Care Home: Cale Green Private Nursing Home

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What the care home does well People were assessed before coming to live at the home. This meant everyone could be sure the person`s needs could be met when they moved in. People that returned surveys told us they always (2) or usually (1) got the care and support they needed and that staff listened and acted on what they said. Comments included " I think the staff are very friendly, helpful at all times" and "The home is well run and the staff are always available for help and ready to listen to any problems". One person we spoke to when we visited the home said the home was "OK, quite good" and two visitors said they were always made welcome, the manager was approachable and their relatives always looked well cared for when they visited. We were told that routines were flexible and an activities organiser was employed who arranged some group activities and also took people out of the home individually, shopping and to local pubs and tourist attractions. However, many people did spend large parts of the day in bed and more consideration should be given as to how their social needs can be met. Most people said the food provided at the home was good and that they had a choice offered to them at each meal time, although people who needed a soft or pureed diet had less variety. The home was warm, generally clean and people had been encouraged to personalise their bedrooms with possessions from their own homes. In the AQAA the manager reported that 81% of care staff had successfully completed National Vocational Qualifications (NVQ). The NVQ is a qualification that is obtained following training in providing personal care and helps to ensure that staff have a good basic knowledge of the care they need to provide and the reasons such care is needed. What has improved since the last inspection? In the AQAA it was reported that a new assessment process had been started to enable staff to record more detail about peoples` needs. Since the last inspection a new activities organiser had been appointed and people had been able to go on more trips outside the home. Menus had been revised following feedback from people living at the home about what their preferences were. Areas of the home had been redecorated on an ongoing basis, the majority of sinks in peoples` bedrooms had been replaced, some new carpets had been fitted and a new dishwasher had been bought. A new food safety management system had been introduced. What the care home could do better: Care plans were detailed but were not always fully up to date so sometimes gave inaccurate information or did not fully address each person`s needs. Staff did not record accurately the care they were giving, especially for people that stayed in bed or in their rooms for the majority of time. This meant there was no clear evidence that care had been given to people as it was stated in their care plans as being needed. From records it appeared that people had not been given enough to drink and had not been helped to move position often enough when they were in bed. The systems for the management of medicines were not robust enough to ensure the safety of people living in the home. Many people needed help to eat and drink but we saw that a number were left for long periods with food in front of them, which was going cold by the time a member of staff was available to help them. Since the last inspection one incident of abuse had been reported to the manager, who had not taken appropriate action immediately. The manager must make sure she follows the correct procedures for reporting suspected abuse in order to ensure the safety of people living in the home. Since the last inspection there have been several investigations which have been carried out by contracts compliance officers as a result of complaints about care practices. These investigations highlighted shortfalls in recording, which meant staff couldn`t show clearly what care they had provided. Although there were systems in place to check how staff were working these need to be strengthened so the manager can pick up shortfalls in how care is delivered quickly and take action to address it. Key inspection report Care homes for older people Name: Address: Cale Green Private Nursing Home Adswood Lane West Stockport Cheshire SK3 8HZ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Fiona Bryan     Date: 0 3 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 31 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: Cale Green Private Nursing Home Adswood Lane West Stockport Cheshire SK3 8HZ 01614771980 01614800989 calegreen@smallwoodcarehomes.co.uk www.smallwoodcarehomes.co.uk Smallwood Homes Ltd Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Kathryn Higginbotham Type of registration: Number of places registered: care home 50 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The registered person may provide the following category of service only: Care home with nursing - Code N. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP. Physical disability - Code PD. The maximum number of service users who can be accommodated is: 50. Date of last inspection Brief description of the care home Cale Green nursing home is a care home that provides 24 hour nursing care and accommodation to 50 adult service users. Many of the service users accommodated at the home have high physical dependency needs. The home is privately owned by Smallwood Homes Ltd. Care Homes for Older People Page 4 of 31 Over 65 50 0 0 50 2 1 0 1 2 0 0 9 Brief description of the care home Cale Green nursing home is situated in Cale Green on Adswood Lane West, about one and a half miles from the centre of Stockport. Local bus services are available. A small driveway leads to a car park and the main entrance to the home. The home is a two storey, purpose built building which has been extended to provide 43 single bedrooms and three shared rooms. Eleven rooms have en-suite toilet facilities. Assisted bathing facilities are available on both floors. There are lounges on both floors. The ground floor also has a separate dining area. Adaptations and aids are provided, including a passenger lift and hoists. The current weekly fees range from £327 to £667.30 dependent on the package of care required. Further details regarding fees are available from the manager. Additional charges are also be made for hairdressing and other personal requirements. