Care Home: Castle Keep Nursing Home

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What the care home does well Senior managers in the company responded quickly to the concerns we had about the services provided in the home. They had already identified some concerns and had produced an action plan. They implemented this quickly. The home provides lots of space and separate rooms for people to visit and sit in if they choose. The company has a good general training plan, which offers mandatory and service specific training. Staff stated, `they look after the staff well i.e. provide relevant training`. Staff members are described as caring and friendly, `All of the nurses and carers are very attentive to the immediate needs of the residents. All duties are undertaken in a friendly and caring manner - I would like to thank them all for their kindness`. Families are kept informed about any issues affecting their relative and visitors to the home are welcomed at any time. One relative stated, `they communicate well`. People liked the meals provided and the home had won a, `Healthy Heartbeat Award` for the last fifteen years. The meals were well presented. Complaints were dealt with promptly. The company had a good recruitment system and all checks were carried out prior to the start of employment. The home managed peoples` finances well. What has improved since the last inspection? The home had a much calmer atmosphere and was managed in a more effective way. Staff morale had risen and they stated they felt supported by management. The staffing numbers have been increased and have stabilised since the last inspection, and residents requiring one to one support receive this in a more consistent way. There have been lots of improvements in the environment since the last inspection in February. Willow has been completely redecorated and some rooms refurbished to provide extra communal space for people. The home has been made much more stimulating for people with dementia. A shower room has been refurbished and looks smart, fresh and modern. One relative stated, `I think the bathroom near to my parent`s room looks great. It now looks more friendly and homely. Also the new bedding which has been fitted a couple of weeks ago on their beds looks brighter and more colourful, my dad even showed them to me a few times the other day`. Another relative stated, `they provide a very clean and healthy environment for people staying there`. Although we could not test out any improvements in the assessment process prior to admission, the experienced acting manager is implementing new assessment proforma and is to complete any assessments for future potential residents. The care plans and risk assessments have all been revised and contain much more information about people and how they need to be cared for. This means that staff have clearer guidance and know what they need to do when supporting people with complex needs. Staff had received training in specific holding techniques for those residents with very complex needs that required extra support during personal care tasks. Those who had not completed any dementia care training have started a course and others have been identified as requiring the training. The recording of care and monitoring charts had improved and gave a clearer record of the care provided. There had been a big improvement in social stimulation for people with dementia. As mentioned the environment has improved but also the activities and occupations people are able to participate in has increased. One relative said, `The other Sunday just before I took my parents out I was pleased to find one of the male carers sitting with my dad reading a book together - thanks for your efforts`. Social needs assessments have been completed and two activity organisers have been employed. They are both enthusiastic about their role and in surveys staff commented on the improvements in this area. Choice has been increased for people. For example, the environment and which rooms to use, what activities and outings to participate in and the choice of finger foods available throughout the day. The way medication is managed has improved although there are still some recording issues to address. What the care home could do better: Patient passports, used to provide important information when a hospital admission is required, should be completed in a more thorough way so that hospital staff have the necessary information to care for the person fully. The recording of medicines could be further improved so that directions are clear on all records and individual plans must be in place for people receiving their medication covertly. Although there have been some improvements in the way staff respond to incidents between residents they continue to happen. Further measures must be put in place to ensure that people are protected from harm. The acting manager should apply for registration with the Care Quality Commission so that her fitness to manage the specific service user group at Castle Keep can be tested. The acting manager should also complete the Registered Managers Award modules related to management skills and knowledge. The quality assurance system should be broadened to include questionnaires to relatives, staff and visiting professionals. This will provide a more extensive range of consultation about the services provided. Care staff should receive a minimum of six, formal supervision sessions each year. This will enable their practice to be monitored and provide an opportunity to discuss issues of concern. Key inspection report Care homes for older people Name: Address: Castle Keep Nursing Home Noddle Hill Way Sutton On Hull East Yorkshire HU7 