Care Home: Camberwell Green Nursing Home

What the care home does well We received positive comments from the majority of residents and relatives spoken to. To many people using the service this home is considered a pleasant place to live Residents feel confident that the staff team are kind, and that staff practices are improving. One area that people like is the flexibility felt. Routines are flexible especially for getting up and going to bed, and having breakfast. in bed if you wish We observed many good examples of positive engagement and resident staff relationships. On the first morning of our unannounced visit we overheard a very pleased elderly resident express her delight to see her key worker. She was delighted to see her back on duty after her days off. The carer showed interest in her welfare and responded by enquiring how her previous day was and if she had received visitors.. We heard from another resident about the many positive aspects of life in the home, she said ," staff cannot do enough for us, every morning I am given an early morning cuppa as this is something I have always liked all my life". One of the relatives complimented staff on the progress made by her mother since she moved to the home from hospital. The lady on admission was in poor health, We heard that since moving to the home she has thrived. Another relative that lives locally and that visits frequently told us of her experiences. She is confident in the home and how people are cared for, she is in he home frequently and can only praise the staff team for their dedication. Residents enjoy the convenience of the location of service, we heard that residents and relatives are familiar with the area and the local services. What has improved since the last inspection? The focus on dignity and privacy training for staff is now being reflected more in practice, however there is room for further improvement so that no further shortfalls are experienced.. Staff practices are improving, all residents experience the changes and appreciate the impact of these. Staff are more effectively supervised and supported, as a result any shortfalls in practice are identified and addressed. Since some new staff members joined the staff team there are signs of a more gentle and caring approach. Staff have a greater awareness of the standards expected and anything less is not acceptable, closer monitoring of practice takes place with deficiencies identified. Training and development is improving staff skills and competencies. Areas of the environment needing attention were responded to. The maintenance person is given directions on his role, he ensures that the health and safety of the environment is promoted. What the care home could do better: The service has been performing poorly for some time and matters have not been addressed by Southern Cross. They have started to do that recently but that has lead to lots of staffing changes and a turbulent time including managers leaving quickly. The ship has been steadied by a management team who have been sent in to the home. This inspection has identified some of their successes but more work is needed and a key need is for a stable, consistent management team to be in place. Until such time we can only view the home as adequate. The service needs to appoint promptly an experienced competent manager to give stability and direction in the service. The majority of requirements from the previous inspection were met. Care planning is not peronalsied and is not considering all areas of individuals need, therefore the care arrangements are not always well informed. The complaint`s procedure needs to be improved, it has to be open and transparent with complainants feeling that they are listened to and that issues are acted upon. Communication too is not as good as it should be, all issues whether they are minor concerns or not must be addressed. Despite staff receiving up to date training on Safeguarding Vulnerable people, procedures are still not fully robust at the service. When the new manager is appointed senior management will need to support the manager in the role to avoid further disruptions in the service. Residents need to be consulted on and have developed up to date care plans in place to inform how services are delivered. Key inspection report Care homes for older people Name: Address: Camberwell Green Nursing Home 54 Camberwell Green Camberwell Green Care Centre Camberwell London SE5 7AS     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: Mary Magee     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 34 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Camberwell Green Nursing Home 54 Camberwell Green Camberwell Green Care Centre Camberwell London SE5 7AS 02077080026 02077080027 camberweelgreen@schealthcare.co.uk www.southerncrosshealthcare.co.uk Apta Healthcare (UK) Ltd care home 55 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 55 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 (maximum number of places: 55) Physical disability - Code PD (maximum number of places: 55) Date of last inspection Brief description of the care home Camberwell Green Care Centre is run by Southern Cross Health Care Ltd. It is registered to provide nursing care, and care for people with physical disabilities, for up to 55 older people. It is not registered for any other groups such as people with dementia or mental health problems. The home is purpose built. The home is located in the centre of Camberwell close to public transport, shopping and leisure facilities. Accommodation is provided on four floors. There are two Care Homes for Older People Page 4 of 34 Over 65 55 0 0 55 Brief description