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This key unannounced inspection, which included a site visit to the home took place on Wednesday 3rd March 2010. The staff at the home did not know that this visit was going to take place. All the key standards were assessed at the site visit and information was taken from various sources, which included observing care practices and talking with people living at the home, visitors, the manager and other members of the staff team. Key standards refers to those standards we feel are particularly important in ensuring the health, safety, welfare and quality of life of people living in the home. The care and services provided to 3 people living at the home were looked at in detail, looking at their experience of the home from their admission to the present day. A selection of staff and care records was examined, including care files, training records and staff duty rotas. Care Homes for Older People Page 6 of 31 Before the inspection we asked for surveys to be sent to people living at the home and to staff asking what they thought about care at the home. Three people living at the home and five staff returned surveys and some of their comments are included in this report. Concerns had recently been raised with us about how medicines were being managed at the home so a pharmacy inspector took part in this inspection. We sent the manager a form called an Annual Quality Assurance Assessment (AQAA) to tell us what she felt they did well and what they needed to do better. The manager completed the form quite well but needs to provide as much detail as possible in the next AQAA to show us she is able to identify shortfalls in the service and plan improvements. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: Care plans were detailed but were not always fully up to date so sometimes gave inaccurate information or did not fully address each persons needs. Staff did not record accurately the care they were giving, especially for people that Care Homes for Older People Page 8 of 31 stayed in bed or in their rooms for the majority of time. This meant there was no clear evidence that care had been given to people as it was stated in their care plans as being needed. From records it appeared that people had not been given enough to drink and had not been helped to move position often enough when they were in bed. The systems for the management of medicines were not robust enough to ensure the safety of people living in the home. Many people needed help to eat and drink but we saw that a number were left for long periods with food in front of them, which was going cold by the time a member of staff was available to help them. Since the last inspection one incident of abuse had been reported to the manager, who had not taken appropriate action immediately. The manager must make sure she follows the correct procedures for reporting suspected abuse in order to ensure the safety of people living in the home. Since the last inspection there have been several investigations which have been carried out by contracts compliance officers as a result of complaints about care practices. These investigations highlighted shortfalls in recording, which meant staff couldnt show clearly what care they had provided. Although there were systems in place to check how staff were working these need to be strengthened so the manager can pick up shortfalls in how care is delivered quickly and take action to address it. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 31 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 31 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. People were assessed before moving into Cale Green to make sure their needs could be met. Evidence: We looked in detail at the care provided to three people living at the home. Pre admission assessments had been carried out for all of them and the information was used to create informative care plans. Staff in general were knowledgeable about peoples care needs and said they were told about any changes in peoples conditions by other staff they were paired to work with or by reading their care plans. However, not all the care plans were completely up to date. We were told carers did not get a handover and some staff that returned surveys thought this would be helpful so they could discuss any issues in meeting peoples care needs and share information with the nurses. Care Homes for Older People Page 11 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some shortfalls in care planning, record keeping and practices in relation to the management of medicines and the provision of personal care meant that peoples needs were not always met. Evidence: We looked in detail at the care given to 3 people. Each person had a comprehensive care plan and two of them had been reviewed with them and their families. The third person had only recently come to live at the home. Care plans were quite detailed but had not always been updated with changes to peoples routines or preferences. For example, the care plan for one person made no reference to the fact that she did not like breakfast and ate very little in the mornings and did not plan how the persons nutritional needs could still be met. We saw that staff offered her a hot drink at 10am which was refused, and although she had eaten no breakfast and then ate very little lunch, there was no attempt to offer her any alternatives to increase her dietary intake. Another person had a spinal condition and when we saw her she was complaining of a lot of pain. Staff and her visitor said she Care Homes for Older People Page 12 of 31 Evidence: regularly complained of back pain but this was not recorded in her care plan and the effect of