4FG     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: Beverly Hill     Date: 1 6 0 6 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 33 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 33 Information about the care home Name of care home: Address: Castle Keep Nursing Home Noddle Hill Way Sutton On Hull East Yorkshire HU7 4FG 01482372402 01482835651 castlecare@barchester.com www.barchester.com Barchester Healthcare Plc Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Carol Sarel Type of registration: Number of places registered: care home 58 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: None Date of last inspection Brief description of the care home Castle Keep is a purpose built, single storey building providing nursing and personal care for male and female residents over the age of 65years. The home is also registered to take up to eight people under the age of 65years. The home is divided into two parts; a Nursing unit called Nightingdale, and Willow for people with dementia care needs. Castle Keep is one of four homes on a site called Castle Care Village, which is owned by a large national company - Barchester Healthcare plc. The home is situated within a residential area and close to bus routes into Sutton and Hull. Care Homes for Older People Page 4 of 33 Over 65 58 58 58 0 0 8 2 4 0 2 2 0 1 0 Brief description of the care home The home has up to fifty-eight placements within single and shared room accommodation. Thirteen bedrooms on Willow and one on Nightingale have en-suite facilities. There is a lounge/dining room on each of the units in which people can relax and enjoy the company of others. The home has recently added more communal rooms by refurbishing a room used for storage into a lifestyle kitchen, rearranging the activities room into a more social area and developing a hairdressing room. Residents also have access to the spacious grounds at the home, which are designed to be accessible to those in wheelchairs and with mobility problems. There are three bathrooms and two shower rooms and sufficient toilets throughout. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home, and copies are given to every new resident. The latest inspection report for the home is on display in the entrance hall and copies are available from the manager on request. The homes weekly fees range between £468.20p and £922.38p and is dependent on the level of need. Residents will pay additional costs for optional extras such as hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Care Homes for Older People Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means that some people that use this service experience adequate quality outcomes. This inspection report is based on information received by the Care Quality Commission (CQC) since the last Key Unannounced Inspection on 24th February 2010. It also included a site visit to the home which lasted approximately nine hours. At the last inspection in February there had been concerns about the management of the home and specific care issues for people with dementia. There has been lots of improvements noted during this site visit and it is clear that staff and management have worked very hard to improve the quality of the service provided to people and the environment in which they live. Throughout the day we concentrated on a part of the home called Willow, which Care Homes for Older People Page 6 of 33 provided care and support to people with dementia care needs. We spoke to some residents and observed the way staff supported people. We had discussions with the Regional Operations Director, the new Acting Manager and staff members. Information was also obtained from surveys received from residents, relatives, staff members and a health and social care professional. Comments from the surveys and discussions have been used in the report. There had not been any new admissions to the home since the last inspection but care plans had all been revised. We looked at the care plans to see how they reflected peoples needs and to ensure that staff had full information about the people they cared for. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. We also checked to make sure that privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. We checked out with staff their understanding of how to maintain privacy, dignity, independence and choice. Since the last inspection the providers had returned their annual quality assurance assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We would like to thank the people that live in Castle Keep, the staff team and management for their hospitality during the visit, and also thank the people who completed surveys and had discussions with us. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the services are not being put at significant risk of harm. In future if a requirement is repeated it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 33 What the care home does well: What has improved since the last inspection? The home had a much calmer atmosphere and was managed in a more effective way. Staff morale had risen and they stated they felt supported by management. The staffing numbers have been increased and have stabilised since the last inspection, and residents requiring one to one support receive this in a more consistent way. There have been lots of improvements in the environment since the last inspection in February. Willow has been completely redecorated and some rooms refurbished to provide extra communal space for people. The home has been made much more stimulating for people with dementia. A shower room has been refurbished and looks smart, fresh and modern. One relative stated, I think the bathroom near