Care Home: Coombe Dingle

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What the care home does well People who are considering moving into the home can be confident their needs will be assessed by a qualified person and their physical needs will be met. People who live in the home have their physical and personal care needs met, staff are respectful and patient. People who live in the home and their relatives who responded to our surveys made the following comments: `The staff are cheerful and friendly. management and staff are helpful and easy to approach and listen to requests which they carry out where possible.` `Food is good.` `I am very comfortable and am happy with the room I am in and all the service I receive.``Very helpful - happy and friendly. They look after me.` People enjoy good home cooked food. The home is clean throughout. What has improved since the last inspection? No specific improvements since our last visit were identified during this inspection however a programme of refurbishment is currently underway. The home has employed a new person in charge who is in process of registering as manager for the home. A new deputy manager has also been employed. What the care home could do better: Before people move into the home a thorough assessment should be carried out to include their spiritual and emotional needs, social interests, individual preferences and lifestyle choices taking account of equality and diversity. The home must make suitable arrangements to ensure that the care home is conducted with due regard to any disability of service users. In that all specialised services offered for people with dementia or other cognitive or sensory impairments are demonstrably based on current good practice, and reflect relevant specialist and clinical guidance. The home must ensure that each person`s care plan is person rather than task centred and provide clear guidance for staff on how to provide care and support for each person in line with their wishes and expectations. To ensure that each person`s individual care needs are met in a way that promotes their individuality and dignity. The home must ensure unnecessary risks to the health or safety of each person is identified and so far as possible eliminated. Including risks associated with the activities of daily life and the administration of medication. To ensure the safety and comfort of people who live in the home. The home must provide adequate support and stimulation to meet specialist needs and promote the wellbeing of people who have dementia. The lifestyle experience of people who live in the home needs improvement to ensure their social and recreational needs are met in line with their individual abilities, expectations and preferences. People must be provided with the opportunity to engage in activities that are meaningful to them.People must be provided with opportunities to exercise choice and control over their own lives. Better planning is needed to ensure mealtimes are more enjoyable and offer choice in a way people can understand. Staff must be provided with up to date training in dementia and challenging behaviours to ensure they understand when people are unhappy and know what Action to take in response. People must be free and supported to move around the home as they choose without restraint in line with their individual care plans and risk assessments. The home must must take account of the specific environmental needs of people who have dementia. Shared rooms should only be occupied by people who have made a positive choice to share a room and the space provided in these rooms must be sufficient to ensure adequate private space with a comfortable place to sit. Staff must be deployed in such a way as to ensure each person receives the attention they need promptly, particularly at mealtimes. Recruitment procedures must ensure the home obtains references from an employer in line with the Care Homes Regulations to ensure people who live in the home are fully protected. There must be an effective system for evaluating the quality of the services provided at the care home to include and take account of the views of people who live there and other people who are involved in their care. The annual development plan for the home should be based on a systematic cycle of planning - action - review, reflecting aims and outcomes for service users.To ensure people are provided with good quality services in line with their wishes and expectations. The registered person must ensure there are effective risk management systems to ensure people are fully protected from risk of harm. A comprehensive improvement plan addressing these issues has been submitted by the provider since our visit. Key inspection report Care homes for older people Name: Address: Coombe Dingle 14 Queens Park Road Caterham Surrey CR3 5RB     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: Ruth Burnham     Date: 0 3 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 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: Coombe Dingle 14 Queens Park Road Caterham Surrey CR3 5RB 01883345993 01883341869 alphacarecaterham@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Alpha Care (Caterham) Ltd Name of registered manager (if applicable) Mr Chen Heng Low Type of registration: Number of places registered: care home 42 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 42 The registered person may provide the following category of service: Care home with nursing (N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following category : Dementia (DE) Old age not falling within any other category (OP) Date of last inspection Brief description of the care home Coombe Dingle is a registered care home providing nursing care for up to 42 people with dementia. The home is situated in a quiet residential road facing a large park. The property is detached and has a large garden to the rear and also offers car parking for several Care Homes for Older People Page 4 of 34 Over 65 0 42 42 0 Brief description of the care home vehicles. Additional parking is on the road. Accommodation is provided over three floors. There are nine en suite single bedrooms and 2 double bedrooms with ensuite facilities. There are seven bedrooms where two people share the room. There is a passenger lift to all floors. The home is owned by Alpha Care (Caterham) who are the registered providers. Fees range from 550 to 750 pounds per week. This fee does not include toiletries and hairdressing. 