her pain killers had not been monitored. This person was also unable to eat or drink anything and was fed by a stomach tube (PEG). Her assessment had identified that she needed help with oral hygiene and she had been seen by the Speech and Language Therapist (SALT) who had also emphasized the need for this but it was not included in the persons care plan. The carer we spoke to said it would be the nurses who would attend to this; the carer did not regard this as a task she should do. Staff recorded care that had been given on charts, kept in peoples rooms. However, these were often poorly completed and appeared to indicate that people being nursed in bed had not been helped to move position as often as was stated as being required in their care plan and that people had not been offered enough to drink throughout the day. On 2 occasions we saw that staff were recording on charts that they had given care several hours after the time they were writing they gave it. We could not be certain therefore, that people were getting care as recorded on their charts or that they were getting the care stated as being required in their care plans. Staff need to make sure they are aware of peoples needs and are conscientious in meeting them. We saw that one person had been given a cup of tea and biscuits but these had been left out of reach and the person had been left in an unkempt state and an uncomfortable position. Another person was given porridge whilst in bed but was not eating it well as she kept falling asleep. The porridge was eventually removed without the person having eaten much. There were a large number of people on the first floor that needed help with eating and drinking. It was reported that carers from the ground floor came to help when they had finished their work (as the ground floor did not have as many highly dependent people so staff were able to provide the care they needed more quickly). However, we still were of the opinion that there were insufficient staff to adequately meet peoples needs in a timely way. During the inspection we looked at the way in which medicines are handled, recorded and stored. We also watched medicines being administered to people after breakfast. We saw that the medicine trolley was left in a convenient place in the corridor, rather than being wheeled to each person. Medicines were then taken to one person at a time; the medicine chart was left with the trolley and signed after each administration. We found that the morning medicine round took three hours to complete, so some people did not receive their medicines until 11am. One person required an injection before her breakfast; we saw this person eating her breakfast and the nurse on duty told us that she had not yet administered the injection that morning. Another person told us My medicines are brought to me every day. This person couldnt remember Care Homes for Older People Page 13 of 31 Evidence: what time she received her evening medication. When we looked at medication administration records (MARs) we saw that, on two charts, the time of administration in the evening had been changed from 10pm to 5pm. The nurse told us that she didnt know why this had happened and that she had changed the time back to 10pm for two medicines as she felt this wasnt safe. We saw from signatures on MARs that some medicines were being given by night staff. The use of creams was recorded on a separate, well designed sheet and on the MAR. However, staff were not all recording the application of creams in the same way and records were incomplete. One person was prescribed strong painkillers twice a day. We saw from records in the controlled drugs (CD) register that this medicine was not consistently being given at twelve hour intervals, so as to keep this person free from pain. We looked at this persons care plan and couldnt find any information about medicines or the need for pain control. When we looked at the CD register we found that the name, strength and form (tablet, injection etc) of the drug was not always written in full at the top of each page. We also saw an inaccurate entry and crossing out. We were told that there were no arrangements for destroying unwanted controlled drugs.Stocks of controlled drugs were not being regularly checked by staff. We counted the quantities of controlled drugs as part of the inspection and found that stock balances were correct. We found that the cupboard used to store controlled drugs did not meet legal requirements. The medicine refrigerator was not locked; the temperature of the fridge was checked each day but the minimum and maximum temperature readings were not recorded. Other medicines were securely stored. Records showed that people had been seen by their GPs, opticians, podiatrists and the tissue viability nurse. We spoke to several people living at the home and some visitors. everyone told us that they were satisfied, in the main with the care being given by staff. One person said they were very happy here. Two visitors said their relatives always looked clean and well cared for. One visitor did say that there had been a high turnover of nurses over the past few months and this had caused some difficulties in building relationships and having confidence that staff knew his relative well. Before the inspection we received three surveys back from people living at the home. They said they always (2) or usually (1) got the care and support they needed and all said staff listened and acted on what they said. Care Homes for Older People Page 14 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements in place for supporting people who needed help with eating and drinking were not good enough which led to a risk that they would not receive enough to eat and drink. Evidence: Of the 3 people that returned surveys one person said there were always activities going on in the home that they could take part in and two said there usually were. People were asked as part of their care plan reviews if activities arranged at the home and food provided met their expectations; some had agreed they did, whilst some had only