of the care home passenger lifts. All bedrooms have ensuite toilets and are single rooms. There are 3 lounges and 2 dining areas. Charges range from £500 weekly. Care Homes for Older People Page 5 of 34 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 unannounced key inspection took place over two days. Three inspectors were involved in visits to the home. We were sent a completed AQAA document when we requested it. This provided information on the residents, the staff team and the progress made in the service. Surveys were sent to relatives , but none of these were received back. As a result we followed this up and telephoned five relatives to get their views, we also met with two people visiting during our inspection. We spoke to three health professionals, this included the GP, the psycho geriatrician, and the specialist nurse from the CHST. We met with all the residents during our visits, and spoke in depth to ten of them. We examined a number of records, and used case tracking to evaluate the service delivery. We met the temporary management team who were helpful and supplied the relevant records requested, we also held discussions with seven members of staff individually. Care Homes for Older People Page 6 of 34 We observed mealtimes and spent some time with residents in the communal lounges. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? What they could do better: The service has been performing poorly for some time and matters have not been addressed by Southern Cross. They have started to do that recently but that has lead to lots of staffing changes and a turbulent time including managers leaving quickly. The ship has been steadied by a management team who have been sent in to the home. This inspection has identified Care Homes for Older People Page 8 of 34 some of their successes but more work is needed and a key need is for a stable, consistent management team to be in place. Until such time we can only view the home as adequate. The service needs to appoint promptly an experienced competent manager to give stability and direction in the service. The majority of requirements from the previous inspection were met. Care planning is not peronalsied and is not considering all areas of individuals need, therefore the care arrangements are not always well informed. The complaints procedure needs to be improved, it has to be open and transparent with complainants feeling that they are listened to and that issues are acted upon. Communication too is not as good as it should be, all issues whether they are minor concerns or not must be addressed. Despite staff receiving up to date training on Safeguarding Vulnerable people, procedures are still not fully robust at the service. When the new manager is appointed senior management will need to support the manager in the role to avoid further disruptions in the service. Residents need to be consulted on and have developed up to date care plans in place to inform how services are delivered. 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 34 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 34 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All prospective residents have needs assessments completed before admission, this is not always effective in ensuring appropriate placements take place. The admission of new people to the service is not particularly personalised with little extra consideration given to individual needs. Evidence: We examined the pre admission assessments and the admission arrangements for residents. Records of pre admission and admission assessments for three residents were examined We found that using the comprehensive assessment tools preadmission assessment was carried out for each person before an agreement was made to admit the individuals. One of of the residents we were told had visited the home prior to her admission. A letter of transfer was provided by the persons previous placement for each resident. On admission a range of assessments were carried out for the residents. Present were records of a review of a placement carried out with the social worker some weeks after one persons admission. This confirmed that the Care Homes for Older People Page 11 of 34 Evidence: placement for this person was appropriate. While all residents we selected for case tracking had evidence of pre admission assessments there are areas of shortfalls as there was evidence of inappropriate placements for some of those admitted. The primary care needs of two people that moved to the home were not considered fully. We found evidence that the pre admission assessment was not used effectively in determining if the placement was appropriate. For one resident with enduring mental health issues and requiring regular Depot injections this was not detailed in the pre admission assessment. Another resident we met displayed challenging behaviour, some of the staff team were good in responding appropriately and reassuring the person but there was difficulty in encouraging the person to remain hydrated and take medication medication prescribed. Following consultation with the doctor this person was readmitted to hospital. We heard that since the hospital admission she has been placed in a more appropaite setting. In general we found that the staff team were not well equipped with training and experience to deal appropriate with this specialist area in menatl health and dementia care. Some of the staff team we met have little experience in supporting people with dementia, or understand how to respond appropriately to people that display challenging behaviour. One of the residents has settled well. However a consultant psycho geriatrician