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 inspection of the Service was an unannounced Key Inspection. The inspection included a site visit. We arrived at the Service at 09.00 and were in the Service for seven and a half hours during which time we spoke to and observed a number of residents. We spoke to staff, the person in charge and the providers. A number of documents were examined. The inspection took into account information provided by the provider since our last review of the service and any information that the Commission has received about the Service. We asked the views of the people who live at the home and other people who responded to surveys we sent as part of the inspection. Responses to surveys were mixed. We received 9 responses from people who live in the home or their relatives on their behalf; 10 responses from staff and one response from a health care professional. We looked at how well the service is meeting the standards set by the government, we Care Homes for Older People Page 6 of 34 made judgements about the standard of the service. There are 11 Required Developments at the end of this Report. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. 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: Before people move into the home a thorough assessment should be carried out to include their spiritual and emotional needs, social interests, individual preferences and lifestyle choices taking account of equality and diversity. The home must make suitable arrangements to ensure that the care home is conducted with due regard to any disability of service users. In that all specialised services offered for people with dementia or other cognitive or sensory impairments are demonstrably based on current good practice, and reflect relevant specialist and clinical guidance. The home must ensure that each persons care plan is person rather than task centred and provide clear guidance for staff on how to provide care and support for each person in line with their wishes and expectations. To ensure that each persons individual care needs are met in a way that promotes their individuality and dignity. The home must ensure unnecessary risks to the health or safety of each person is identified and so far as possible eliminated. Including risks associated with the activities of daily life and the administration of medication. To ensure the safety and comfort of people who live in the home. The home must provide adequate support and stimulation to meet specialist needs and promote the wellbeing of people who have dementia. The lifestyle experience of people who live in the home needs improvement to ensure their social and recreational needs are met in line with their individual abilities, expectations and preferences. People must be provided with the opportunity to engage in activities that are meaningful to them. Care Homes for Older People Page 8 of 34 People must be provided with opportunities to exercise choice and control over their own lives. Better planning is needed to ensure mealtimes are more enjoyable and offer choice in a way people can understand. Staff must be provided with up to date training in dementia and challenging behaviours to ensure they understand when people are unhappy and know what Action to take in response. People must be free and supported to move around the home as they choose without restraint in line with their individual care plans and risk assessments. The home must must take account of the specific environmental needs of people who have dementia. Shared rooms should only be occupied by people who have made a positive choice to share a room and the space provided in these rooms must be sufficient to ensure adequate private space with a comfortable place to sit. Staff must be deployed in such a way as to ensure each person receives the attention they need promptly, particularly at mealtimes. Recruitment procedures must ensure the home obtains references from an employer in line with the Care Homes Regulations to ensure people who live in the home are fully protected. There must be an effective system for evaluating the quality of the services provided at the care home to include and take account of the views of people who live there and other people who are involved in their care. The annual development plan for the home should be based on a systematic cycle of planning - action - review, reflecting aims and outcomes for service users.To ensure people are provided with good quality services in line with their wishes and expectations. The registered person must ensure there are effective risk management systems to ensure people are fully protected from risk of harm. A comprehensive improvement plan addressing these issues has been submitted by the provider since our visit. 