rated them as OK. An activities organiser was employed who was not working on the day of our inspection so we were unable to speak with them to find out their views on their job. The manager said the activities organiser arranged a mixture of group and one to one activities to try to meet individual needs. A programme of activities was displayed around the home and this included several sessions of bingo, which we were told people enjoyed, cake decorating and a cinema club. It was reported that the activities organiser had recently taken individuals out for pub lunches, shopping and to local museums. Care Homes for Older People Page 15 of 31 Evidence: We sat for some time in the lounge on the first floor and noticed that people were left sitting most of the morning with little staff interaction (staff popped in and out but did not have significant time to spend actually talking with people). Apart from the television, which was on extremely loud there was no form of social stimulation. There were also many people who stayed in their rooms and stayed in bed for the most part, and further consideration should be given as to how these people can be supported and their social and mental stimulation promoted. One person whose mobility was poor and who stayed in her room for long periods said she did get bored. On the ground floor one person who lived at the home was able to play the keyboard and organ and played for some residents who enjoyed singing along. People told us routines were flexible, they were supported to get up and go to bed when they wanted and their visitors were made welcome. Of the 3 people that returned surveys 1 person said they always liked the food provided at the home, whilst 2 said they usually did. Five staff also returned surveys and in answer to the question What could the home do better? one had written Improve food options and another had commented By giving residents more choice. A visitor whose relative needed a pureed diet said there was not much variety but the quality of food was good. We asked one person if they liked the food offered at the home and they said it depends - they also needed a soft diet and said there was not much variety and the food was not very inspiring. Lunch on the day of the inspection was toad in the hole, mashed potatoes and green beans followed by sponge and custard. People told us it was tasty and seemed to be enjoying it. We did notice that staff served the hot pudding at the same time as they served the main meal so people were leaving it to go cold whilst they ate their lunch. It would be better if staff waited until people had finished the first course before serving the dessert so they dont feel they have to rush in order to eat their dessert before it goes cold. The first floor mealtime was not a social occasion, as people were served on small side tables and stayed sitting in their own armchairs in the lounge. This meant people were less inclined to socialise and consideration could be given as to how mealtimes could be enhanced for people living on the first floor. As stated in the previous section we saw that some people were not always supported appropriately to eat and drink. Systems need to be improved to ensure everyone Care Homes for Older People Page 16 of 31 Evidence: living at the home is regularly offered food and drink, proper records are kept for those who are identified as being at risk nutritionally, and staff have the time and resources to help people who need it. Care Homes for Older People Page 17 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Reporting procedures in respect of safeguarding were not always followed. This means there is a risk that appropriate steps to keep people safe may not be in place. Evidence: A copy of the complaints procedure was available in the reception area of the home and a copy was provided in each bedroom. We spoke to people living at the home and they said if they had any concerns or complaints they would see the manager and were confident she would deal with the matter appropriately. However, since the last inspection one incident was reported to the manager, who did not alert the appropriate agencies and dealt with the matter herself. The incident only came to light because the person involved told a nurse from the Primary Care Trust (PCT), who was holding a review of her care. The incident should have been referred to the safeguarding team in Stockport local authority and it is of concern that the manager failed to take the proper steps to protect other people living at the home. This incident raises questions about the knowledge and understanding of the manager regarding adult safeguarding policies and procedures and some staff also appeared to be unsure of the policies to follow or where to access information within the home about safeguarding. Care Homes for Older People Page 18 of 31 Evidence: As a result of reviews held by the PCT other concerns were raised about how medicines were being managed in the home and further investigation showed many shortfalls in the practices and procedures being carried out. The manager and the owner of the home were asked to carry out their own investigation and confirm what actions they had taken in response and they did act quickly to provide further information and assurance about how they were going to improve. Although we still found shortfalls in the management of medicines we could see that steps had been taken to start addressing the issues outlined in the initial reports. Several other investigations have been carried out by contracts compliance officers as a result of complaints about care practices. These investigations highlighted shortfalls in recording, making it difficult for staff to be clear about what care they have provided. This inspection has identified similar issues, which need to be acted on and improved. The manager had kept a record of complaints received and this provided information about how issues raised had been investigated and responded to. However, it did not provide information as to whether the complainant was satisfied with the response