spoken to expressed the view that the placement was not appropriate as the home has not the desired skills and competencies within the staff team to support this peron. The lack of information on EMI needs recorded in the pre admission assessment would support this too. The home has provided training for staff in promoting privacy and dignity, and dementia care but there is much more required to develop the staff team. There are plans to deliver this in March 2010. There are changes taking place within the staff team as new staff members are introduced, some of the staff are currently performanced managed. The service has applied to CQC for a variation to have a dedicated dementia care unit, this was not processed at the time of inspection. Currently the home has not the staff team in place to meet the needs of people whose primary needs are dementia or that are mentally frail. We found that the resident with dementia has settled well, she enjoys her new home, was calm and responding well to her keyworker. In the AQAA supplied it recorded that comprehensive pre admission assessments were completed before any new admissions took place. It also stated that team feedback is sought after each assessment to discuss the potential residents needs and whether the home can meet these needs. Recently it is unclear if all these procedures were followed. Care Homes for Older People Page 12 of 34 Evidence: We heard from the nurse that completed the pre admission assessment. She was confident that the residents primary needs were for support with physical care. However we spoke to a psychogeratrician that is familiar with the resident. She confirmed to us that the placement was not appropriate at this time, and that the residents needs would better met in an EMI home where staff are trained and competent in this field. A requirement is stated that the home must not accept any persons unless it is confident that it can meet the individuals assessed needs. The service user guide was displayed in several bedrooms, it included extracts from the summary of the most recent inspection report. It would be helpful to reader if information was provided about where a full copy of the report can be obtained (including that the home can provide one). We viewed the contracts and agreements between residents and the home. We found some confusion on charges. The contract was not fully clear on the arrangements when top fees are payable and how this is paid. Contracts should specify clearly the fee arrangements in relation to funder and top up fees. Care Homes for Older People Page 13 of 34 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. Care arrangements are getting better, but there still areas of shortfall that need improving. Staff respect privacy and dignity and to contribute to achieving positive outcomes for residents. Care plans can be inconsistent, and lack some essential information. As a result the care delivered may not be what is required and may not deliver in accordance with expectations.. Evidence: We looked at care plans and arrangements for residents on all three floors in the home. Each resident has a care plan but the practice of involving residents in the development and review of the plan is variable. The plans in place include basic information necessary to deliver the individuals care but plans are not detailed or person centred, risk assessments are developed alongside care plans. All risk assessment records seen with care plans appeared approrpiate for the relevant residents but some were not reviewed for some time. Not all the care plans seen include sufficient detail and reference to particular needs regarding stimulation, mental health, dementia. We found that the written care plan is Care Homes for Older People Page 14 of 34 Evidence: not always used to fully inform practice, and does not consistently reflect the care being delivered. There were occasions during the past twelve months when the quality of care delivered fell short on what was required in the plan of care.This evidence was gained from the complaints raised with the service.We were also copied in on complaints raised with the service. Daily records record the care given but there is still not enough detail on the welfare and well being of the resident or of the response to treatment. The service demonstrates that it actively supports residents with the promotion of continence. Nutritional screening takes place on admission, and is regularly undertaken afterwards, evidence is recorded of this. This also needs to be cross referenced with care plans and include this in care planning reviews. Staff are good at using relevant records, for example recording on body maps any injury or changes identified on admission, and not on initial assessment. However this information is not always used to respond appropriately to and inform procedures. This is further noted in Outcome Area 4. There is evidence on written records and regulation 37 reports that relatives are kept informed when a resident is unwell. However there was a small number of complaints raised relating to relatives not always being kept informed of changes that arise, or of named relatives not being kept updated. Some of these relate to a period of change of management in 2009. A recommendation is made that relatives and next of kin should be kept fully informed on any notable changes that arise to individuals conditions. We found signs that health needs are monitored and appropriate action and intervention is taken. This is an area that has improved since the last key inspection. Some occasions arose in 2009 when there were signs of communication not being effective and information