. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service, and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, provision, training and supervision of staff were inspected, as was the overall management of the home. A tour of the premises took place with particular attention to the maintenance and cleanliness. We required an Annual Quality Assurance Assessment (AQAA) from the home, which was provided, the contents of which informed part of this inspection. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? The home has had a new manager since the last inspection, and she clearly demonstrates a commitment to improving standards in the home, and shares a good rapport with the residents. A new pre-admission assessment tool has been devised, which is now being implemented. This will provide better opportunities for the homes assessor to gain and record a more in depth understanding about prospective residents needs before they come into the home. Key-worker sessions have been introduced, so that residents have more opportunity to have better quality individual time with a particularly familiar member of the staff Care Homes for Older People Page 8 of 36 team, and also so that a better understanding of person-centred care planning can develop for the benefit of the resident. There is an ongoing maintenance and redecoration programme. Two regular housekeeping staff have been employed and the home is now becoming cleaner and more hygienic, although there is still more to do in this area. There have been some challenges to overcome within the staff group, but the manager and her deputy share a very positive working relationship, and are working together to resolve these. An evacuation plan has been implemented for the event of fire. What they could do better: Generally the systems for managing medications are satisfactory, however a degree of review would help clarify the directions for the use of certain items, particularly analgesia. Also, despite the home taking all the appropriate measures to ensure secure storage of medications, there has been a recent breach of security beyond the homes control that has resulted in the medication store cupboards being damaged and requiring replacement. Residents advanced wishes regarding the care and arrangements they would choose at the end of their lives have not been consistently recorded, but this is an area that is being looked at more closely, with more staff training planned. A social activities programme is offered at Bredon View, however the programme could be increased and made more varied for residents. Some of the cooking and serving containers used for residents food are old, very tarnished and in very poor condition and should be replaced. The home provides the minimum of staff. Also carers are regularly removed from direct care because they are expected to carry out non-care duties, such as catering and laundry. We have strongly recommended that two waking night staff are provided here. The staff recruitment procedures have not been consistently applied, and we have required an improvement here to promote the protection of vulnerable residents. Despite the delivery of training to staff in safeguarding vulnerable residents from abuse, some of them have not clearly understood what they have been taught, appearing not to have retained the information. There are certain aspects of the environment where we have required some improvement in terms of health and safety for residents. Despite some good quality monitoring systems the homes policies and procedures have not been reviewed for some time. Care Homes for Older People Page 9 of 36 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 10 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 11 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. An assessment process and access to information prior to admission to the home gives prospective residents an assurance that their needs can be met. Evidence: The homes AQAA stated that all potential residents were provided with a copy of the information brochure. Each of the two residents who responded to our survey confirmed they had received information to help them decide if Bredon View was the right place for them. We inspected two examples of pre-admission assessments, each of which was for residents more recently admitted to the home. Each of these residents had been issued with the brochure, and a letter of confirmation regarding the outcome of their assessment and their placement in the home had been issued to them. The assessments had been carried out prior to admission being agreed and had been Care Homes for Older People Page 12 of 36 Evidence: recorded on the homes designated tool for the purpose. The tool used at the time was basic and in most regards was a tick list, with additional comments made as an addendum. A new assessment tool was being phased in for all prospective admissions in the future. We saw an example of this, and it was much more comprehensive and would provide the assessor with better opportunities for capturing more information about the persons needs. The AQAA stated that all prospective residents and their families were encouraged to visit and view the home before making any decision about coming in here. It also reported that high occupancy levels had been achieved, and that many of those who came to the home for respite care chose to come here if and when they needed permanent care. We found examples where people, now residing in the home, had come round to visit and view, sometimes with members of their family, before making their decisions about it. Bredon View does not provide intermediate care. Care Homes