Care Home: Bybrook House Nursing Home

What the care home does well Bybrook House is a large country house, set in attractive, peaceful grounds. All of the rooms are different from each other and exceed minimum standards for room size. People can bring in their own items if they wish and some of the rooms had a highly personalised appearance. The home has enthusiastic catering staff, who are keen to respond to individual resident`s likes and dislikes. Meals are attractively presented. Care staff take much care and attention when assisting residents who are frail to eat their meals. Staff were keen to ensure that residents received the care that they needed, this included domestic as well as nursing and care staff. People commented on the home. One person described Bybrook House as "a lovely place" and that the situation was "great" and another that "my report would be favourable". One resident reported that they had been in hospital recently and that it was "so nice to get back here." People commented on the staff. One person reported that staff listened and acted on what they said "all down the line", another that staff "deserve high praise for the standards they set" and another "all the staff are helpful". Staff also talked about their enjoyment of their work. One person reported "it`s a pleasure to come to work" and another that they loved their job and "should have done it years ago". What has improved since the last inspection? The home have put in many improvements since the last inspection, to the extent that now they are assessed as providing good outcome for residents, where previously they were assessed as providing poor outcomes to residents. The home have ensured that communal use of clothing, particularly under-clothing no longer takes place. Improvements have been made in care planning, care records and audit of care provision, to ensure that residents are protected from risk such as pressure damage and manual handling. Care plans are now clearer and describe actions to be taken in measurable terms. Management systems for disposal of Controlled Drugs have been improved. Records relating to changes in medicines prescriptions have improved. Residents are now given full information about the services offered by the home. The home have made a range of improvements to ensure that residents are safeguarded. All staff have been trained in abuse awareness and showed understanding of the importance of this area. The provider has put in safeguards to the home environment, including alarms to fire doors, to protect residents who may put themselves at risk by wandering behaviours. The public areas of the home have been fully re-decorated and re-carpeted. The number of hours devoted to maintenance has been increased. A full review of equipment such as commode chairs has taken place and any deteriorated equipment disposed of. Plans are being developed to improve a range of areas, including bathing facilities for people with a complex disability and the home`s sluice rooms. The provider has ensured that the home provides suitable beds for people with complex nursing needs and equipment to support frail people is now correctly used. Practice in prevention of spread of infection has improved, including safe use of topical creams and cleaning of mop-heads. The home have much improved its systems to ensure the health and safety of people in the home. This includes protecting people from risks associated with hot water and surfaces, safety in storage of oxygen cylinders, correct use of bed rails and fire safety procedures. The provider has set up regular health and safety meetings, which includes staff and residents. What the care home could do better: The home needs to continue its development of care plans. There continue to be some areas where staff know about resident`s care needs but these are not documented. Documentation is needed to ensure that all staff know about significant matters for residents and provide care in a consistent manner. Not all people who are unable to move themselves, give themselves food or fluids have monitoring charts in place. This is needed, so that staff on each shift know what care has been given and managers can monitor how effective interventions have been. Some details in care plans need improvements, for example to document the precise consistency of fluids for people who need thickening agent in their drinks and what topical applications are being used for a person. Some improvements are needed in medicines administration and storage. To ensure that access to Controlled Drugs cupboards is kept to a minimum, only Controlled Drugs may be stored in the Controlled Drugs cupboard. Where a person is prescribed a medicine on an "as required" basis, there needs to be a protocol or care plan to direct registered nurses on the reasons for administration of such drugs. Where people are prescribed drugs which can affect their daily lives such as mood altering drugs or painkillers, care plans should be drawn up, so that staff can evaluate the drug`s effectiveness. Further systems should be developed in certain areas, including more detailed quality audit of accidents, assessments of benefits of activities provided to residents and management systems to ensure that staff fully complete all records at the time care is given. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Bybrook House Nursing Home The Lodge Bybrook House Middlehill Box Wiltshire SN13 8QP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Susie Stratton     Date: 1 2 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 32 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 32 Information about the care home Name of care home: Address: Bybrook House Nursing Home The Lodge Bybrook House Middlehill Box Wiltshire SN13 8QP 01225743672 01225744281 pen.b@talk21.