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. People who are considering moving into the home or their representatives are provided with information about the service. Some of this information is inaccurate and out of date and would not be helpful in enabling people to decide if the home is suitable for them. People who are considering moving into the home can be confident their needs will be assessed through admission and assessment processes and their physical needs will be met. However the home does not provide adequate support, stimulation or a suitable environment to meet specialist needs or promote the wellbeing of people who have dementia. Evidence: People who are considering moving into the home or their representatives are provided with information in the Statement of Purpose and Service User Guide. The information about staff and management in these documents is out of date and Care Homes for Older People Page 11 of 34 Evidence: inaccurate. Some of the information about the services provided is also inaccurate. We went through the current information with the person in charge and one of the providers of the service. They agreed to ensure all the information was revised and updated within 3 months to ensure people who are considering moving into the home receive a more helpful and accurate picture of what life in the home is like and what services they can expect to receive. People have their needs assessed before they move into the home to ensure their needs are understood. The home has a policy and procedure on admission to the home. We reviewed a random sample of four peoples individual files which showed that pre admission assessments are being carried out. Assessments seen do not include sufficient information about peoples background and social histories, interests and lifestyle preferences or emotional, social and spiritual needs. Issues relating to equality and diversity are not identified. Forms to capture this information are in place in files sampled but have not been completed. Staff therefore do not have the information they need to engage people in meaningful interaction and activities in line with their individual backgrounds, wishes, expectations and lifestyle choices. The majority of people who live in the home are experiencing significant levels of dementia. It was clear during the visit that the home does not meet these specialist needs in a way that promotes the wellbeing and enhances the quality of life for people who live there. The home does not offer sufficient specialised services or reflect relevant specialist guidance such as providing an environment that promotes the wellbeing of people with dementia and helps them to find their way around. Interactions observed between staff and residents showed that not all staff are sufficiently well trained and competent to meet the specialist needs of people who live in the home. Care Homes for Older People Page 12 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. People who live in the home have their physical and personal care needs met. However insufficient information about peoples backgrounds, emotional, spiritual and social needs and preferences limit the staffs ability to provide a person centred service. Risk management systems do not include the day to day activities of people who live in the home. Staff who are focused on the task rather than communicating with the person are not promoting the well being or dignity of people who live in the home. The unsafe practice around the administration of medication is compromising the safety of people who live in the home. Evidence: The majority of people who responded to our survey were satisfied with the care and support provided. Comments included: I am happy with the care given to my mother, she responds well to the staff.She is kept clean and great patience is shown to her if when is having problems eating. She is always clean and physically cared for. Caring atmosphere People who live in the home have a plan of care. However reviews do not take place Care Homes for Older People Page 13 of 34 Evidence: regularly and are not set up to monitor changing circumstances. Three of the four care plans seen had not been reviewed since 2007, some minor hand written amendments had been written in some of the sections of the care plans however some information was completely out of date and, if followed, would place the person at risk. For example in one persons care plan the section on food states she has food of a normal consistency and drinks independently. This is not accurate. This person requires a soft food diet and needs to be fed and helped to drink. Risk management systems focus on physical and health needs. No risk assessments were seen in relation to day to day activities. Daily records are minimal with little information about how the care plan has been followed or the welfare of people promoted. Lack of information gathered in the assessment process means people may not have their social, emotional and spiritual needs met. Four care plans were sampled. These are adequate for health and personal care needs although they are not person centred. There is limited guidance and information to enable staff to meet peoples emotional, spiritual and social needs or preferences. The service is unable to demonstrate up to date knowledge of social care issues relevant to peoples individual needs where they have dementia. Only one of the three care plans seen had any information about the persons social history. There was no information about peoples lifestyle, interests and preferences to enable staff to provide person centred care to each resident or interact with them in a meaningful way. The environment does not promote the wellbeing of people who live there in that it has not been designed with the needs of people who have dementia in mind in line with specialist guidance. There is very little signage around the home to help people to find their way around or recognise their own rooms. The layout of the home is difficult for people who have dementia in that there are many corridors with doors that all look the same. Staff were observed providing care and support throughout our visit. On four occasions staff were observed moving people, using hoists or other lifting aids without warning or explanation or any communication with the person they were moving. it was of further concern that items of clothing seen in the laundry, folded and ready to be put away were not labelled or were in need of repair. Some staff were heard using phrases like good boy or good girl to residents. These practises compromise the dignity of people who live in the home. People who live in the home can be confident there are sufficient qualified nursing staff in the home to meet their healthcare needs and people are supported to access a variety of health care services