to my parents room looks great. It now looks more friendly and homely. Also the new bedding which has been fitted a couple of weeks ago on their beds looks brighter and more colourful, my dad even showed them to me a few times the other day. Another relative stated, they provide a very clean and healthy environment for people staying there. Although we could not test out any improvements in the assessment process prior to admission, the experienced acting manager is implementing new assessment proforma and is to complete any assessments for future potential residents. Care Homes for Older People Page 8 of 33 The care plans and risk assessments have all been revised and contain much more information about people and how they need to be cared for. This means that staff have clearer guidance and know what they need to do when supporting people with complex needs. Staff had received training in specific holding techniques for those residents with very complex needs that required extra support during personal care tasks. Those who had not completed any dementia care training have started a course and others have been identified as requiring the training. The recording of care and monitoring charts had improved and gave a clearer record of the care provided. There had been a big improvement in social stimulation for people with dementia. As mentioned the environment has improved but also the activities and occupations people are able to participate in has increased. One relative said, The other Sunday just before I took my parents out I was pleased to find one of the male carers sitting with my dad reading a book together - thanks for your efforts. Social needs assessments have been completed and two activity organisers have been employed. They are both enthusiastic about their role and in surveys staff commented on the improvements in this area. Choice has been increased for people. For example, the environment and which rooms to use, what activities and outings to participate in and the choice of finger foods available throughout the day. The way medication is managed has improved although there are still some recording issues to address. What they could do better: Patient passports, used to provide important information when a hospital admission is required, should be completed in a more thorough way so that hospital staff have the necessary information to care for the person fully. The recording of medicines could be further improved so that directions are clear on all records and individual plans must be in place for people receiving their medication covertly. Although there have been some improvements in the way staff respond to incidents between residents they continue to happen. Further measures must be put in place to ensure that people are protected from harm. The acting manager should apply for registration with the Care Quality Commission so that her fitness to manage the specific service user group at Castle Keep can be tested. The acting manager should also complete the Registered Managers Award modules related to management skills and knowledge. The quality assurance system should be broadened to include questionnaires to relatives, staff and visiting professionals. This will provide a more extensive range of Care Homes for Older People Page 9 of 33 consultation about the services provided. Care staff should receive a minimum of six, formal supervision sessions each year. This will enable their practice to be monitored and provide an opportunity to discuss issues of concern. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 33 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 33 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. Although there has not been any new admissions since the last inspection, the admissions process has been part of the homes improvement plan. We have been assured that people are only admitted after a full and comprehensive assessment has taken place. This means that staff are able to meet needs and the resident can be confident their needs can be met in the home. Evidence: There have been no new admissions to the home since the last inspection. However, we discussed the admissions process with the new acting manager. They confirmed that full assessments of need would be carried out prior to admission and any assessments completed by health and social care professionals would be obtained. The acting manager advised that in addition to considering the range of individual needs when deciding on whether the home was able to meet needs, the focus would also be on the dynamics between current, and any potential new residents, the environment, and any equipment required. Care Homes for Older People Page 12 of 33 Evidence: The acting manager is devising a new person-centred assessment form to focus more specifically on individual needs, preferences and wishes about the kind of care and support people would like. The acting manager advised they were to assess all new admissions for the time being. Those care files examined were for people admitted to the home prior to the last inspection and each had an assessment completed by the local authority. People admitted for nursing care continue to have an assessment completed by a nurse employed by the primary care trust regarding the level of nursing care they require. This determines the health authoritys financial contribution to the persons care. The home does not provide intermediate care services so standard 6 does not apply. Care Homes for Older People Page 13 of 33 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements were noted in the way care and risk were planned for and carried out. This means that staff have clearer guidance in how to support