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Avon Care Homes Limited care home 30 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 30 The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home Bybrook House provides care and accommodation for up to 30 older people. The home is privately owned by Avon Care Homes Ltd. The company owns other services, including a nursing home in Wells, Somerset, where its administrative operations are based. The principal company director is Mrs Maria Cristina Bila, who regularly visits Care Homes for Older People Page 4 of 32 Over 65 30 0 1 6 1 2 2 0 0 8 Brief description of the care home Bybrook House. The home does not currently have a registered manager. A person is working into this role and they are in the process of applying to be the registered manager of the home. This person leads a team of registered nurses, care and anciliary staff. The home is in a rural area, close to the village of Box. The city of Bath is approximately five miles away. The house is an older building set in extensive grounds, with views of surrounding countryside. There is car parking on site. Fees charged to residents range from 700 pounds to 1,200 pounds per week. Information for prospective residents is provided in the main entrance hall, in their rooms and on request. Care Homes for Older People Page 5 of 32 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: As part of the inspection, 30 questionnaires were sent out and 10 were returned. Comments made by people in the questionnaires and to us during the inspection process have been included when drawing up the report. As part of this inspection, the homes file was reviewed and information provided since the previous inspection considered, including the improvement plan from the last inspection. We also received an Annual Quality Assurance Assessment (AQAA) from the home. This was their own assessment of how they are performing. It also gave us information about what has happened during the last year. We looked at the AQAA, the surveys and reviewed all the other information that we have received about the home since the last inspection. This helped us to decide what we should focus on during the visit to the home. One inspector performed the site visit. This person is referred to as we throughout the report, as the report is made on behalf of the Care Quality Commission (CQC). The Care Homes for Older People Page 6 of 32 site visit was on Friday 12th June 2009, between 9:10am and 3:55pm. It was unannounced. The manager designate came on duty during the inspection. The manager designate was available for all of the feed-back and the provider was able to make herself available for much of the feedback, at the end of the site visit. During the site visit, we met with five residents and observed care for four residents for whom communication was difficult. We toured all of the home and observed care provided at different times of day and in different areas of the home. We reviewed care provision and documentation in detail for four residents, including a resident who had recently been admitted to the home. As well as meeting with residents, we met with a registered nurse, three carers, the housekeeper, a domestic, the activities person, the chef and a catering assistant. We observed a lunchtime meal and an activities session. We reviewed systems for storage of medicines and observed one medicines administration round. A range of records were reviewed, including staff training records, staff employment records, complaints records and maintenance records. What the care home does well: What has improved since the last inspection? The home have put in many improvements since the last inspection, to the extent that now they are assessed as providing good outcome for residents, where previously they were assessed as providing poor outcomes to residents. The home have ensured that communal use of clothing, particularly under-clothing no longer takes place. Improvements have been made in care planning, care records and audit of care provision, to ensure that residents are protected from risk such as pressure damage and manual handling. Care plans are now clearer and describe actions to be taken in measurable terms. Management systems for disposal of Controlled Drugs have been improved. Records relating to changes in medicines prescriptions have improved. Residents are now given full information about the services offered by the home. The home have made a range of improvements to ensure that residents are safeguarded. All staff have been trained in abuse awareness and showed understanding of the importance of this area. The provider has put in safeguards to the home environment, including alarms to fire doors, to protect residents who may put themselves at risk by wandering behaviours. The public areas of the home have been fully re-decorated and re-carpeted. The number of hours devoted to maintenance has been increased. A full review of equipment such as commode chairs has taken place and any deteriorated equipment disposed of. Plans are being developed to improve a range of areas, including bathing facilities for people with a complex disability and the homes sluice rooms. The provider has ensured that the home provides suitable beds for people with complex nursing needs and equipment to support frail people is now correctly used. Practice in prevention of spread of infection has improved, including safe use of topical creams and cleaning of mop-heads. Care Homes for Older People Page 8 of 32 The home have much improved its systems to ensure the health and safety of people in the home. This includes protecting people from risks associated with hot water and surfaces, safety in storage of oxygen cylinders, correct use of bed rails and fire safety procedures. The provider has set up regular health and safety meetings, which includes staff and residents. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details 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 32 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 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents and their supporters will be given information about the home and have a full assessment, so that they can be assured that the home will be able to meet their needs, prior to admission. Evidence: In their AQAA, the home reported that they had fully revised their service users guide. We reviewed this information. We observed that the guide now fully conformed to our guidelines. The guide was in a format which would be easy to access and provided a range of information to people who may be considering admission to the home. A range of information is available in the front entrance of the home, including our full inspection report, as well as being provided to people individually. All of the five people who responded to this section of the questionnaire reported that they had received enough information about the home prior to admission. One relative described the information as excellent. Care Homes for Older People Page 11 of 32 Evidence: The manager reported that they go to visit all prospective residents before admission, so as to assess if they could meet the persons needs. One person reported My [relative] was visited by the Matron in charge in their home and had a long talk. We were given every opportunity to visit Bybrook and ask questions. Another person reported It was selected by [my relatives] after a couple of visits as it is only a short distance from home and they were favourably impressed by the staff. Bybrook House is in a rural area, close the the large village of Box and not far from the city of Bath. Several people reported that they had chosen Bybrook because of this, liking its peaceful rural location, but pleased that it was close to local amenities. One person reported that the proximity of the home to Bath meant that friends from Bath could also visit them, as well as their family from Box. In their AQAA, the home reported that they had up-dated their admissions documentation. We met with one person who had been recently admitted and reviewed their records. We noted that the home had performed an assessment before the person was admitted, this outlined the persons nursing and care needs. Immediately after admission, the home completed a more detailed assessment of the persons nursing and care needs, including detailing information which had not been fully available at the assessment visit. The assessment formed a sound basis for the development of the persons care plan. We noted that assessments included social needs as well as nursing and care needs, described the persons past life, the importance of family to them and how they preferred to spend their days. Staff we spoke with reported that they were fully informed of prospective new admissions. The chef reported that they would try and go and visit any newly admitted person soon after admission, to find out their needs and preferences for meals. Care Homes for Older People Page 12 of 32 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 will be generally fully supported by the homes systems for ensuring that their personal and healthcare needs are met. A few areas need to be addressed to further reduce risk to people. Evidence: All of the five people who responded to this section of the questionnaire reported that they received the care and support that they needed. One person commented Bybrook staff are always kind, considerate and patient, another no trouble seems to be too much and another I am always impressed by the level of care an support. Some people commented to us on care. One person reported Im very well looked after and another they always gives me a good wash down. A relative commented staff have acted on all times with advice given by [a doctor] on communicating with [my relative] and this seems to have been effective. We observed that staff consistently knocked on residents doors prior to entering the persons room. All personal care was performed behind closed doors. We met with one very frail person, who was asleep most of the time and we observed that they were Care Homes for Older People Page 13 of 32 Evidence: nicely turned out, including fresh attractive nightwear. Staff commented that they were given up to date information about the needs of the people they cared for. One person commented care plans are reviewed monthly and added to as and when things change. A registered nurse we spoke to during the inspection was very aware of residents needs and was open to suggestions about how documentation could be further developed. A carer knew residents individually and reported on how they were encouraged to read care plans and how useful they found them. In their AQAA, the home reported on the high standards of care provided, particularly for people with terminal care needs, reporting that they liaised closely with the local hospice. They also reported that they were aware that they needed to continue to work on improving documentation. In their AQAA they reported that they had two people who had sustained pressure ulceration in the home. When we performed the site visit, the registered nurse reported that both people had had only minor pressure ulceration, that they had responded well to interventions and that both peoples ulcers had now healed. The home performs regular assessment of need, including risk assessments, for residents. Assessments include risk of pressure ulceration, risk of falls and nutritional risk. Assessments were regularly reviewed, including if a persons need changed. For example, a persons manual handling assessment had been reviewed when they started to spend most of their time in bed. If a person was identified as having a need or a risk, care plans are drawn up to direct staff on how the persons need was to be met or risk reduced. For example one persons records indicated that they had difficulties with communication. They had had a care plan drawn up, which directed staff on how the person was to be supported in communication. The plan was clear and written in non-judgemental language. Another person had a care plan which directed how their continence needs were to be met, this was detailed and directed staff on the type(s) of continence aids needed to support the person. Some areas in care planning would benefit from improvement. One person had a particular need in relation to their breathing, which they were able to tell us about and which the registered nurse also knew about, but this