such as dentists, opticians, chiropody and the local GP. A health care professional who responded to our survey commented on what the Care Homes for Older People Page 14 of 34 Evidence: home does well: Residents are encouraged to maintain their skills and independence as far as possible. I am happy with the management and care of residents. People are not always adequately protected when medication is administered. The morning medication round was observed. The medication trolley was located in the lounge whilst two members of nursing staff administered medication from this trolley to other areas of the home. The trolley was full and was locked when staff left the room, however, there was no room in the trolley for the blister packs containing a variety of tablets, these were therefore left out and unattended while staff were elsewhere in the building. Clearly this practice is placing people at risk. This was drawn to the attention of the person in charge and the nursing staff at the time. The providers agreed to provide adequate lockable storage for all medication to ensure this does not happen in the future. Medication is stored securely when not in use and administered by trained staff. Records seen were in good order. Care Homes for Older People Page 15 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lifestyle experience of people who live in the home needs improvement to ensure their social, spiritual and recreational needs are met in line with their individual abilities, expectations and preferences. People have limited opportunity to exercise choice and control over their own lives. People enjoy good home cooked food however better planning is needed to ensure mealtimes are more enjoyable and offer choice in a way people can understand. Evidence: The lifestyle experience of people who live in the home does not satisfy their social and recreational interests and needs or lifestyle choices in that staff are not provided with adequate information or training to meet these needs in line with peoples wishes and preferences. Care plans do not provide guidance for staff to promote choice and autonomy. For example, in two of the care plans seen staff were advised that the person could not dress themselves so staff must choose their clothes for them. During the morning there were no activities offered, staff were too busy to spend time with people who were sitting in the lounge and dining area. Lack of information about previous lifestyles, interests and preferences mean that when activities are provided by staff they may not be meaningful. Ten of the twenty one people who responded to Care Homes for Older People Page 16 of 34 Evidence: our survey expressed the view that people who live in the home do not have enough to do and need more activities.Their comments included: The home is too big, need more things to do. Need more activities as it gets boring at times, staff try hard. I enjoy music, more would be nice. Need more to do in the day. I would like to see more activities but the patients are not responsive, they do need motivation. Maybe the use of television where all patients can see and music that they hear and listen to. Need more organised outings and social activities. More activities for clients. More suitable chairs for certain clients. More cushions to support clients and foot rests. Need to put on more activities and more time for the residents to enjoy and achieve something more. During our visit we spent 4 hours in the lounge/ dining area. During that time none of the people were offered anything to do. There was nothing to look at or touch or hold. No magazines or objects for people to engage with. Some music was put on at around 11.30 am. There is a television in the central lounge area, however this is sited high up on a central pillar from where only a handful of people could actually see it if it were on. Chairs were placed around the perimeter of the lounge which is divided into 2 areas. There is no room for tables in between the chairs where people could place items. There is no activities programme either for the home or for individuals within their care plan. The manager told us that they have interviewed 2 people for the role of activities coordinator, however neither of these people have any training in this field that the management of the home were aware of. Currently staff are expected to provide activities as they can between carrying out their other duties. The manager and deputy manager did spend some time engaging with two residents, other than that the only time any interaction between staff and people in the home was observed was when they were being fed or moved from place to place. Even then there was little conversation, comments from staff such as good boy and good girl were occasionally heard between mouthfuls. Staff were too busy to spend any time just chatting, there was nothing for people to do unless staff engaged with them. lack of information about background and social histories meant staff have little information to promote meaningful conversation or support people to engage in meaningful activities. Peoples previous interests are not recorded. There are no religious services in the home and no information on care plans seen about religious preferences. A member of staff has taken the initiative to lead a prayer service each Sunday. There are no restrictions on visitors to the home and people are supported to maintain contact with family and friends. Care Homes for Older People Page 17 of 34 Evidence: People who live in the home enjoy good home cooked food. The lounge and dining areas are open plan. We observed two people sitting at dining tables for the whole morning. They were not finally assisted to leave the table until one thirty. We observed one of these people try to get up from the table on three occasions. We saw that the table had been moved close to him and the chair he sat on was pushed against a sideboard, so that he could not move. This was drawn to the attention of the manager who moved the table