people and important care has less chance of being missed or provided in an inappropriate way. Clearer guidance on the management of topical products, eye drops and medicines administered covertly will ensure that people receive their medicines as prescribed. Evidence: We examined three care plans in detail during the visit and there was evidence that staff had worked very hard on improving them. They contained more detailed information about people and how they preferred care to be provided for them. They were written in a person-centred way and gave staff clear directions in how to support people. One residents care plan for communication for example, explained to staff how they wished to be addressed, how they communicated, what they mean when they say particular words, what type of phrases to use and how they communicate to staff that they are anxious. Care Homes for Older People Page 14 of 33 Evidence: At the last inspection we were concerned that staff did not have clear guidance in how to support people whose way of communicating posed a challenge for them and other residents. Staff were using holding techniques to support specific residents with personal care and these were not identified in care plans. Since then, best interest meetings have taken place with family members and professionals involved in the persons care and the care plans have been updated to reflect the consensus of opinion in the best way to support the person. The acting manager advised that they were also working on inputting specific pictures of the holding techniques into the care files to provide staff with easy to use instructions. There were several areas where staff recorded the care provided. These included a daily living profile incorporating bathing, showering and other personal care, a progress and evaluation report, key worker notes and a care assistant communication sheet. The acting manager advised that a new evaluation sheet was due to be started that would be located after each care plan area and staff would be expected to complete it monthly to help build a picture of the care the person had received and whether changes to the care plan were required as a result of the analysis. The acting manager is looking at ways to streamline the recording systems. Risk assessments had been improved so that they included clearer directions in how to minimise risk. They included moving and handling, nutrition, falls, the use of bed rails, the possibility of choking, skin integrity and behaviours that can be challenging. One specific risk assessment had a shortfall that was updated during the visit. There was evidence that people had access to a range of health and social care professionals. Monitoring charts were completed and those seen showed an improvement in recording, which made it easier to provide health professionals with the detailed information they may need to support their treatment. The acting manager advised that they were introducing , health action plans to bring together health needs in one defined care plan. Staff had also been completing, patient passports, so that any person admitted to hospital had ready information about their care to be shared with hospital staff. The ones seen required some adjustment to ensure full information was included. There was a calm atmosphere in the home and staff were observed supporting people in a friendly and caring way. In surveys, people that were able to, told us that they received the care and support they needed and that staff members were available when required. Four surveys from relatives told us that they were kept informed and the resident received the support and care that was expected. Some comments from relatives were, all cares and requirements needed are carried out well and they give Care Homes for Older People Page 15 of 33 Evidence: good care as well as personal care - they communicate well. There had been improvements in the way medicines were managed, although there were still some minor issues to address. Some of the directions written on the medication administration Record (MAR) were not fully clear. For example, creams and eye drops were not consistently clear about their use and a product for constipation was written, as directed. One resident was prescribed a tablet that stated, one daily, normally at night, but the person had been having this at noon. This was discussed with the GP on the day and the instructions changed. A small number of residents received their medicines covertly, as they often declined them and a best interest meeting had decided they needed them for their health and safety. The home has a generic care plan for covert medication but these need to be individualised to show how each individual receives their medicine. For example, whether staff offer the medicine first and only give it covertly if they decline, what the medicine is given in, whether it is crushed or given whole and what the order of priority is. In a discussion with a nurse they stated that they would contact the pharmacist to seek advice about the type of food or fluid medicines were to be administered in. A primary care trust pharmacist has been supporting the home in best interest meetings and is to attend them. The acting manager could evidence that they have written to some GPs to seek clarification on some medicines that are prescribed, when required. Care Homes for Older People Page 16 of 33 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There has been a marked improvement in the activities and stimulation provided to people living in the home, which has impacted positively on their wellbeing. The addition of the breakfast cafe, and healthy finger foods to augment the main