for Older People Page 13 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home have their health and personal care needs met through appropriate assessment and care planning, which takes account of their privacy and dignity, and through systems for managing medications that are mostly suitable. Evidence: Each resident had a documented plan of care that was based on an assessment of their needs. We chose four particular care plans for closer inspection. Each contained a regularly reviewed needs assessment, with plans of care devised to meet the identified areas. Risk assessments had been carried out to address mobility and risk of falls, vulnerability to developing pressure sores and nutritional risks. Residents were regularly weighed. We saw some very good examples of risk management for residents who were at risk when going out alone, which took account of the persons rights, choices and abilities, with the appropriate risk reducing measures in place. Care Homes for Older People Page 14 of 36 Evidence: We found that the risk level of developing a pressure sore calculated in one particular case was not accurate, putting the person at a higher risk than they were actually at; the manager reviewed and amended this at the time we pointed it out. We saw good care arrangements in another case where a definite pressure sore risk was being well managed in terms of prevention, but in a third case found that there was no documented plan of care to address a similar risk. When we explored this further it transpired that this persons pressure areas were healthy and intact, with the appropriate measures in place in practice. Care planning was personalised and individual, and promoted independence and choice. It took account of the whole person, and was mindful of residents past life and dignity. There were records to show the multidisciplinary involvement from visiting healthcare professionals to meet residents health needs. Records of medical interventions, reviews and treatments were maintained, and body charts recorded and monitored any marks or bruises that materialised on a residents body, whatever the reason. The AQAA stated that staff had received the necessary training to enable them to deliver and focus upon a more person-centred care service. Key-worker sessions were being introduced so that residents could have more opportunity to share their views on person-centred care. It also reported that staff worked to ensure good working relationships with the Primary Care Trust. The manager had taken appropriate steps to address some recent concerns about the unsatisfactory manner in which two staff had addressed aspects of a particular residents care needs. Residents who responded to our survey told us that they received the care and support that they needed, and that staff made sure that they received the medical care that was necessary. Those we met in person appeared cared for and comfortable, telling us that they were well looked after. One person had just been escorted to a medical appointment when we met him, and he told us that he had very good care. Another told us that, although they were very independent, the staff were on hand to help and support them if they needed anything. Residents told us that staff were sensitive and respectful, and knocked on their door before entering. One person said that not all staff waited for an answer before coming in though. Care Homes for Older People Page 15 of 36 Evidence: Staff told us that they received up to date information about the needs of the residents, and had access to care plans. Residents were supported to manage their own medications within a risk management framework if they wished and were able. We saw one such example, where a risk assessment and care plan to support the residents self medication had been documented. Residents were able to express their wishes regarding the management of their medications, however to date this process had not been formalised or necessarily recorded, but the newly implemented assessment forms addressed this for the future. The home had previously provided the appropriate storage arrangements for residents medications. However, these had recently been breached and damaged during a break-in by intruders just prior to this inspection. A medication audit after the event determined that all drugs could be accounted for, and that none had been taken. Alternative temporary storage was in place, with new cupboards ordered to replace the damaged ones. Medication administration charts were clearly printed by the supplying pharmacist, with a record of administrations maintained. There were photographs of residents with their medication charts to aid identification, although there were an isolated few for whom photographs were still awaited. There was supplementary guidance on the use of topical creams, which cross referenced with individual care plans. There were separate records of administration in cases where the care staff were applying creams as part of personal care; we found just one gap where this had not happened. In some cases there was regularly prescribed analgesia, which had evidently not been required by the resident concerned. There was no record of omissions in some cases, and we advised that cases such as these be reviewed by the doctor so that the directions for usage could be more relevant to the residents needs. In the absence of that staff should consistently record why an omission is made if a drug is prescribed to be given regularly. Medications were supplied in a monitored dosage system, with some items being boxed and bottled. Containers were dated to ensure safe use, and to assist with auditing. We