was not documented in their records. Several of the residents were assessed as being at high risk of pressure ulceration. Staff spoken with were aware of interventions to perform to prevent risk and the home had a robust review process for if a person showed any signs of Care Homes for Older People Page 14 of 32 Evidence: pressure ulceration. However while equipment to be used to prevent risk was documented, other interventions, such as how often the person needed to be turned or additional food supplements, were not documented in a care plan. Where people were very frail and not able to support themselves with activities of daily living, such as moving their position, feeding themselves or giving themselves drinks, there was a lack of consistency in approach. One person who needed to have their position changed by staff had clear records, which were observed to be accurately completed, showing that they had their position changed regularly to prevent risks of pressure ulceration. However two other people who were also unable to more their positions did not. Observations indicated that one of these peope remained in the same position for in excess of five hours. Some people had food and fluid charts completed to assess their daily dietary and fluid intake. Whilst some charts were fully completed, others were not, indicating some days and times when the person was documented as not having any fluids or meals. Discussions with staff indicated that staff were supporting residents but not documenting care provided. Such records need to be accurate, so that people can assess that the persons needs have been met. It was also discussed that such records provide much data which can be used when evaluating responses to treatment in care plans. Most of the care plans were very detailed. For example one persons care plan documented which parts of personal care the person was able to perform and which parts they needed full assistance with. Another persons care plan documented how they liked their door to be closed very quietly at night when people came to check on them, as otherwise they would be disturbed. The resident reported that they were pleased that staff kept to this plan. Some care plans needed more detail. Where a person was prescribed thickening agent to enable them to swallow safely, care plans did not state how thick the person needed their drinks to be. Some care plans directed which topical applications they needed, whilst others just stated apply creams, although the person was prescribed more than one cream. Some food charts documented that the person had eaten a cooked lunch without documenting what the lunch was. The chef confirmed that residents who need to be fed their meals were able to have choices of meals. Full records of the meal given are needed, so that staff can assess what very frail people are able to eat and to indicate what may be their preference, if they are unable to communicate verbally. Where a person is prescribed oxygen, the care plan should state how often the tubing for the oxygen needed to be changed, to prevent risk of re-infection. We observed a medicines round and noted that it was performed in a safe manner, with the registered nurse carefully checking the medicines administration record, Care Homes for Older People Page 15 of 32 Evidence: selecting the correct drugs, dispensing them and signing only after they were assured that the resident had safely taken the drug. All medicines records were fully completed. Medicines were safely stored, including Controlled Drugs. We observed that two different envelopes for valuables were stored in the Controlled Drugs cupboard. This is contrary to the Medicines Act which states that only Controlled Drugs may be stored in a medicines cupboard. This is to ensure that access to Controlled Drugs cupboards is kept to a minimum. We noted that some residents were prescribed medicines on an as required basis. Where this is the case, a protocol or care plan for each drug for each resident needs to be drawn up, so that registered nurses are fully aware of the indicators for such drugs and the resident is consistently given the drugs by registered nurses when they need them. Some residents were prescribed drugs which can affect their daily lives, such as painkillers, aperients or mood altering drugs. It is advisable that care plans be drawn up about such drugs, so that their effectiveness in practice can be evaluated and prescribers informed. Care Homes for Older People Page 16 of 32 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 will be supported in exercising choice in how they live their lives, including recreational activities and at meal times. Evidence: A new activities coordinator has been appointed since the last inspection. This person had only recently come in post. They had worked in the home in another capacity previously, so knew the residents and their needs. During the inspection, we observed an activities session, where the residents were taking part in a game of drafts. One of the residents was helping the activities person in the details of the game, all the people were participating and we observed that there was laughter from all parties during the game. Some residents did not wish or were unable to come out of their rooms and the activities coordinator reported that they visited such people and provided individual activities. For example they knew much about the past life of one resident and reported that they engaged them in conversation about this, to support them in memory retention and in communicating. One person commented about the activities person shes very good, we play games and Im going to teach them all how to play chess. We noted that all residents had records completed relating to their past lives, what Care Homes for Older People Page 17 of 32 Evidence: had been important to them and how they wished to spend their lives. Many people had been supported in bringing items of their own into the home and one persons room in particular was very personal, very much reflecting their likes and preferences. One person reported to us you can