Care Home: Coombe End Court

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What the care home does well Care plans are in place on the day that people come to live at the home. The plans are regularly reviewed and revised as people`s needs change. The daily reports show good information about how staff are meeting and monitoring people`s care and support needs. People are encouraged to make their own decisions about how they live. People choose who provides their intimate personal care. The home makes sure that people who have a period of time in hospital can return to the home knowing that their needs can still be met. People`s healthcare needs are fully met. People have good access to relevant healthcare professionals. Safe systems are in place for managing peoples medication. People can administer their medication following a risk assessment. Care plans identified when and why specific prescribing instruction are made. People live in a purpose built home, which provides them with a pleasant and well maintained environment. People benefit from an effective staff team. They are protected by the way in which staff are recruited. Staff members receive training and undertake qualifications, which helps to ensure that they are competent to do their jobs. Mrs Linsley keeps herself up to date with current good practice with regular training in dementia care provision. During the time she has managed Coombe End Court, Mrs Linsley has demonstrated her ability to improve the service, particularly the environment for people with a dementia and the activities that people are involved in. What has improved since the last inspection? New pre-admission documentation means that a fuller picture of people`s care and support needs can be made. Care plans are more detailed about people`s needs and how they are to be met and monitored. Care plans focus on the positive aspects of people care needs and how they can be supported to remain independent. Staff make sure that people are supported with eating and drinking to ensure good health. Care plans identify how people communicate, particularly those people who may not be able to talk about themselves. People have their risk of developing pressure damage regularly assessed. If people are at risk, strategies are put in place to prevent or reduce the risk. All other risks of daily life are now detailed in people`s care plans. New features and areas of interest have been developed, which have added to people`s enjoyment of the home and gardens. A lounge has been given a 1950s style makeover, so that it is a focus for reminiscence with the people who use the service. What the care home could do better: The full date should be recorded not just the day and month on all records. Body maps should record size and colour of any marks that are found for monitoring purposes. Staff must take steps to save life unless anyone provides the home with a legal Advanced Statement that includes the specific refusal of treatment. Some staff were seen to use poor moving and handling practice, despite all staff receiving training. Soon after our visit Mrs Linsley told us that she had implemented a retraining programme for all staff in moving and handling people. Mrs Linsley also told us that she had provided training in working with people with epilepsy. The organisation does not have a policy on provision of intimate personal care by staff of a different gender. Soon after our visit, Mrs Linsley produced a local policy on intimate personal care being provided by staff of different gender. The home`s quality assurance should be developed further, with the aim of being able to assess the outcomes for people with dementia in a more individual and direct way. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Coombe End Court London Road Marlborough SN8 2AP     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sally Walker     Date: 2 8 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 34 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Coombe End Court London Road Marlborough SN8 2AP 01672512075 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : manager.coombeendct@osjctwilts.co.uk The Orders Of St John Care Trust care home 60 Number of places (if applicable): Under 65 Over 65 30 40 dementia old age, not falling within any other category Additional conditions: 0 0 The home may from time to time admit residents between the ages of 60 and 65 Date of last inspection Brief description of the care home The home was registered on 20th September 2005 to The Orders of St John Care Trust. The home is registered for a total of 60 beds for older people, including a separate unit for people with a diagnosis of dementia. There are 10 beds in the main home registered for dementia. The building was purpose built in 2005 and comprises three named areas: Emerald, Ruby and Pearl. A day service is also attached to the building. Accommodation is all single bedrooms with ensuite toilet and shower. Mrs Susann Linsley is the registered manager. On registration it was agreed that care staffing levels of 1120 care hours per week would be provided. Care staffing levels are 5 care staff in the dementia unit with 20 residents and 4 care staff and a care leader in the main home with 40 residents. At night there are 2 waking night staff to each unit. The weekly fees for the home are between 436.28 and 680.00 pounds a week. Care Homes for Older People Page 4 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: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced Key inspection took place on 28th May 2009 between 9.20am and 5.40pm. Mrs Susann Linsley, registered manager, was present during the inspection. Mrs Jill Mitchener, locality manager, was present when we gave feedback. We looked at care plans, activities, risk assessments, staff training and recruitment records, staffing rotas, medication, quality audits, mealtimes and menus. We spoke with people who use the service and staff. We made a tour of the building. As part of the inspection process we sent survey forms to the home for people who use the service, staff and healthcare professionals to tell us about the service. Comments are found in the relevant part of this report. Care Homes for Older People Page 5 of 34 We asked the home to fill out their AQAA (Annual Quality Assurance Assessment). This is the homes own assessment of how their service is doing. It was filled out in full and returned on time. Some of the information we received can be found in the body of this report. The last key inspection was on 5th June 2007. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the care home does well: What has improved since the last inspection? What they could do better: Care Homes for Older People Page 7 of 34 The full date should be recorded not just the day and month on all records. Body maps should record size and colour of any marks that are found for monitoring purposes. Staff must take steps to save life unless anyone provides the home with a legal Advanced Statement that includes the specific refusal of treatment. Some staff were seen to use poor moving and handling practice, despite all staff receiving training. Soon after our visit Mrs Linsley told us that she had implemented a retraining programme for all staff in moving and handling people. Mrs Linsley also told us that she had provided training in working with people with epilepsy. The organisation does not have a policy on provision of intimate personal care by staff of a different gender. Soon after our visit, Mrs Linsley produced a local policy on intimate personal care being provided by staff of different gender. The homes quality assurance should be developed further, with the aim of being able to assess the outcomes for people with dementia in a more individual and direct way. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 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 9 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be sure that the home will know their needs before they move in. Evidence: Action had been taken to address the requirement we made at the last inspection, that a suitable pre-admission assessment format is used. We said that the assessment must cover all aspects of the persons care needs, so that a full care plan can be produced for them. The organisation had now produced a new system which continued to be developed, following feedback from staff and managers. The home carried out assessments with people who may be referred as an emergency, to ensure that their needs can be met. Mrs Linsley told us that everyone who is considering using the service had an assessment of their needs, whether a care management assessment had been received or not. She told us that anyone who had spent a period of time in hospital would also have their needs assessed to ensure that Care Homes for Older People Page 10 of 34 Evidence: the home could still meet their needs. Care plans were in place on the day that people came to live at the home. One person told us that they had used the respite service many times before they came to live at Coombe End Court. Another person told us that Mrs Linsley had been to see them at home to discuss their care needs. Care Homes for Older People Page 11 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples care and support needs are set out in their care plan, which is regularly reviewed. People choose who provides their care. People have good access to healthcare professionals. Peoples healthcare needs are being met and monitored. Safe systems are in place for managing medication. Evidence: Action had been taken to address the requirement we made at the last inspection that care plans must identify peoples current care needs and how they were to be met. The new care planning format meant that peoples different care needs could be identified, with good detail of how they were to be met and monitored. Care plans focused on positive aspects of peoples care needs, supporting them to remain independent. There was good information about peoples preferred daily routines and how any night care would be provided. We saw a very detailed care plan for someone who needed support with nutrition and eating. There was information about what they preferred to eat and how they should be offered different foods at times other than mealtimes. There was a fluid chart which clearly showed monitoring of their intake. Care Homes for Older People Page 12 of 34 Evidence: One of the care leaders told us that the district nurse had shown them how to test blood glucose levels for those people with diabetes. They said that they then showed other staff how to carry out the tests. Care plans identified how people communicated, particularly if they had a dementia and could not necessarily talk about themselves. We saw that all care plans were regularly reviewed. As there was now an evaluation sheet accompanying each part of the care plan, rather than through the daily report as before, staff were able to better monitor peoples progress. We saw in some daily reports that some staff were only putting the day and month in the record, not the year. Action had been taken to address the requirement we made at the last inspection that people have their risk of developing pressure damage assessed. We said that strategies must be in place to prevent further risk. Everyone had an assessment of their risk of developing pressure damage. People were now assessed when they come to live at the home and monthly thereafter. The document had clear guidance on what must be put in place, depending on the outcome score. People who had been identified with a risk had a detailed care plan showing how their continued good skin health was to be maintained and monitored. We saw that some people had pressure relieving cushions and mattresses when needed. Action had been taken to address the requirement we made at the last inspection that all risks of daily living must be assessed for each person. We saw risk assessments for smoking, pain, falls, moving and handling, bathing and use of a wheelchair. One persons file showed in a body map that they had developed a bruise. The map was dated and the location identified. The care plan for that date did not record the size or colour of the bruise or any record of investigation into its occurrence. We saw that care plans detailed that some people had been assessed as not to be left alone when bathing. People were weighed on admission and regularly each month. We saw from the care plans that any significant changes were reported to the persons GP. We saw from the daily records that staff regularly reported on peoples