carried out some random audits on boxed items, and found each to be in order. Due to the spatial constraints in the dining room, the lunchtime medications were being prepared for administration from the drug trolleys storage location, and carried Care Homes for Older People Page 16 of 36 Evidence: individually to the resident concerned in the dining room. We saw that the trolley, although in sight through a glass door, was left unattended whilst the carer did this. This must not be permitted to happen. Either staff must lock away medications each time they leave the trolley, or ensure that the trolley is in the dining room ready before walkways become blocked when residents are seated for their meal. One of the residents records contained a care plan regarding their preferred care and arrangements at the end of their lives. Initial assessments could also take account of peoples wishes and views in this area, however these had not been consistently completed in every case. Staff had been particularly sensitive in one case, for whom discussion about this at this particular point of their lives would have been too upsetting for them. In another case the resident had stated that they did not wish to take any decisions in this area at present. Some of the staff had received training in End of Life care, but this was an area for further development. 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. People living in this home have a good level of choice and autonomy, and have a nutritious diet, however planned improvements to the limited social activity programme should provide more residents with better opportunities in this area of their lives for the future. Evidence: The AQAA reported plans to implement more individually tailored activities, with more one-to-one support being offered. It also reported that more social outings were being planned, and that residents personal interests and hobbies were being actively encouraged. We found examples of one resident carrying on with her tapestry hobby, and others going out to local shops and for walks. The manager was evidently trying to increase social opportunities for people, and had been consulting with them about their ideas for a programme to suit them. A monthly programme of activities was displayed in large print, but this was for the previous month and was now out of date. The displayed programme for a whole month contained only a few activities, including a quiz, a discussion group, a meeting and a music and movement session. There were also key-worker sessions, where the resident and their key-worker could spend some time together doing whatever activity Care Homes for Older People Page 18 of 36 Evidence: the resident chose. Residents told us that there were sometimes activities in which they could participate. All staff who responded to our survey said that the provision of social activities could be made better, with residents having more things to do. One resident told us that the level of social activities was not always right for him, and that he preferred something much more active. He was managing to sustain this, and took walks every day and generally went out a lot. One lady told us that she liked to do her own chores and often dusted her room. She told us that she preferred not to join in socially with other residents in the home, and that this choice was respected by the staff. We saw a quiz taking place on the first day of our visit, with residents sitting in comfortable social groups watching a large screen television during the afternoon on the second day. The home did not impose any restrictions upon visitors, with residents supported to maintain their social contacts. Residents families and friends were encouraged to join them for a meal, and to participate in the social life of the home as much as they wished as well. We met two visitors who spoke very favourably about the care their relative received at Bredon View. They confirmed that they were made to feel welcome when they came in, and were offered refreshments. Residents were encouraged to personalise their private rooms in accordance with their taste and preference. Most of the bedrooms were very individual, with lots of personal treasures in them. One resident told us that the home allowed a feeling of freedom, with residents able to do most things. They went on to say that staff were not overbearing. A resident told us that he enjoyed a lot of independence and autonomy and that staff did not interfere with this. Residents were evidently able to spend their time where they chose, and could take their chosen meal where they wanted to. Most of the residents ate their meals in the dining room, with some having it on a tray in the lounge or their room. The dining area is openly adjacent to the lounge, and space is quite restricted here. The lunchtime meal was served by the cook from a trolley, with staff offering vegetables and other accompaniments separately. The lack of space meant that the medication trolley could not be brought into the area for the lunchtime medication round. The main part of the meal was served from heavily tarnished, battered and unsightly looking containers. The meals looked appetising once served however, with good Care Homes for Older People Page 19 of 36 Evidence: portions provided and individual choices and needs catered for. Some of the residents were enjoying a drink of sherry or beer with their meal. Staff were sitting to feed a resident where needed, and were offering all sorts of choice to people, and generally being attentive. There were some residents who sat to eat their meal in the vicinity of the staff office. We noted that the