do what you like here. Records were maintained of activities participated in, these would be improved if the benefit to the resident were also included. Residents and relatives in questionnaires reported on how the home had introduced residents and supporters meetings. The home have also started producing a newsletter for people of events and happenings. Residents were enabled to go out of the home. One person reported that they usually went out with their family every Sunday. The manager reported on how they had continued to work to develop closer links with the local community. One relative reported on how they appreciated being able to join in with church services from the local clergy in the home. One persons records detailed the importance to them of continued practice of their faith and how they were to be supported in this. Relatives also commented on how the home kept in touch with them. One relative commented on how the home had kept in close contact with them about their relatives changing condition. All people responded in questionnaires favourably about the meals. One person commented we have a choice and they will make me something else if I do not like the menu. another person commented My [relative] says the food is good which is high praise from [the person] as [the person] was an excellent cook. During the inspection, we talked to people about the meals. One person said the food is very good, this is although Im not interested in food, another the food is excellent, I have to ask for a smaller portion, another I like whats on the menu and another we have very good food. We met with the chef during the inspection. They reported that they have started going out regularly to meet with the residents and hear what they have to say about meals. The chef showed a flexible approach to meals provision and reported that they were happy to cook something different if the resident asked. They reported that they cooked nearly all their meals from raw ingredients. We observed a meal during the inspection. Many of the residents eat in the dining room, which is laid out in a similar manner to a hotel. People sat at tables and were supported in conversing with each other. People were offered a choice of drinks with their meals. Meals were attractively laid out, with attention paid to colour of foods on the plate. Aids to support people in independently giving themselves their meals were provided. Where people needed assistance to eat, staff sat with them and supported Care Homes for Older People Page 18 of 32 Evidence: them. Residents could eat in their own room if they preferred. We observed a carer carefully assisting a person to eat who had swallowing difficulties. We observed that their meal was finely chopped, rather than liquidised. The carer supported the resident in eating their meal, whilst at the same time carefully observing if they were swallowing safely. Care Homes for Older People Page 19 of 32 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. People will be listened to when they raise issues of concern to them and people will be safeguarded by the homes procedures. Evidence: People are informed of the complaints procedure in the service users guide and the procedure is also displayed in the entrance area of the home. All of the people who commented to us in questionnaires reported that they knew how to make a complaint. One person reported that their relative obviously raises whatever is on [their] mind with staff, who either deal with it or discuss it with me. All of the staff who returned questionnaires to us also reported that they knew what to do if a person had concerns about the home. We also asked people during the inspection about how they raised concerns. One person reported I could always talk to sister - very easy to talk to, another in the first instance Id go to [the manager], shed fix it for me and another Id talk to Matron or one of the others - theyre very good. In their AQAA, the manager reported on their open door policy, which reduced complaints, as they could take action when issues were first identified. The manager reported that they had received no formal complaints since the last inspection. They had had several issues of concern raised with them. Records showed that they had documented these and ensured action was taken if matters were identified. Care Homes for Older People Page 20 of 32 Evidence: The manager reported to us that they had continued their review of security in the home, to ensure that people with additional dementia care needs could be kept safe. Since the last inspection, they had invested in a range of equipment to ensure that they would be alerted if someone inadvertently tried to exit the building by using an external fire escape. At the time of the inspection, they were receiving costings for a security device for the front door. The manager was aware of local procedures for safeguarding people and this information was also freely available in the home. Records showed that staff had been trained in protection of vulnerable adults. Discussions with staff showed that they were aware of the importance in their role in ensuring that vulnerable people were safeguarded. Care Homes for Older People Page 21 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported by a well maintained home, which is clean and where the principals of infection control are up-held. Evidence: Bybrook House is a large country house, where accommodation is provided on different floors and at different levels. There is a passenger lift between the three main floors. Four rooms are provided down a small flight of stairs. Only one of these rooms was occupied and this person could manage the stairs. Another two rooms were provided up two steps. Only one of these rooms was occupied and the person did not choose to come out of their room. As the home was originally a country house, all of the rooms are different from each other. Nearly all are large and much exceed our minimum standards. Some of the rooms are en-suite and where they do not, all have wash hand basins. Rooms all overlook the homes garden