or show how any changes to practices had been made as a result of lessons learned from investigations. In the care files we looked at it was recorded that each person had been asked about their wishes in relation to voting. Several people had stated that they intended to vote at the next election and the manager said postal votes would be arranged for them. Care Homes for Older People Page 19 of 31 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. A generally clean and comfortable environment is provided for people living at the home. Evidence: There had been no significant changes to the environment since our last inspection. A partial tour of the home was conducted. The home was fresh and clean and there were no bad smells, except in one room, which smelled strongly of urine. Some of the armchairs in both lounges also smelled musty and unclean. The bedrooms were of a good size, nicely decorated and personalised with peoples own ornaments, photographs and belongings. The first floor lounge, despite several recommendations from us to review its use, remained unattractive. Half the room was used as a lounge whilst the other half housed a collection of armchairs haphazardly stored and taking up a lot of space. One person had been put to sit in amongst the chairs away from other people and looked abandoned. As stated in the Daily life and social activities section the meal time on the first floor was not a social occasion and much better use could be made of this room to provide Care Homes for Older People Page 20 of 31 Evidence: dining tables for people to sit at and enjoy each others company whilst they eat their meals. Care Homes for Older People Page 21 of 31 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. The high turnover of nursing staff has led to some inconsistency in care. Evidence: Of 3 people that returned surveys, 2 said there were always enough staff and one person said there usually were. Of 5 staff that returned surveys one person said there was always enough staff whilst 4 said there usually were. One staff member in response to the question What could the home do better? replied Having more staff to give residents more time with the staff i.e to be able to toilet them when they ask. People we spoke to during the inspection said there were generally enough staff, although one visitor commented that there had been a high turnover of nursing staff making it difficult to get to know them and gain confidence that they were fully aware of their relatives needs. A new senior sister had just been appointed so it was hoped that this would lead to more stability in the nursing team. Although people seemed generally happy with staffing levels we saw that a number of people were left for a significant time at meal times before they were helped to eat. Some people had meals in front of them but were unable to manage on their own; staff did not have time to check on their progress leaving their meals to go cold. The mid morning drinks were not served until 11.45am. The manager did say that she was reviewing staffing levels and had plans to implement a new shift pattern that would Care Homes for Older People Page 22 of 31 Evidence: provide extra help over lunch and tea time. As there were a large number of people on the first floor that needed help to eat, the importance of assessing this before agreeing to admit people to the home was discussed; the manager needs to ensure that any decision to admit people is based on staff resources. We looked at two staff personnel files. Both contained CRB disclosures and appropriate references. One person had gaps in their employment history which had not been explored or explained. This information is needed so the manager can be satisfied on reasonable grounds as to the fitness of the person to work in the home. In the AQAA the manager reported that 81 of care staff had successfully completed National Vocational Training (NVQ). Staff files contained records of induction training. This was mainly provided through DVDs, which covered topics such as principles of care, abuse, the role of care workers and food hygiene. Having watched the DVDs carers completed short written tests to assess their understanding but there was not always evidence that these were checked or marked to make sure they had achieved a satisfactory result. A training matrix recorded staff training and the manager told us she was also introducing individual staff files which would clearly show what training people had received and when refresher training was due. From the records it did appear that many staff still needed to attend training in key topics such as skin care and pressure relief, feeding and swallowing difficulties and continence awareness and some mandatory training needed updating. Whilst we recognise that all training is an ongoing process all staff members should have a clear and agreed learning and development plan to ensure that their training is structured and meets their needs. Care Homes for Older People Page 23 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The current management systems are not robust enough to ensure the correct delivery of care for all people living in the home. Evidence: Since the last inspection the manager has been registered with us after demonstrating that she has the knowledge and ability to manage the home. Staff said the manager was very supportive and met with them regularly to discuss any problems and how they were working. One person living at the home that returned a survey commented The home is well run and the staff are always available for help and are ready to listen to any problems and do what they are able or to find some other staff member who can. Records showed that their had been several resident meetings. Issues were raised at these but it was not always clear whether they had been acted on. At one meeting in August 2009 the minutes recorded that people had raised several complaints and suggestions about the food provided at the home. Minutes of the next meeting held in Care Homes for Older People Page 24 of 31 Evidence: November 2009 