further away. later on in the morning he stood up, a member of staff immediately went to him and told him to sit down, moving the table closer to him again so he could no longer get up. This deliberate act of restraint was drawn to the attention of senior staff who told the staff member responsible not to do this, however the gentleman was not helped to leave the table even then. Other people were brought to the dining tables between eleven and eleven thirty when tea was served and remained there until after lunch was finished at around half past one. Some people were given biscuits in the saucer with their cup of tea but no one was offered any choice. At lunch time There were not enough staff to ensure each person was served at the same time. Staff began serving food at five past twelve. Some people at the tables were served their meal whilst others at the same table waited for up to an hour before they were helped to eat their meal by staff. No one was offered any choice of food, the meals were plated up in the kitchen and collected by staff from the serving hatch giving people no control over portion sizes or content. There was no menu and people have no way of knowing what will be served or if there is any alternative. Kitchen staff said there was a choice of pudding but this was chosen by staff according to the physical ability of people to eat it rather than in line with any individual preference. There was no choice of drink, everyone was given orange squash with their meal. Only one person was given a knife and fork to eat with, everyone else was given a spoon although no individual risk assessments were seen in relation to this. Care Homes for Older People Page 18 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. People who live in the home cannot be confident staff will understand or take appropriate action when they express unhappiness. Staff need additional training in safeguarding to ensure people who live in the home are not unlawfully deprived of their liberty. Evidence: The owner tells us there have been no complaints about the service in the last year. There is a written complaints procedure although this is not provided in a format that people who live in the home can easily understand. It cannot be concluded that people are listened to in the home. The majority of people have dementia and are unable to express their views or complain if they are unhappy. There are residents who exhibit challenging behaviour which could be understood as expressions of unhappiness or boredom. this is contained rather than the cause investigated and addressed. A health care professional who responded to our survey commented that the home needs to Improve training facilities for staff in challenging behaviour problems. The incident of restraint observed and detailed in the previous section of this report indicates that staff need additional training in safeguarding to ensure people who live in are not prevented from moving around the home as they choose in line with individual care plans and risk assessments. Care Homes for Older People Page 19 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a clean environment and is well equipped to meet the physical needs of the people who live there. However failure to take account of the specific environmental needs of people who have dementia has a detrimental effect on people who live in the home. Evidence: The layout of the home is suitable for its stated purpose to provide care for people who have dementia however adaptations have not been made to promote their wellbeing. For example signage to enable people to find their way around the home. Colour in decor is uniform throughout communal areas of the home. Patterned carpets may increase confusion. The home does not provide a homely environment which meets peoples individual and collective needs in a way which is designed with reference to relevant guidance to enhance the lives of the people who live there. Some refurbishment work is underway in the entrance hall and the person in charge said that further work is planned to improve the environment. Paintwork in a number of areas needs attention. There are seven shared bedrooms in the home. Although curtains are provided around beds the layout of the room does not provide the occupants with clearly designated private areas. There is insufficient space in these rooms to provide each person with a Care Homes for Older People Page 20 of 34 Evidence: comfortable chair. There was no evidence these residents had made a positive choice to share. There are vacant single rooms in the home but the person in charge said these had not been offered to those who currently share a bedroom. There is a well equipped kitchen and laundry and all areas of the home seen were clean and tidy. Care Homes for Older People Page 21 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. People who live in the home can be confident there is a competent staff team who are trained to meet their physical and nursing needs. A review of staffing levels and deployment of staff is necessary to ensure staff have enough time to support people in a way that promotes their dignity and meets their emotional and social needs. Current recruitment processes are not sufficiently robust to protect people who live in the home. Evidence: People who live in the home are cared for by a staff team whose competencies vary. There are 2 nurses on duty each day, supported by 6 care staff. On the day of the inspection 2 of the care staff were agency staff. The person in charge said these were agency staff who worked in the home regularly. Comments from people who responded to our survey included: Very helpful - happy and friendly. Look after me. The home is well run, very clean and tidy. Staff are helpful and friendly. I am very comfortable and am happy with the room I am in and all the service I receive. Has permanent staff which means residents know them and recognise their voices. The staff are cheerful and friendly. management and staff are helpful and easy to approach and listen