meals served throughout the day, has resulted in more choice for people and a gain in weight for some residents. Evidence: The changes the home has made to the quality of daily life and activities for residents with dementia care needs has been significant. One staff member said in a survey, in the last few months there has been so much improvement towards all residents general holistic care and most importantly their social care. The environment has been made much more stimulating, care plans contain information about peoples preferences and abilities and residents are supported and encouraged to be involved in activities and occupations. For example, the home has repositioned chairs in the main lounge in a more social way, pictures have been put on the walls, and stimulating objects have been placed on tables for residents to look at and pick up. Care Homes for Older People Page 17 of 33 Evidence: The home has created more communal space for residents by refurbishing a storage room into a lifestyle kitchen. This includes two tables and chairs for residents to sit at, a sink where they can be supported to wash up pots, a bread making machine that staff use daily to make fresh bread, a filter coffee machine and other kitchen equipment. Staff were pleased that residents had started to use the kitchen as a, cafe. They told us that the smell of bacon cooking and coffee brewing each morning enticed some residents to have their breakfast there and this had impacted on the weight of some residents. There was clear evidence that confirmed some residents had used the room on the morning of the site visit and that breakfast had gone on for as long as residents required it. A further room, previously used as an activities room had also been updated with tables and chairs, a piano, games and magazines and drinks making equipment. The changes to the environment means that people have increased opportunities for finding stimulation in various parts of the home. An activity organiser has been employed for forty hours a week and this has been supplemented by a second staff member for sixteen hours a week. Each resident has had an assessment of their social needs. This includes likes and dislikes, abilities and previous interests. Staff spoken with told us that the assessments had influenced the type of stimulation provided to people. This included, sensory items such as glow balls, soft, tactile objects, items for people to smell to encourage memories and musical instruments. Other stimulation included reminiscence and life story work, exercises, skittles and other ball games and doll therapy. Residents have enjoyed outings to a museum, shops, pubs and other local facilities and entertainers had visited the home. Staff also advised that they supported some residents with occupations of their choice such as washing up, setting and clearing tables, hoovering, pegging clothes onto a clothes horse and feeding birds. One resident likes to walk around pushing a pram and another enjoys sanding wood. There were no restrictions on visiting times and surveys confirmed that relatives were kept informed about their family members. Staff told us that there was a much more relaxed atmosphere in the home and this was evident on the day. Since the last inspection the home had improved the nutritional input of people with dementia. They had done this by providing, in addition to the main meals, a healthy selection of finger foods for residents to snack on at intervals throughout the day. This Care Homes for Older People Page 18 of 33 Evidence: helps to augment the dietary intake of residents whose concentration span prevents them from sitting for long periods at the dining table. Other residents were under the care of the dietician and were prescribed food supplements. The meals were well prepared and presented and there were plans to increase pictorial menus. Staff had clear guidance on how to present meals on trays for people to have in their own bedrooms and how dining tables should be set to ensure mealtimes were a pleasant and social experience for people. The catering manager advised that the selection of finger foods was replenished twice during the day - more often if required. In the afternoon fruit smoothies and cakes were added to the usual tea trolley and in the evening sandwiches were provided. Fresh fruit was available throughout the day. The catering manager attends residents meetings to ensure any complaints or requests can be identified and addressed. Care Homes for Older People Page 19 of 33 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. Although there have been improvements in the way staff support people with behaviours that can be challenging, further work is required to ensure that people living in the home remain safe and protected from harm. Evidence: The home had a corporate complaints policy and procedure. This was displayed in the entrance and a pictorial version had been produced. A complaints form was available for residents and visitors to complete and covered areas such as the nature of the complaint, the investigation process and how it was resolved. We saw evidence that in the last twelve months the home had received four minor complaints and all had been resolved appropriately. Since the last key inspection in February the home had not received any formal complaints. All staff had received training in how to safeguard vulnerable adults from abuse. In discussions they were clear about what constituted abuse and what to do should they witness any abuse or poor practice. The acting manager had completed the local authority training specifically for the managers role in referral and investigation and was clear about any actions she