shared with the next team on handover. However the lead nurse is now responsible for more thorough handovers on each floor. The home is generally able to provide the aids and equipment recommended, there is evidence of the provision of presuure relieving equipment. The signs of improvements seen include attention to individuals. During our visits we found that residents had drinks close at hand, also call bells were within reach for those in their beds. For residents that remain in their bedrooms staff were observed to visit frequently and check on their welfare. The training in the promotion of dignity delivered to staff has address weakness in care delivery but this must be maintained. We spoke to a visiting GP, she was complimentary on the progress so far at the home. Weekly surgeries are held, if a resident is unwell the GP is notified and a visit takes place, and residents are reviewed regularly, also medication. A small number of residents have pressure sores/ulcerated conditions. Care plans are developed for people with these conditions and treatment is given in accordance with care plans. We found evidence too of consultation with the tissue viability nurse and of Care Homes for Older People Page 15 of 34 Evidence: appropriate response to recommendations made. Residents receive support with accessing statutory services, there are records held of appointments with the podiatrist, dentist, optician. We heard from some residents that have difficulty with communication. We were not confident that staff are always aware of the need to support residents with using hearing aids, glasses and dentures. This information should be recorded in the care plans. We examined care plans for a resident that has a PEG feed, an appropriate risk assessment was in place for this resident but the care plan was not specific for this. There was evidence of the involvement of the specialist team and of their recommendations on a separate document rather than in the care plan. Also maintained were up to date records of nutritional intake. For another resident with diabetes we found that the care plan was absent for this although regular blood sugar monitoring takes place, there was no plan for the use of Insulin. Over both days we observed that staff promoted privacy and respect of people living in the home. There were several occasions when staff were observed to speak in a loving reassuring manner to residents, encouraging them with taking meals and drinks. Key workers were observed spending quality time with individuals, understanding the things that makes individuals more anxious, avoiding unnecessary delays in responding to requests. We found that the approach of staff is more gentle and considerate, many of the new staff demonstrate that they enjoy working with older people. Two of the staff members spoken to informed us that the home is becoming a nicer place to work, many new caring people have joined the staff team. Relatives spoken to complimented the service, one person said staff are kind and gentle, my mother enjoys life at the home and feels valued by all the staff. The training delivered to staff is reflected. Doors were kept closed as staff delivered personal care, individuals were see by the GP in the privacy of their own bedrooms. The risk assessments identify and record when an individual lacks capacity to recognise environmental hazards, guidance is recorded on supporting the individual with this risk. The service also identifies people at risk of falls and operates procedures to minimise this risk. We found that we were notified of occasions when individuals have experienced falls, also if there are subsequent injuries. Risk assessments are in place for those at risk of falling out of bed at night. As a result some residents have cot sides used to support them at night time. Many of these cot side risk assessments are well out of date and need to be updated with the care plans. We inspected all three medicines storage areas, a sample of medication records on Care Homes for Older People Page 16 of 34 Evidence: each floor, and observed staff giving medicines to residents. Medicines are all stored safely on all floors. Medicines storage areas are well managed, and the temperature is monitored to ensure medicines are kept at the correct temperatures. Regular medication audits are now being carried out at the home, which have been effective at picking up issues, and there is evidence action is being taken to address the issues found. On two floors, good records are kept of medicines received into the home and given to residents, and medicines are being managed well. The first floor had a number of issues with recording, for example signing for giving medicines at a time medicines are not due, issues with temperature monitoring of the medicines fridge, and records not clearly stating when a medicine has been stopped or changed by the GP. For example, for one resident, it was difficult to track the changes made to their insulin dose, as the hospital discharge note kept with the medication record stated a different dose of insulin to that being given. The home must keep insulin care plans updated whenever any changes are made. All medicines were available on the day of the inspection, and there is evidence residents are receiving their medicines on time except in a few occasions during the past month. These were discussed withe nurse in charge. Due to the issues found on the first floor,a requirement has been made to ensure accurate records are kept and medicines are ordered on time so that residents do not miss any doses. Information on files confirmed that residents had been referred to and attended appopintments with