nature and general activity in the office could impact on the mealtime for some residents, and recommended that the office door be closed during mealtimes, or at least more consideration be given towards this situation. There was choice offered with the teatime and breakfast meals. Snack baskets were available to residents, which offered fresh fruit, plus savoury items and biscuits. We visited the kitchen after the lunch preparations. It was clean and organised. We spoke to the cook, who demonstrated a flexible approach to cater for peoples individual tastes and preferences. The necessary catering records were being maintained, and despite not using a specific cleaning schedule, contained evidence that cleaning tasks were being carried out each day. Food stores were checked, and one out of date item had to be removed from the refrigerator. We saw staff going in and out of the kitchen, the impact of which from a hygiene perspective we discussed with staff. It transpired they were only permitted to enter the washing up area of the kitchen, and not the adjacent food preparation area. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Despite some gaps in an isolated number of staff members knowledge regarding safeguarding procedures for the protection of vulnerable residents, there are generally some good policies in place to protect the rights of the people living in this home. Evidence: The home had a clear procedure for addressing any complaints and concerns that arose. The procedure was displayed in the entrance hall, and was included in the information brochure that was issued to each resident. The procedure on display on the first day of our visit was out of date, containing the incorrect contact details for CQC, but this had been rectified on the second day. The complaints register contained records of any concerns and complaints that had been raised, and records of investigations, corrrespondence and audits demonstrated that each had been taken seriously and addressed. Residents told us that they knew how to raise a complaint if they needed to, and also confirmed there was always someone they could talk to informally if they were not happy. A visitor told us that any little concerns they had raised had always been addressed very quickly. The home had policies and procedures for the protection of vulnerable residents, but these had not been reviewed for some time. Safeguarding training had been provided Care Homes for Older People Page 21 of 36 Evidence: for the staff, which had included recognition and prevention of abuse, whistle blowing procedures and the Mental Capacity Act (2005) (MCA) and The Deprivation of Liberty Safeguards (DoLS). Some had received this training through the County Council, whilst others had received it from the companys trained trainer. When we interviewed staff about their learning in this area, at least two were unable to recall or discuss it with us in any depth. Whilst we have significant concerns about their apparent lack of comprehension, this has not affected any outcomes for residents thus far. However, in view of this concern the manager should assess staff competency and understanding about safeguarding vulnerable adults following training. Staff did however demonstrate that they would not hesitate to inform the manager if they had any concerns at all about the rights and safety of any residents. Safeguarding issues were enforced during induction training and through any ongoing risk management work. Residents care plans were drafted in such a way as to direct staff to be fully mindful of residents rights and protection. The home had kept us informed about instances where any staff practice had given cause for concern, and the manager had not hesitated to implement the necessary staff disciplinary procedures in order to afford the necessary protection for the vulnerable residents. The AQAA stated that these would be applied for those whose work ethic was not in line with the companys policies and procedures. When we reviewed this service last year concerns were identified to us by a visiting healthcare professional about certain care and staff skill related issues. When we referred to the home about this, we were satisfied that the concerns were addressed satisfactorily at the time, in conjunction with the healthcare services, with the necessary staff training implemented to avoid a recurrence. However, a recent incident for which two staff were disciplined, related to an incident of a similar nature. These staff have since left the home, but before they did the manager had discussed the circumstances with the Local Authority Safeguarding Team. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are improving standards of cleanliness in this home, however more work is needed to continue this, and to address certain risks that currently exist in the environment to ensure that people living here are provided with a safe and hygienic place to live. Evidence: The home had a designated maintenance person, and also a gardener. Since the last inspection two years ago the home had redecorated the communal sitting rooms, and had also re-carpeted them. There was a rolling programme to redecorate and recarpet residents bedrooms as well. The garden had been improved, with the creation of a garden pond, raised flower bed and more seating areas. The kitchen had been redecorated, with new flooring fitted. The maintenance person was present in the home during our visit decorating one of the bedrooms. The garden was beautifully planted, having recently won a local award. The pond, an attractive addition, had been risk assessed for its general safety, however risks to individual