needed to take should there be any allegations of poor practice or abuse. At the last inspection we noted that we had received a lot of notifications regarding incidents between residents, which included physical and verbal assaults. The local Care Homes for Older People Page 20 of 33 Evidence: authority had also been made aware and care management teams had been monitoring the incidents. Some residents receive specific one to one support for part of the day and since the last inspection this has been managed more effectively. However, there are other residents without one to one support that have behaviours that are challenging to others. Staff have received training in how to manage difficult situations and try to engage quickly with residents to diffuse situations. Care plans have also been improved to give clear guidance on how to support people with their communication methods. However, the assaults between some specific residents have continued and further measures are required to protect people. We discussed this with the acting manager and regional operations director and they told us that they had plans to reorganise a section of the home so that it would provide a more focused area of support for specific residents. Since the last inspection any resident that staff use holding techniques, to support them during personal care tasks, has had a best interest meeting and details of the support has been clearly recorded in their risk assessments and care plans. Care Homes for Older People Page 21 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environmental improvements have helped to create a positive, relaxed and stimulating environment for people living in the home. Evidence: The home is divided into two distinct areas; Nightingale and Willow, with a further area called Rainbow, which is attached to Willow. Currently people living in Nightingale have nursing care needs and people in Willow have dementia care needs. There has been a significant improvement in the environment since the last inspection, especially in Willow and a redecoration and refurbishment plan has been developed and started. Willow has been completely redecorated and carpets cleaned. New furniture has been ordered. A store room has been refurbished into a life skills kitchen and an old activities room transformed with tables and chairs and drinks making equipment. A hairdressing room is now available and a walk-in shower room completely refurbished. Six bedrooms have been completely redecorated and three of them recarpeted. Curtains, bedding and pictures have been purchased. The garden has been tidied to make it more comfortable and accessible to people. A quiet room is planned to be organised in the next few weeks to meet the needs of those residents requiring space and peace. Redecoration on Nightingale has started. The main lounge on Willow has been rearranged to make it a more social room and it Care Homes for Older People Page 22 of 33 Evidence: is now a more stimulating environment with pictures on the walls, and items on tables and chairs for people to pick up to read or use. Pictures have also been placed in corridors. The alterations to the communal areas mean that there are more rooms for people to move about in and an increase in choice about where to sit and have meals. A selection of bedrooms were checked and staff had supported some residents on Willow to make collages of photographs of their families. The rooms were personalised to varying degrees. There were sufficient bathrooms and toilets and the newly refurbished shower room provided a safe, convenient and pleasant environment for residents. The doors of the bathrooms and toilets were painted a specific colour with pictorial signs to aid recognition for people with dementia. The acting manager advised that there are plans to modernise the two bay toilets into a larger disabled toilet with a shower facility. This would provide both the resident, and staff supporting them, with more room to manoeuvre. There are three garden areas all accessible from various parts of the home. These have been tided up to ensure that people can walk around them safely. A new fence has been erected in one section to ensure the garden is secure. The home was clean and tidy and domestic staff obviously work hard to maintain the standards. The laundry was completed from a central building on the site. Care Homes for Older People Page 23 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements have been made in the deployment of staff and the provision of specific training in care needs associated with dementia. This has meant that challenging incidents between residents have been managed more effectively and, whilst not fully addressed, has led to a reduction in them. Evidence: The staffing numbers have been increased and stabilised since the last inspection. There were three carers and one nurse supporting fifteen people with nursing care needs on Nightingale and eight carers and one nurse for Willow. Three of the carers provided one to one support for specific residents thoughout the day for various hours. A new deputy manager had twenty-four of her full-time hours that were supernumerary to enable time for administration and staff supervision and the acting manager spent two full days at the home. There are plans that she will become fulltime in the home in July 2010. There is a full time activity organiser and an additional activity organiser, from another home in the company, working sixteen hours a week. Staff spoken with confirmed the staffing numbers and told us that there had been lots of improvements. They told us there were now sufficient numbers of care staff and nurses on each side of the home and