areas or the front entrance area. The garden areas have been improved since the last inspection, with attractive planting and attention to tidiness of areas. Since the last inspection, all of the entrance hall, corridor and stair areas have been redecorated and re-carpeted. This gives the home a much more attractive atmosphere. One person commented how they appreciated that there were always fresh flowers in the home. The manager was able to describe plans they were developing for the home, including improved bathing facilities for people with a range Care Homes for Older People Page 22 of 32 Evidence: of disabilities and sluicing facilities. In their AQAA, the manager reported that they had invested in new equipment such as chairs, slings and slide sheets. Flat screen televisions had also been provided. All frail people were now cared for in profiling beds. Equipment used commonly, such as commode chairs were of a good standard and systems had been put in place so that they were not used communally. The hours dedicated the maintenance have been increased since the last inspection. The housekeeper was able to clearly describe the systems for ensuring that maintenance is regularly performed. They also described how improvements are made to rooms which have been vacated before they are offered to a future resident. Where emergency maintenance is needed, the manager has a list of local contractors who can take action if needed. The home was clean throughout, including difficult reach equipment such as the backs of bath hoists and the undersides of raised toilet seats. A domestic reported that the home had revised its policies and procedure on use of cleaning materials in accordance with current national guidelines. They reported that they had a good supply of disposable gloves and aprons, including a range of sizes to meet the different needs of staff working in the home. The laundry has been improved and there was no dust visible behind the machines. Full systems had been put in place to stop communal use of underclothing. Many of the topical creams were named, but not all. This is advisable to ensure that risks associated with communal use of creams are reduced. In order to ensure that modern guidance on infection control are followed, it is advisable that wall glove dispensers be placed in all areas where they they are needed, such as residents en-suites, bathrooms and toilets. Care Homes for Older People Page 23 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be supported by staff who have been safely recruited and who are trained to perform their role. Evidence: In their AQAA, the home commented on staff, reporting that they were loyal, committed to the home and to each other. Information from the home indicated that there was a low turn-over in staff and that agency staff had only been needed on three occasions since the last inspection. One person commented on the good no of staff per shift. When we discussed staffing levels with people during the inspection, we also received favourable comments. One person reported I ring the bell and they come, theyre very helpful, another that staff were quite prompt when they rang their bell and another yeah, they come quickly when they rang the bell. One person reported that this did not change with the night shifts, reporting with me, its at night, theyre very good about coming to see me and that. One resident asked to show us a demonstration of how quick staff were by ringing their bell when we were with them, and this was observed to be the case. We looked at systems for staff recruitment, reviewing the files of three recently employed members of staff. We observed that all staff had two references, a full employment history and proof of identity. Where a member of staffs clearance from the protection of vulnerable adults list had been returned and they had started work Care Homes for Older People Page 24 of 32 Evidence: before their criminal records clearance had been returned, there were clear systems to show that they were fully supervised, until criminal records clearance was obtained. The manager reported on the improved induction which had been developed, to support newly employed staff. One person who had been employed for a longer period of time reported that they had not been given an induction when they started working, some time ago. Another person reported induction to new workers is now being carried out and another a lot to take in but with the help of my colleagues I got there!. We met with two members of staff who reported that they were undergoing induction and they reported that they felt supported. In their AQAA, the home reported on improvements to training and supports from the providers training officer. The manager has systems for ensuring that all people undertake mandatory training as and when required. People are also encouraged to undertake training in areas relating to residents needs. Recent training has included palliative care, dementia care and the home report they are planning to have support from the speech and language therapist shortly. Staff are supported in undertaking national vocational qualifications. Care Homes for Older People Page 25 of 32 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. People will be protected by the management systems in the home, which will ensure their health and safety. Evidence: The manager has been in post for nearly a year. This person has applied to be the registered manager, in accordance with our processes. The manager is experienced in their role. They are also a registered nurse. Several people commented on the manager. One person commented The running of Bybrook House has gone through various phases since..... [the manager] has initiated considerable changes, which are good. [The manager] is also clearly respected by other staffers. Another person described the excellent manager and staff team. In their AQAA, the home described how they had worked on developing a friendly and professional atmosphere. They commented also on the development of resident, relatives and staff meetings to improve communication