showed that a new menu was brought to the meeting for discussion but this was 3 months later so the time taken to act on peoples feedback was quite lengthy. Although systems for checking staff practices (audits) were in place it appeared that they did not always highlight shortfalls, or issues were not always effectively addressed. This was evidenced in the recent investigations where poor recording and medicine management was seen, despite a system of audit in these areas being in place. Systems need to be more robust to ensure that policies and procedures are being correctly followed and to assess the quality of care being delivered in the home. Also the manager must ensure that we are notified of important incidents and events in the home in a timely manner; there had been several issues that had not been reported to us appropriately. Procedures for the management and safekeeping of peoples money were satisfactory at the last key inspection in January 2009 and were therefore not looked at during this inspection. The manager said an audit was undertaken by two members of staff every six to eight weeks of all money held at the home. Records were available to show that health and safety checks had been carried out in the building and equipment had been regularly serviced. Accident and incident records were kept but were not filed in any order and had not been reviewed or analysed for some time. The manager should audit accidents to check for patterns, for example in the times accidents happen. This information could then be used to determine staffing needs for high risk parts of the day. Care Homes for Older People Page 25 of 31 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 26 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 People in the home must be safeguarded by staff who are competent to handle medicines and who follow safe and consistent procedures in accordance with a written policy that meets nationally recognised guidance for the health and safety of people living in the home. 30/04/2010 2 9 13 Medicines must be administered as prescribed. This must be demonstrated by record keeping practices for the health and well being of people living in the home. 02/04/2010 3 9 13 Controlled drugs must be stored in a cupboard that complies with The Misuse of Drugs (safe custody) regulations, 1973. A clear, accurate stock record must be kept in the controlled drugs register 30/04/2010 Care Homes for Older People Page 27 of 31 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 for security reasons and to meet legal requirements. 4 15 16 People who require help to eat and drink must be supported consistently. Accurate records must be kept so staff can properly review the care and treatment given and evaluate its effectiveness to promote and make proper provision for the health and welfare of people living in the home. 5 18 13 The manager must provide further information about what steps they have put in place to ensure that they and all the staff are fully conversant and confident in local authority inter agency safeguarding procedures so they will be able to react appropriately to protect people in the event of future safeguarding incidents. 6 38 37 The manager must notify us 02/04/2010 of any event that happens in the home as described under regulation 37 of the Care Standards Regulations 2001 in order to be transparent 23/04/2010 23/04/2010 Care Homes for Older People Page 28 of 31 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 about what is happening in the home and ensure relevant agencies are involved. 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 7 Care plans should include details about all aspects of peoples personal and health care needs and should accurately reflect peoples preferences and routines. Monitoring charts should be kept contemporaneously and accurately so the care actually given can be reviewed to ensure it is effective. If the medicine trolley is not taken to each person at medicine administration times, then the medication administration record (MAR) should be carried with the medicines, so that the MAR can be signed immediately following administration. Stocks of controlled drugs should be regularly checked by two nurses and the stock check recorded in the CD register. The medicines refrigerator should be locked and the fridge temperature should be monitored over each 24 hour period by recording minimum and maximum temperatures. The current edition of the British National Formulary (BNF) or other suitable reference book should be available for staff use. Further consideration should be given as to how mental and social stimulation can be promoted for some people living at the home, especially those that are more highly dependent. Consideration should be given as to how mealtimes for people living on the first floor can be enhanced to make them more social occasions. Staffing levels should be kept under review to ensure that Page 29 of 31 2 8 3 9 4 5 9 9 6 9 7 12 8 15 9 27 Care Homes for Older People 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 they are appropriate to the levels of dependency and support required by people living at the home. 10 29 Gaps in employment histories should be explored to ensure as far as possible the fitness of people to work in a care setting. Staff should have annual learning and development plans so their training needs are identified and planned for. Further training and support is needed for the manager to ensure she operates effectively and in the best interest of the people living at the home. Quality assurance systems need to show clearly who is responsible and accountable for any improvements that are required and need to show that actions required are followed through. This will ensure improvements actually happen and peoples experience of living at the home continues to improve. 11 12 30 31 13 33 Care Homes for Older People Page 30 of 31 Helpline: Telephone: 03000 616161 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) 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. 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