to requests which they carry out where possible.Sometimes they appear to be short of staff. This means feeding those residents who need it requires everyone available to concentrate on that particular task. They have to cope with several residents at the same time. The kitchen and domestic staff sometimes seem to Care Homes for Older People Page 22 of 34 Evidence: the extremely busy for long periods. Observations throughout the day showed that some staff are less competent than others. Observations of times when people were moved using hoists and other lifting aids showed that some staff are task focused, they did not talk to the people they were moving or provide reassurance or explanation of what they were about to do. They provided physical support efficiently but without taking account of peoples dignity or emotional wellbeing. This was also observed during lunch when people were fed efficiently but hardly spoken to during the process. People who live in the home can be confident there are sufficient numbers of staff on duty to meet their physical needs. The owner employs a number of overseas students who work at the home for part of their time as paid carers and nursing staff and part of their time on placement as part of their college courses. It was unclear during the visit whether problems described earlier in this report that we observed during the mealtime were as a result of there being insufficient staff to support the high number of dependant residents or if the difficulties were a result of poor organisation. This was discussed with the provider and the person in charge who agreed to review staffing levels and the organisation of mealtimes to ensure people are supported in a way that ensures their dignity and emotional wellbeing is promoted. The provider and person in charge were informed of the high number of surveys in which we were told there was not enough for people to do. They told us they are already in the process of recruiting two activities coordinators. It was agreed that the provider would ensure these staff have relevant training to organise meaningful activities for people who are experiencing dementia. Four staff files were examined and a number of staff were spoken to throughout the day. Staff files show some shortfalls in recruitment processes designed to protect the people who live in the home in that there were no employer or professional references in one of the files seen. Checks are carried out through the Criminal Records Bureau although there were no records on file of checks in staffs country of origin. The person in charge told us that all staff are trained in infection control. basic food hygiene, first aid, fire safety, health and safety and moving and handling. Some practises seen during our visit indicate there is a need for some refresher training in moving and handling. The owner said he also arranges for an outside trainer to come in and provide training for staff about how to care for people who have dementia, however the quality of interaction observed during our visit indicates that a number of staff need further training in this area. The person in charge confirmed Care Homes for Older People Page 23 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. People who live in the home can be confident the home is now being managed by well qualified and experienced people. However lack of continuity in management of the home over the last two years has resulted in some slippage in the standard of service provided. Ineffective quality assurance and management systems have a negative impact on the service people receive and, in some instances, place people at risk of harm. Evidence: There has been no registered manager in day to day control of the home for some time. A new home manager, referred to as the person in charge throughout this report, has been in post for the last three months and is in process of applying for registration. The person in charge is a registered mental nurse. Our findings at this visit show that that lack of continuity in the management of the home has resulted in some slippage in standards since our last inspection in 2007. The new person in charge and the providers are aware of the need for improvement in a Care Homes for Older People Page 24 of 34 Evidence: number of the areas identified within this report and have already begun to address some of these. For example activities coordinators are being recruited and some areas of the home are being refurbished. A new and well qualified deputy manager has also been recruited. The person in charge also told us he is actively seeking to recruit staff who reflect the ethnic and cultural background of people who live in the home. Quality Assurance systems in the home have not been effective in identifying the need to improve care planning and practice, risk management or equality and diversity issues to ensure people receive care in a way that meets their individual spiritual, emotional and social needs. People are presented with very little choice about the way they are supported and cared for. It is difficult to see how the views of people who live in the home are taken into account in the way the service is provided when there is little or no information gathered about individual preferences or interests. Annual customer satisfaction questionnaires are sent out to relatives however other stakeholders such as health and social care professionals are not included. A recommendation was made following the last inspection in 2007 that the owner should expand their quality assurance system to include seeking the views of stakeholders in the community (e.g. GPs, chiropodists, care managers and other health and social care professionals). No action has yet been taken to ensure feedback is obtained from professionals who are involved in the care of people who live in the home to promote continued improvement in the service is sustained. The safety and welfare of people who live in the home is generally promoted through safe working practices. However improvement in risk management to identify risks around moving and handling, medication and individual day to day activities is needed to ensure people are protected from harm. A comprehensive improvement plan has been submitted by the provider since our visit. Care Homes for Older People Page 25 of 34 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 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 3 14 People should not be 31/12/2009 admitted to the home unless all their needs have been assessed. Including their social, spiritual and emotional needs and the specific needs associated with dementia. To ensure the home meets all their needs. 