and supports to people. Meetings include a health and safety group, which includes a resident representative, so that the impact of health and safely issues for residents can be fully considered. As the home is part of a group of Care Homes for Older People Page 26 of 32 Evidence: homes, it was discussed with the provider that it might be beneficial for groups of people, such as the activities organiser and chefs to meet across the group, to exchange ideas and further develop quality programmes in these more specialist areas. The manager reported that they regularly seek the views of people. Most recently they have completed a staff survey and analysed the reports. Currently they are surveying residents and their supporters and will analyse results in a similar manner when they have been returned. The provider regularly visits the home and completes a report. Following the last inspection, they provided us with an improvement plan when we asked for it. We are aware that after the last inspection, the Health and Safety Executive issued directives. The provider ensured that issues detailed in these directives were fully addressed within timescales. The home reviews a range of other matters as part of its quality audit, such as incidence of infection and pressure ulceration. They have set up a system for reviews of care plan documentation. We advise that that management systems should be put in place to ensure that all monitoring records are always fully completed by the person providing the care. The home do perform reviews of accidents. We advice that reviews of accidents be extended, to include time of day and day of the week. The home has clear systems for ensuring that charges for additional services, such as chiropody and hairdressing, are correctly managed and charged to individuals accounts. At present there is not a full receipted system of valuables handed in for safekeeping and we recommend that this should be considered, to ensure that there is a full audit trail relating to residents valuables. The manager has established clear systems for supervision of staff. As part of these systems they ensure that all relevant areas, such as protection of vulnerable adults, health and safety and meeting residents care needs are regularly considered during supervisions. One member of staff described the very supportive manager and another I feel confident and efficient in working because of the right support/knowledge from my supervisors. The home now has clear systems to ensure that the health and safety of people is upheld. This includes management of hot water temperatures, ensuring that people are protected from risks of contact with hot surfaces and that windows above the ground floor are safe. There are safe systems for the use of bed rails, including assessment of need, regular evaluations and use of safe equipment. Records showed that equipment and services to the home are regularly services and maintained. The homes fire log book was fully up to date. Care Homes for Older People Page 27 of 32 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 28 of 32 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 12 Care plans must include all factors, to direct staff on how residents needs are to be met. Where some staff are aware of how to meet residents needs but care plans are not drawn up about this, there is a risk that not all staff will be aware and residents will not have their needs met in a consistent manner. 17/07/2009 2 7 12 If a person needs assistance 17/07/2009 with changing their position, drinking fluids or eating meals, a monitoring chart must always be put in place and all interventions be documented. Where people are frail and not able to perform activities of daily living for themselves, they may be at risk, so monitoring charts are needed so that Care Homes for Older People Page 29 of 32 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 management and staff can ensure that peoples needs are being met. 3 9 13 Only Controlled Drugs may be stored in the Controlled Drugs cupboard. Due to the nature of Controlled Drugs, access to the Controlled Drugs cupboard needs to be reduced to a minimum, therefore other items must never be strored in Controlled Drugs cupboards. 4 9 13 Where a person is rescribed 31/07/2009 a drug on an as required basis, a protocol or care plan must always been put in place. People need to know that they will be given their drugs in accordance with their needs and in a consistent manner, therefore the registered nurses need to be informed of these factors. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 30/06/2009 1 7 Records relating to administration of topical creams should state which creams were applied, not just that the person Care Homes for Older People Page 30 of 32 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 was creamed. 2 8 Where a person is being fed their meals, records whould state what the person has eaten, not just that they have eaten a meal. Care plans relating to adminstration of oxygen should also state how often oxygen tubing needs to be changed. Where a person needs thickening agent to enable them to swallow safely, their care plan should state the consistency of their drinks. Where a resident is prescribed a medicine which can affect their daily lives, a care plan should be drawn up so that staff can evaluate the effectiveness of the medicine for the resident. The benefits to resident of activities they have participated in should be documented. Management systems should be put in place to ensure that staff consistently complete monitoring records at the time nursing and care is given. Meetings for specialists such as activities coordinators and chefs should be set up across the providers group. Reviews of accidents should include time of day and day of the week, as well as other factors. A receipting system should be set up for when valuables are handed in for safekeeping 3 4 8 8 5 9 6 7 12 31 8 9 10 31 33 35 Care Homes for Older People Page 31 of 32 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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