residents had not been specifically assessed, and we required that this be done to ensure that any risks to the safety of those using the pond area could be reduced. Care Homes for Older People Page 23 of 36 Evidence: The lamp shade was missing in one of the residents ensuite bathrooms, and also it was dim in there. The dining area outside the staff office was also very dim for those eating here. When we asked about this we were told that the ceiling light had been removed but was about to be replaced, which would then greatly improve the level of lighting here. The AQAA identified that some concerns existed regarding the standards of cleanliness and hygiene in the home, and that this was an area that needed improvement. Two designated house-keepers had been appointed in order to do this, and a prioritised cleaning schedule, a cleaning rota, a domestic communication book, and an auditing system had been introduced as part of the strategy to effect the necessary improvements. The home had a faint, stale odour when we entered on the first day at midday. The entrance hall had not been cleaned by this time, with the carpet unvacuumed. This was rectified soon afterwards. We found there were unpleasant odours in isolated areas of the home, and that the two house-keeping staff were trying to address them. We spoke to each of these workers, and each was extremely helpful, professional and clearly committed to making things better in the home. They confirmed that they had access to plenty of cleaning materials and equipment, and that they had been able to make good progresss since starting work here. Cleanliness in most areas of the home was evidently improving. We saw isolated parts that needed closer attention, and we pointed out a window frame and handles in a particular residents bedroom that needed priority due to their unhygienic condition. The laundry room on the first floor was functioning efficiently, with a washing machine capable of sluicing and disinfection cycles, and with residents laundry being attended. The room was reasonably clean and tidy, however the flooring around the washing machine was badly damaged and scored, posing a potential infection control risk. Also, chemicals were stored in here and staff had no means of securing the room. There were handwashing facilities around the home, with liquid soaps, paper towels and sanitising handgels. Staff were provided with aprons. The home did not have a contract for the disposal of clinical waste, with continence waste being put into the household waste for collection by the local council. We have previously recommended that the home have a clinical waste disposal contract, but Care Homes for Older People Page 24 of 36 Evidence: been assured that CTCH Ltd has consulted with the council about this arrangement. Care Homes for Older People Page 25 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. People living in this home receive care from a minimum but generally competent workforce, however the isolated shortfalls in the staff recruitment procedures are posing a degree of risk to their health and safety. Evidence: The staff rotas demonstrated the very basic staff numbers that were on duty at given times. Apart from the manager and the deputy manager, who tended to be supernumerary during week days, there were three care staff on duty at all other times of the day and evening, with one waking and one sleep-in carer overnight. As well as care duties the staff were also involved in catering and laundry duties. When we commented on the impact that these arrangements might have on how staff meet the residents needs the manager said that the home had a very low dependency group of residents. Staff told us that their numbers suited the needs of the home, and residents confirmed to us that their bells generally got answered promptly. It will be important for these staffing levels to remain under review to ensure that they remain appropriate, particularly overnight. We have strongly recommended that there are two waking night staff in this home. There were a number of housekeeping and catering staff to provide cover over a seven day period, although as previously reported the care staff had to undertake some catering and laundry duties as well. There had been practically no agency staff Care Homes for Older People Page 26 of 36 Evidence: usage in recent months. The AQAA reported that the temporary transfer of the deputy manager to another care home in the group, the second assistant manager leaving, other recruitment issues, and conflicts between the managers and staff views had all been barriers to improvements in the home. We found that the manager and deputy shared a very positive working relationship and were intent on improving this situation. The staff rotas and key-worker allocations had been revised in order to improve the staff skill mix. Staff confirmed that they received a good handover of information about residents needs between shifts. There seemed to be a relaxed atmosphere amongst some of the staff, with an isolated number appearing to have little regard for the inspection process. Residents and visitors spoke well of the staff, saying that they were good, caring and kind. The AQAA stated that the NVQ training programme was actively encouraged for the carers, but only five out of the sixteen care staff had achieved the award. One other person was currently working towards the award. We inspected the recruitment arrangements for three members of staff. Each staff file contained an application form, an offer of employment letter and a contract. Interview notes were included, although in one case these were very brief. In another case