a range of health care professionals, including the GP, podiatry, optical and audiology services. The service delivered a training programme for staff at all levels so that they can promote the concept of dignity in the home. There are displays in the home reminding staff about the importance of dignity and how to provide care which has regard for residents dignity. When we spoke to one of the residents a member of staff told us that the lady had a hearing problem, but when she checked she was not wearing her hearing aid. Staff should be reminded that if care is to preserve a residents dignity it should take account of their communication needs and care practice should include assistance with hearing aids. We noted that residents can spend time alone in their rooms if they wish to do so and their privacy is respected. Care Homes for Older People Page 17 of 34 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. Although there is a lack of individualised social care planning an experienced activity coordinator is making provision to meet the social needs of residents. Mealtimes are pleasant with individual needs specifically catered for. Evidence: We found that policies, procedures and guidance promote individual independence and the right to live in a flexible environment. Individual choice of routines and activities are met when possible. In the AQAA supplied we heard of the efforts made by staff at the home in this outcome area. The service we found is currently developing individualised social care plans and that this is in its early stage, the outstanding requirement remains unmet. We observed that the environment was more stimulating on our second visit. The new activities leader had begun to introduce changes to the service. Discussion with her reassured us that she understood the need for any activity programme to reflect the residents interests and needs. She is experienced in her role and has received training in a previous post. The provision of activities will be assessed more fully at a future key inspection. we were informed that representatives from a local Catholic church come to the home and give Holy Communion to those residents who choose. Care Homes for Older People Page 18 of 34 Evidence: We saw that relatives come to the home without unnecessary restriction. The home was without an activities lead for a period of time. During the inspection a full time activity coordinator commenced employment in the home to take the lead in social life facilitation. We saw positive signs of engagement by residents that told us we dont generally join in things but we now feel keen to take part when we heard the music . We saw evidence of this change, and that it is making life better for residents. We observed on our visits that the new coordinator took time with individuals to get a feel of what peoples expectations are. Activities are designed to suit individuals choices and needs. Dignity lead persons in the organisation continue to facilitate visits to the home forth nightly to support key staffs and dignity champions to achieve goals. The service encourages families, friends and local community to come and visit residents. Contact details of relatives are incorporated in files and social care plans. Individuals are consulted on day to day activities such as personal hygiene, food preferences, activity. The activities coordinator has the experience, the drive and the commitment to provide a stimulating environment for residents. The majority of staff had training in how to promote dignity in eating and drinking activities. People are asked of their food preferences and this is currently being incorporated in the developing care plans. We heard many positive reports on life in the home. Residents are offered an early morning hot drink which they enjoy. We observed mealtimes, routines are flexible with individuals that choose to enjoying breakfast in their own bedrooms. Dining rooms are used for lunch and dinner, although individuals that choose to can take meals in their rooms. We observed that tables are layed properly with cutleries, condiments, serviettes, jugs of liquids and glasses. As lunch was served there were generous numbers of staff present to assist and support those with meals. The lunch was beef casserole, residents all seemed to enjoy it and said it was hot and nutritious. Residents are involved in meal selection nd planning, each day another option other than the one on the menu may be selected. People are generally satisfied with meals in the home. We heard that meals are good and more varied since a new chef began work at the home. We spoke to this chef, she takes pride in her cooking and told of how much enjoys preparing and cooking meals, rather than using prepared meals. The environment was calm and staff assisted with meals at the pace favoured by individuals. Meals were served promptly and all were hot. A catering audit is done monthly. We found evidence that residents with special Care Homes for Older People Page 19 of 34 Evidence: dietary needs are referred promptly to the dietitian, or for those with swallowing issues to the SALT team for assessment and management. Nutritional screening takes place and staff know how to use the screening tools effectively. Care Homes for Older People Page 20 of 34 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. The inconsistencies experienced results in people not having full confidence that their complaints are always listened to and dealt with effectively. Despite training and relevant safeguarding policies and procedures in place senior staff have not always followed robust procedures to respond to suspicions of abuse. Evidence: The service has experienced further management changes with the departure of the latest appointed manager in October 2009, this impacted somewhat on how complaints were responded to. Residents and relatives are aware of the complaints procedure, all new residents are supplied with this information. The main area of dissatisfaction is in relation to how complaints are handled. We viewed records of complaints received, the response, the follow up to the complainants. The findings are that complaints received were not always responded to appropriately. As a result issues that could have been resolved in the early stages were not addressed. The service has received a relatively high number of complaints since the last key inspection. Staff are aware of the complaints procedure but often have not realised the importance of listening to, and then acting on issues raised, or residents or relatives concerns. There are signs that this is now improving. All residents spoken to feel that their views are heard and describe how staff respond, such remarks reresent the views of residents, the carers are good at listening to me, they cannot do enough for me. At a period in 2009 when the manager was absent there was a distinct lack of Care Homes for Older People Page 21 of 34 Evidence: coninuity, poor communication about appointment times that were arranged to resolve issues. As a result complainants felt further disillusioned with the service as they their concerns were not listened to.. We found that a number of complaints are about the same issue with signs that there is a lack of action being taken to address emerging themes. We examined the records of investigations, in some of these reports we found reports to be rather subjective and defensive rather than open and transparent. Interim management changes recently show some signs of improvements in how complaints are handled. The number of complaints raised are also reducing in recent months. The home must ensure that the complaints procedure is effective and produces the best outcome for residents. All four relatives spoken to during the inspection are satisfied with the service and have no issues about how complaints are handled. On the training matrix provided there was evidence that staff were provided with up to date training in how to safeguard vulnerable adults. The interim management team are addressing areas of practice within the staff team. Working practices are more closely monitored, staff are more accountable for their work . We spoke to a number of staff from carers to nurses. The majority had received training on safeguarding and protecting vulnerable adults. Staff in discussions demonstrated that they were aware of the procedures. However our findings highlight a lack of knowledge by qualified members of staff. Some months earlier a nurse identified some issues in relation to a resident discharged from hospital into the home. An unexplained injury was identified at point of admission. We in CQC were informed in accordance with Regulation 37 that the resident was discharged with some injuries not listed on the discharge notes. The resident was seen by the GP shortly after admission to the home. However on this occasion the nurse in charge failed to follow safeguarding procedures and follow up on this unexplained injury. Neither were the interim management team informed of this incident. The management team madea referral to the safeguarding team when this was brought to their attention Care Homes for Older People Page 22 of 34 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. This purpose built home is safe and suitable for its purpose, it is wheelchair accessible throughout. Improvements continue to be made to the environment, this contribute to improved standards of health and safety. The premises are clean and comfortable with a refurbishment programme in place. Evidence: This home was purpose built in 1997. Some areas have become outdated, there is some limitation on communal space and storage space. A redecoration programme for the home is underway. The third floor was newly decorated with bright colours and comfortable sturdy furniture. Redecoration is scheduled for the rest of the home we were told. A number of bedrooms were viewed, the majority were personalised, spacious and comfortable. Suitable adaptions have taken place to support people with disabilities, profiling beds were supplied to residents needing them. The home is wheelchair accessible. Some areas appeared shabby from wheelchair use and need redecorating. We heard from the management team that these are scheduled for attention in the refurbishment programme. We have concerns that other floors in the home need attention too. It is required that a copy of the refurbishment plan is submitted to CQC. Communal space is located on the ground and third floors. Care Homes for Older People Page 23 of 34 Evidence: There is an attractive sensory garden to the rear of the home, and to the front is a fenced in safe area where residents can sit in the warmer weather and observe the community. The home was clean on both visits, and there were no problems with mal odours. The home has a maintenance person, we found that repairs are attended to promptly. Areas of shortfalls that were highlighted in previous inspection are now addressed. The kitchen is kept in a clean hygienic condition, and has new flooring. Environmental reports recently conducted were good. Care Homes for Older People Page 24 of 34 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. Vetting procedures are robust with all the necessary information gained before appointment. The staff team has experienced many changes to staffing