one to one support was used for the benefit of Care Homes for Older People Page 24 of 33 Evidence: the residents to meet their individual needs. Residents were complimentary about the staff. Comments were, if I need help, they are there to assist me and I am very satisfied because if I need anything I only have to ask. The company has a good training programme that covers mandatory training and service specific areas. There are designated training officers and a computerised system for keeping records up to date regarding what training staff have completed and when updates are due. At the last inspection it was highlighted that staff working with people with dementia required more training in how people communicated and how behaviours that were challenging were to be managed. Since then the company has ensured that all staff have either completed practical training or have had their knowledge refreshed. Sixteen staff were progressing though a dementia awareness course at level 2, seven of which had completed all the work and were awaiting validation. The companys training department has developed additional workshops called, being a star, specifically to support staff when caring for people with dementia. These are due to start near the end of June 2010. Staff have had additional guidance in recording and reporting incidents. Nurses in charge of the administration of medication, have all had competency tests and person-centred care training has been added to the home training agenda. The training manager advised that 54 of care staff had gained a national vocational qualification (NVQ) in care at level 2 and 3. This was a very good achievement and reflects the companys commitment to a trained workforce. All five surveys from staff indicated that they received the training they required and staff spoken with confirmed that specific training had improved and they felt better equipped to support people with dementia care needs. Staff told us, provides relevant training, we are stepping slowing forward - it is a work in progress, theres been a lot of changes, staff are more confident and there has not been so many incidents and theres a different staff attitude now - more person-centred. The company had a good recruitment system. All checks were carried out prior to the start of employment and there was a system in place to verify that nurses had a valid registration. On the rare occasions that staff started their employment prior to the return of the full criminal record bureau check (CRB), a check was made against the list barring people from working with vulnerable adults. By the time their induction Care Homes for Older People Page 25 of 33 Evidence: had been completed the CRB had usually been returned or the staff member would pair up with another until they were completely cleared. In surveys all staff confirmed that they had a criminal record bureau check completed as part of their recruitment. Care Homes for Older People Page 26 of 33 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. There have been considerable improvements in the way the home is managed. However, the home needs to have a full time registered manager to provide stability, to ensure the safety and wellbeing of residents and to continue to provide support and guidance to staff. Evidence: Since the last inspection there has been a change in management of the home. A new acting manager, currently the registered manager of another home in the company, is working at the home two days a week. This is to be put on a more permanent basis in July and will add some stability to the home. The acting manager is a registered mental nurse (RMN) and is very experienced in working with vulnerable people. She had completed and submitted work for the registered managers award but the validating organisation misplaced the work and she has to re-submit. She has completed relevant training courses and keeps herself up to date. Throughout discussions with her it was clear that she was very focused on the needs of residents and had a good understanding of supporting people with dementia. Care Homes for Older People Page 27 of 33 Evidence: The new acting manager is supported by a new deputy manager (matron), who is also a qualified nurse. She has worked for the company for nine years, two of which have been at Castle Keep. At the last inspection staff had reported that there were shortfalls in management support and this had affected morale. Staff told us at this site visit that the management changes had been significant and they felt very supported. Comments from surveys and discussions were, there was a lack of support in the past and I was ready to leave, we have a very good manager now - very person-centred, we are working well as a team, staff morale has been raised by just knowing that we have some support - that is by our manager, I hope we always get the support from our manager because believe you me it does make a difference, they look after the staff well, there has been lots of staff changes, you were isolated on Willow but now there is continuous input to Willow, the manager is strict but fair - very focused on the residents as individuals and its a better place to work now - happier. Staff also told us that they could speak to the regional operations director when they visited and one staff member stated, we have a structure of management now. There was evidence that senior managers completed reports of their visits and carried out an inspection of records and spoke to staff and residents. The acting manager demonstrated that their management style was very inclusive of the residents and staff team. Staff and residents meetings were held and people were able to make