it was clear that any gaps in the employment history had been explored with the person concerned. A criminal convictions declaration had been signed, and medical fitness confirmed. Proof of identity had been sought, but there was no photographic identification of the staff on file. It was not entirely clear either what type of identification, photographic or otherwise, had been checked. Two written references were on file in each case, including from previous employers, having been received in advance of them starting work here. In one case one of the referees had supplied their handwritten comments on unheaded paper. The authenticity of this reference had not been verified. A Protection of Vulnerable Adults (POVA) check had been done in each case, with a full Criminal Records Bureau (CRB) disclosure on file. Where concerns arose over CRB results, decisions had been taken to offer employment on the basis of a risk management strategy. Care Homes for Older People Page 27 of 36 Evidence: Induction training was provided for all new staff. New workers were assessed for the level of induction training that they needed using a skills scan assessment tool. Records showed that those with no previous experience received training with an external training provider in accordance with the Common Induction Standards (CIS) for care workers. The outcome of this was further assessed in order to identify any further knowledge gaps for which additional training might be required. We were told that for a worker with previous care experience, any gaps in training and knowledge identified on the skills scan assessment would also lead to further training. New staff worked under supervision during their induction period, and the manager demonstrated her awareness that this level of supervision would remain if ever a worker started work ahead of the receipt of a CRB disclosure. Staff confirmed they had received a good induction to the home, which covered the things they needed to know in order to do their job, and that they had worked under supervision. They also confirmed that they had ongoing training that was relevant to their roles, which helped them to understand peoples needs and new ways of working. The AQAA confirmed that staff had received training in core values and diversity, and we were told that the organisation was making training in Equality and Diversity mandatory for all staff. Infection control training was also being made mandatory. The training matrix had not been consistently recorded, and could not be relied upon to give us a clear picture of what was happening in the home. Staff had individual development portfolios however, and these contained certificates of their achievements. Examples of training included Health and Safety matters, End of Life care, Dementia Awareness, Safe Food Handling, Medication Management, Control of Substances Hazardous to Health (COSHH), and First Aid. A number of training courses were provided as distance learning courses with local colleges and training providers. The manager had plans to provide training for staff in Nutrition. Care Homes for Older People Page 28 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Despite some very good management systems here that are designed to ensure the health and safety of the people living in the home, there have been unexpected risks posed to their interests that were beyond the control of the staff. Evidence: A new manager has been appointed to Bredon View since the last inspection. This person is an experienced carer, has an NVQ level 4 in Care, and has achieved the Registered Manager Award. She had recently been assessed by CQC for her fitness to manage the home, and confirmation of the outcome of this was awaited at the time of this inspection. The manager was present throughout our visit, and although slightly anxious about her first inspection, appeared a calm and kind person, who was very helpful and cooperative with us. She remained fully accessible to residents, and clearly shared a good rapport with them. One resident told us specifically that the manager was just the loveliest person. One resident told us that in their view Bredon View was well run, and that the staff were well chosen. Care Homes for Older People Page 29 of 36 Evidence: The manager demonstrated her commitment towards monitoring and driving improvements in the home to benefit the lives of the residents in particular. A range of auditing had been carried out, and we were able to view the records for these, and the actions planned and implemented to address areas of concern. Residents views had been sought as part of this process, not only through consultation during audits, but also at resident meetings. Minutes of these meetings clearly showed that residents views and ideas for their home were sought, welcomed and acted upon. Recorded minutes of staff meetings also showed that an inclusive and reassuring style was adopted by the management of the home. There were no residents currently subject to a Deprivation of Liberty Safeguard (DoLS)arrangement. Staff had received training in this area to undertsand when such circumstances might warrant a referral to the local DoLS team. The homes AQAA did not include a comprehensive list of policies and procedures, and those which did feature in it had not been kept under review, and were not current. Residents were able to place money and valuables with the home for safe-keeping, however a recent burglary at the home had resulted in the theft of all monies held in the safe. There have been two security breaches at Bredon View within the past year, including this one. The other was also a burglary carried out