personnel, this has a positive outcome as a more caring environment is fostered. Staff supervision and appraisal systems are improving, with robust monitoring of work practices and delivery of care taking place. The service has introduced a good range of training for staff that is linked to the aims of the home. Evidence: Throughout the day the staffing levels are 3 qualified nurses on duty with 10 care staff. When we visited some staff were on their induction to the home so there were additional staff available. Staff during induction are supernumerary to the staff team. At night time, one member of the nursing team is on duty with 5 care staff. In addition the deputy manager is on duty between 9 and 5. Two managers are providing temporary management cover until the recruitment of a permanent post holder. Their hours of work vary, but all weekdays are covered. The continuing management changes has exposed some of the underlying issues historically within the staff team. Frequently issues raised in supervisions and meetings with staff members related to performance, and competence and practice, these were not addressed as they arose. Since the interim management arrangements commenced there are clear signs that poor practice, incompetencies and inappropriate attitude are being addressed. Care Homes for Older People Page 25 of 34 Evidence: Disciplinary procedures are used effectively to address such issues. There is a change within the staff team, staff told us how this reflected. We heard how the home is moving forward. An example was given of the positive impact felt as a result of standards expected, also the training delivered. Staff members said , The home is a nicer place to work in, staff that are not interested in their roles are no longer in the team, we feel that staff now are working better as a team there is less negativity as management give clear directions. We recognise that that there is much work to do and recommend that team building takes place. The procedures in place for monitoring staff and the standard of care being delivered are much more robust in recent months. As management changes took place there was a lack of constructive supervision. This is now addressed A more structured supervision is now in place and staff speak of feeling that is more worthwhile, they also feel that they can raise issues. Staff training is linked to the aims and objectives of the service, also to the planned dementia care unit proposed to open in 2010. According to records over 50 of the staff team have achieved NVQ level 2 or equivalent. According to records staff have received a good amount of relevant training including mandatory training. Additional training was delivered on communication, dementia care, challenging behaviour,planning placement reviews. The majority of training required by staff is now up to date, with training on the promotion of dignty ongoing. Further training on dementia care with specialist team from the PCT is planned for March 2010. If the service progresses the application to have specialist dementia care unit it will need to employ relevant staff members such as psychiatric nurses(RMN). We checked a selection of staff recruitment records, including those for staff who had been employed recently. We found that although there was evidence of appropriate checks and references being taken up the files were in poor order. We also noted that the contracts for staff who were in the country on student visas did not specify how many hours were to be allocated to study and how many to work. This must be specified. Two of the files did not include photographs of the staff members, this is also required. It is also recommended that a system is introduced to identify when work and student permits are due for renewal Care Homes for Older People Page 26 of 34 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. Stability in the home remains an issue with further management changes experienced. Interim management arrangements have ensured the safety and welfare of residents and staff . The lack of a permanent registered manager is preventing the service progressing and achieving a higher standard of service. Evidence: The service has experienced further management changes with the departure of the latest manager in October 2009. The service was showing signs of improvement for a period in 2009 during this managers spell. External professionals spoke highly of the expertise of the previous manager. As referred to earlier several management changes have arisen in a short period in recent years. We are aware as a regulator that the previous managers have not always received the support and backing required to address internal issues. The current management team of two managers, one full time and one dedicating hours as required are making progress. They are addressing some of the underlying issues and concerns. There are clear signs that Care Homes for Older People Page 27 of 34 Evidence: staff practice is improving. Staff recognise that this is an interim arrangement short term and are concerned about further instability. We share the concerns of staff and outside professionals for the need for stability, and for the appointment of a full time permanent manager that is experienced and registered. The previous requirement is unmet. It is repeated with increased timescales to allow for recruitment and appointment of a manager. We are unsure of the effectiveness of the quality assurance tool in the service as it would have identified the deficits in the service. Some of the tools used are medication audits, care plan audits, monthly visit reports. Regulation 26 visit reports should be sent to CQC