suggestions and were listened to. The company had a quality assurance system that included monthly audits, some of which involved questionnaires to residents. At the inspection site visit on 24th February we were told that an in-house audit had found several shortfalls. These related to a lack of stimulation for residents in the dementia care unit, some recording issues in care planning and risk management, a dining experience that fell short of expectations and required improvements in infection control. During this visit we have found that these shortfalls have been addressed very well. Part of the companys own action plan was to complete dietary screening on all residents in Willow to establish any nutritional changes from point of admission. The audit did show some residents had lost weight and successful measures have been put in place to address this. Whilst the auditing part of quality monitoring has improved the consultation part, via questionnaires to people, could be broadened, for example, to include staff, relatives and visiting professionals. People with dementia care needs in Willow did not have the Care Homes for Older People Page 28 of 33 Evidence: opportunity to complete questionnaires. We discussed this with the acting manager and they were to try and resolve this by tailoring a questionnaire for them or having more one to one discussions with them and documenting their replies. The home had completed a residents questionnaire on food and received three returns. These indicated that people were happy with the meals provided although two had stated they were unaware of the alternatives menu and that any reasonable catering request could be accommodated. The action taken evidenced that catering staff visited the two residents and discussed menu arrangements with them. The home had completed their annual quality assurance assessment. The content was rather sparse and we suggested ways to improve it. The acting manager took advice and, during the writing of this report, sent us an updated version with more information. The home had gained a, A in the local authority food safety assessment - scores on the doors and had been awarded a, healthy heartbeat award for the last fifteen years for ensuring a healthy option on the menu. Catering is produced centrally and food delivered in hot trolleys to each of the homes in Castle Care Village. The management of finances is the same in each of the homes. Families mainly manage the residents finances. An administrator maintains individual records on a computerised system and invoices are sent to relatives regarding any expenditure. Receipts are obtained for any purchases such as chiropody and hairdressing. Bedrooms have lockable facilities for people to store personal items. Although there has been a reduction in the amount of incidents between residents there are still some occurring and specific residents have been harmed. We are receiving notifications for all incidents that affect the wellbeing of residents, which is positive, however, the issue of incidents between residents needs further attention. The regional operations director advised that there are plans to reorganise a part of the home to accommodate residents with more complex needs. This will be staffed accordingly and may protect the more vulnerable residents who are prone to wander into the personal space of others and thereby resulting in confrontations and physical harm. Care Homes for Older People Page 29 of 33 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 30 of 33 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 12 People receiving their medication covertly must have individual care plans in place with clear directions for covert use. This will ensure that staff have full and specific directions in covert administration for each individual resident. 31/07/2010 2 18 13 Further measures must be put in place to ensure that people are protected from harm. This will ensure that peoples safety and wellbeing is protected. 31/07/2010 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 8 Patient passports, used to provide important information Page 31 of 33 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 when a hospital admission is required, should be completed in a more thorough way so that hospital staff have the necessary information to care for the person fully. 2 9 There should be clear directions on all medicines so that staff have full instructions and care is not missed. It is acknowledged that the acting manager has written to some GPs to seek clarification on some medicines that are prescribed, when required. The acting manager should complete the Registered Managers Award modules related to management skills and knowledge. The acting manager should apply for registration with the Care Quality Commission so that her fitness to manage the specific service user group at Castle Keep can be tested. The quality assurance system should be broadened to include questionnaires to relatives, staff and visiting professionals. This will provide a more extensive range of consultation about the services provided. Care staff should receive a minimum of six, formal supervision sessions each year. This will enable their practice to be monitored and provide an opportunity to discuss issues of concern. Plans to reorganise the home to provide a specific area for people with more complex needs, should be completed quickly. This may help to reduce the number of incidents between residents. 3 31 4 31 5 33 6 36 7 38 Care Homes for Older People Page 32 of 33 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. © 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. 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