during the night, during which some equipment was stolen. Residents were not harmed or disturbed in any way during these incidents, and were reimbursed for any losses they suffered. The police are investigating each case. A staff supervision matrix was in place, and examples of some supervision records were seen. The AQAA reported that observational supervision was also provided to staff in order to identify any failings or concerns with practical aspects of their work. Supervision and appraisal was an ongoing development tool for new and existing staff, and staff confirmed to us that they received good levels of supervision and support. Records showed us that regular checks had been carried out on the fire safety systems, including the fire alarms, smoke detectors and emergency lights. A fire safety risk assessment had been carried out. Staff had been individually risk assessed to determine the frequency of their ongoing fire safety training. A fire safety evacuation plan had been formulated, and evacuation scenario training was being introduced into the staff training. Regular fire drills were being carried out. Care Homes for Older People Page 30 of 36 Evidence: Two fire extinguishers were not secured to the wall, and had been left free-standing on the floor. This posed a risk to residents should one fall over. The manager was aware of this, and had already reported it to the maintenance person. Safety checks and maintenance of utilities and equipment had been undertaken. Passenger shaft lift inspection records repeatedly showed that a water problem in the shaft pit required attention. The shaft lift was out of order at the time of our visit, with parts awaited in order to effect a repair. Residents had not been directly affected by this however, as they could come downstairs by using the stair lift. There was a Legionella risk assessment in place, which was provided to us in advance of our visit. This demonstrated that regular checks were carried out on cold water tanks, hot water temperatures at outlets and at storage and distribution, with a flushing programme for irregularly used areas. The gas boilers were reportedly serviced annually, however the latest certificate was not available in the home to see. Staff had been trained in basic first aid, and first aid facilities were available. Accident records were being maintained and any incidents were being regularly audited, with safety and risk reducing measures instigated as appropriate. It has not been fully established how the breaches in security reported above actually occurred. The management of the home was addressing this in the best way they could, and procedures to carry out more robust security checks of the premises had been communicated to all staff. Care Homes for Older People Page 31 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 32 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 19 13 The registered person must conduct individual risk assessments for residents regarding access to the garden pond. This is to ensure that any risks posed to residents health and safety can be identified and reduced or eliminated. 30/11/2009 2 19 23 The registered person must replace the light shade or repair the light fitting in the identified en-suite bathroom. This is to ensure that this particular residents environment is improved for their comfort. 30/11/2009 3 26 13 The registered person must ensure that the laundry room floor surface is maintained in an intact condition or replaced. 31/12/2009 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 This is to ensure that the surface can be maintained in an hygienic condition so as to reduce the risks of cross infection. 4 26 13 The registered person must ensure that the storage of chemicals in the laundry room is made secure. This is to ensure that any risks to residents who may enter this unsecured room are reduced. 5 29 19 The registered person must ensure that records are retained in the home to confirm that proof of identity, including a recent photograph, has been obtained when recruiting new staff. This is part of the required pre-employment checks so that only suitable people can be employed to care for the vulnerable residents in the home. 6 29 19 The registered person must confirm the authenticity of written references when recruiting new staff to the home. This is part of the required 30/11/2009 30/11/2009 30/11/2009 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 pre-employment checks so that only suitable people can be employed to care for the vulnerable residents 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 1 9 Staff should ensure that the directions for usage of analgesia are reviewed to ensure that they remain relevant to the residents needs and requirements. The old tarnished and battered cooking and serving containers should be replaced with new ones. The level of staff understanding regarding abuse and the local Safeguarding procedures, should be assessed following their training to ensure they have understood what they have learnt. The registered person should improve the level of lighting in the identified en-suite bathroom. The registered person should review the catering and laundry arrangements to ensure that care staff involvement in these areas does not impact on the care and time spent with the residents. The registered person should review the night care arrangements and provide two waking night carers every night. The homes documented policies and procedures should be reviewed and updated where necessary. 2 3 15 18 4 5 19 27 6 27 7 33 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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