until the service is stabilised by the appointment of a permanent manager. There was a lack of detail in the AQAA on this quality assurance process. We have not received any report on the outcome of annual quality assurance monitoring system. A copy of the annual quality assurance report should be sent to CQC. We checked a range of health and safety records. A fire risk assessment was conducted in late September 2009, it identified actions which were needed and an action plan was put in place to address the issues identified. Fire drills take place regularly, several have taken place since January 2009 to ensure that staff respond speedily and safely. Checks of fire safety systems are regular and records and discussion with the staff responsible showed that issues which need addressing are reported. Maintenance and repairs are much more satisfactory, the maintenance person in post is responsible for undertaking daily checks on each floor for any hazards or repairs needed. There are no outstanding issues in relation to the safety or the maintenance of the premises. Other safety systems include checks of the water to ensure that safe temperatures are maintained; environmental safety checks are made, including of the operation of the call bell system.. We examined how residents are supported with looking after their finances and how personal allowances are distributed. For two of the residents the local authority has power of attorney. Personal allowances are distributed and organised by the administrator. We sampled the financial records for two residents. Receipts books and allowance statements were examined. The IT system holds all records of transactions too. We were concerned to find that there was no evidence of recent financial audits, and that that there was only one signature present for a number of transactions recently undertaken. This demonstrates that financial procedures are not always adhered to. For one resident the bank card is held in the office safe for safe keeping. This was the subject of a recent review undertaken by the social worker. The review records were not available for viewing It is recommended that regular audits are conducted of financial transactions. Care Homes for Older People Page 28 of 34 Evidence: Care Homes for Older People Page 29 of 34 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 37 8 The home must appoint and 30/07/2009 register a manager without delay. This is so that residents and staff can be assured the home is run by a fit and competent person. The date is extended to 30/04/2010 to allow for recruitment and appoinment Care Homes for Older People Page 30 of 34 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 4 14 The home must not admit any persons to the home unless it is satisfied that assessed needs of the individual can be met. This to be confirmed in writing. To avoid admitting people whose needs cannot be met at the home. 31/03/2010 2 7 15 Each resident must have a 31/05/2010 care plan that sets out in detail all the care and support needed to meet the individuals , health, personal and social care needs. Up to date care plans are needed so that staff are clear on all the care and support needs. 3 9 5 The home must ensure that accurate records are maintained of all medicines. 31/03/2010 Care Homes for Older People Page 31 of 34 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 Medicines need to be ordered on time so that residents do not miss any doses. 4 16 22 The home must ensure that 31/03/2010 there is an effective complaints system operated in the home, for responding appropriately to comaplaints received. So that residents and people that act on their behalf are confident that their complaints are listened to. 5 18 13 The home must ensure that robust procedures are in place for responding to evidence of abuse or neglect. In order to make sure that residents are proteted from abuse. 6 19 23 The home must submit a copy of the refurbishment programme to CQC So that residents live in a comfortable pleasant environment. 7 29 7 Staff employed on student visas must have a contract that specifies clearly hours of work permitted, staff files must have available 30/04/2010 30/04/2010 31/03/2010 Care Homes for Older People Page 32 of 34 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 photographs of the member of staff So that staff do not breach employment laws. 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 1 We recommendation information should be provided in the service user guide, about how to obtain a full copy of the most recent CQC inspection report, including on request from the home. Contracts should be transparent, and specify clearly the fee arrangements in relation to funder and top up fees Residents should be included in care plan development. Staff should ensure that attention is given to supporting residents use appropriate aids such as glasses and hearing aids. Relatives and next of kin should be kept fully informed on any notable changes that arise to individuals conditions It is recommended that a system is introduced to identify when work and student permits are due for renewal We recommend that team building exercises take place to strengthen and develop the staff team. The service should forward to CQC a copy of the most recent quality asurance report. Regular audits should be undertaken of all transactions involving residents funds. We also request that copies of regulation 26 visit reports are forwarded to CQC every month. 2 3 4 2 7 8 5 6 7 8 9 10 8 29 30 33 35 37 Care Homes for Older People Page 33 of 34 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). 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