2 7 12 The home must make 31/12/2009 proper provision for peoples health and welfare in that each persons care plan should be person rather than task centred and provide clear guidance for staff on how to provide care and support for each person. To ensure that each persons individual care needs are met in a way that promotes their individuality and dignity. Care Homes for Older People Page 27 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 3 9 13 The home must ensure unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Including risks associated with the activities of daily life, health and safety, restraint and the administration of medication. To ensure the safety and comfort of people who live in the home. 31/12/2009 4 12 16 People must be offered 31/12/2009 opportunities for stimulation through leisure and recreational activities in and outside the home which suit their needs, preferences and capacities with particular consideration given to people with dementia. Individual and group activity programmes should be in place. To improve the quality of life and physical, mental and emotional wellbeing of people who live in the home 5 14 12 The home must take into account peoples wishes and feelings and conduct the home so as to maximise their capacity to exercise 31/12/2009 Care Homes for Older People Page 28 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 personal autonomy and choice in all aspects of their lives including what they wear, where and how they want to spend their time. Presenting all choices in a way that people who have dementia can understand. To ensure people have as much control over their own lives as possible. 6 15 12 The home must take 31/12/2009 account of peoples wishes and feelings. In that meals must be provided in a congenial setting, offering a choice of food in written and other formats to suit peoples capacities, including people who have dementia. Mealtimes should be organised so that people do not have to wait for extended periods while they watch other people eat their meals. To ensure mealtimes are enjoyable and people are presented with choices in a way they can understand. 7 18 12 People who live in the home would not be unlawfully restrained. The registered person must monitor staff practices to ensure that no 31/12/2009 Care Homes for Older People Page 29 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 service user is subject to physical restraint. To ensure people are free to move around the home as they choose in accordance with individual plans of care and risk assessments. 8 19 23 The Registered person must 31/12/2009 ensure that the physical design and layout of the premises meet the needs of the service users. Adaptations must be made to ensure people with dementia are assisted to find their way around.They must ensure that shared rooms are suitable to maintain adequate private space and of adequate size to provide somewhere comfortable for the occupants to sit should they choose to do so. Where rooms are shared, they should be occupied by service users who have made a positive choice to share with each other. When a place becomes vacant, people should be offered the opportunity to choose not to share, by moving into a different room if necessary. To ensure that everyone Care Homes for Older People Page 30 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 who lives in the home, including people who have dementia, can find their way, have sufficient space in their bedrooms (There own private space unless they have chosen to share a bedroom with someone else.) and are comfortable in the environment. The providers must provide as action plan on how they intend to meet this requirement by the date indicted. 9 27 18 The home must ensure that there are sufficient numbers of staff employed to work at the care home who receive training appropriate to the work they are to perform. Training provided in the home must be adequate to ensure all staff understand how to meet the specific needs of people who have dementia and understand challenging behaviours. Staffing levels and deployment should be reviewed. To ensure there are sufficient numbers of staff who are competent to meet the needs and promote the wellbeing of people who live 31/12/2009 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 in the home. 10 30 19 The registered person must obtain full and satisfactory information in relation to staff employed including an employer reference. To ensure people who live in the home are protected. 11 33 24 There must be an effective 31/12/2009 quality assurance system for evaluating the quality of the services provided at the care home to include and take account of the views of people who live there and other people involved in their care. The annual development plan for the home should be based on a systematic cycle of planning - action - review, reflecting aims and outcomes for service users. To ensure people are provided with a good quality service which meets all their needs in line with their wishes and expectations. 31/12/2009 Care Homes for Older People Page 32 of 34 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 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). 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. Care Homes for Older People Page 34 of 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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