condition when they were in hospital. We saw that the daily reports had good details of how the care was provided. We saw Care Homes for Older People Page 13 of 34 Evidence: that staff were recording conversations with people and discussing how they felt. There was also good evidence that people were encouraged to make decisions about their lives, even if others wanted to make that decision for them. At the last inspection we made a requirement that a gender working policy is in place for the giving of intimate personal care. We saw that people had been asked about their preferences. Decisions on behalf of those people who could not tell staff their wishes had been made either by their family or by staff based on observations and this life history. We asked people about who provided their intimate personal care. One person told us that they were happy for staff of a different gender to be involved. They also said they could object if they wanted to. There was no policy in the organisations policies file that made mention of how staff were protected from any allegations of abuse when carrying out their role. Soon after we visited, Mrs Linsley produced an in house policy for gender sensitive intimate care dated 04/06/2009. Action had been taken to address the requirement we made at the last inspection that fluid charts must be totalled, to ensure proper monitoring. We saw that those people who spent time in their bedrooms had jugs of juice and glasses within easy reach. This was replaced with fresh juice during the morning. When we spoke with people about visiting their GP, they told us that they would tell staff if they wanted a GP appointment. They said their GP visited them at the home. Another person told us about how the district nurse had visited and provided treatment for their legs. We spoke with one of the visiting district nurses. They told us that they felt that peoples care was good. They said staff consulted them for advice on treatments and would always put that advice into action. They said staff were prompt in referring any concerns to them or their GP. They told us that the district nurses carried out any invasive treatments such as injections. Their colleague had trained care staff in taking and monitoring blood glucose levels for people who have diabetes. We looked at the arrangements for medication. People could administer their own medication following a risk assessment. People had lockable storage in their rooms to keep their medication safe, if they managed it themselves. Only staff who had undertaken training and were assessed as competent gave out the medication. Staff were trained by a senior staff member to administer the medication. New staff were expected to be in post for at least six months before being considered for this role. The consultant psychiatrist had provided training on medication and its effects. Staffs competence was continuously monitored by one of the care leaders. There was a medicine trolley for each of the different wings. Medicines were generally given before Care Homes for Older People Page 14 of 34 Evidence: mealtimes so that meals were not interrupted. Specific prescribing times for taking medication with food were adhered to. The care leader checked the medication records at the end of each medication round. We saw that staff asked some people if they needed their painkillers. Care plans identified specific prescribing instructions and why people were taking medication. There was information in care plans about when to give medication that was prescribed to be taken only when needed. We saw clear guidance on how to give medication delivered via an adhesive patch. We saw guidance about which medication would cause a reaction if taken with alcohol. The medication administration record contained separate information about where to apply topical creams and details about administering eye drops. Controlled medication was appropriately stored and administration records were being satisfactorily maintained. Staff told us that they checked new peoples medication with their GP to establish what they should be taking. Care plans showed details about why some people were prescribed pain killers and other medication, prescribed to be taken only when needed. The care plans were clear about when this medication was to be taken and there were body maps showing sites of peoples pain. Care plans also gave details of application of topical creams with details of where to put the cream and why. Some peoples files had a form entitled Allow a Natural Death Form. Mrs Linsley told us that the forms were newly introduced by the organisation. There were no legally drawn up Advance Statements for anyone living at the home. We referred Mrs Linsley to the Department of Health website where guidance is available on Advanced Statements. We saw that Macmillan nurses were involved with some peoples care. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a range of interesting things to do and places to go. Activities are being developed and increased as a result of a full time activities coordinator. Further activities are being developed specifically for those people who may have a dementia. Visitors are encouraged and made welcome. People enjoy a range of healthy and nutritious meals. Evidence: Action had been taken to address the requirement we made at the last inspection that sufficient hours must be provided for the activities that were advertised. We said that people must be able to access the community as they wished. Over the last two years the number of hours had gradually increased to a full time post of 37 hours. Mrs Linsley told us that she hoped that the budget would be approved for another post so the activities could be further developed. People talked about their social activities during their assessment before they come to live at Coombe End Court. Care plans recorded what people liked to do. There were photographs of people involved in different activities. Some of the activities included a tea dance, VE day,baking and a camel race. The organisation arranged different interCare Homes for Older People Page 16 of 34 Evidence: home activities. There was a separate day service where people could join in with the activities. Mrs Linsley had created a 1950s room on the ground floor in the area for people with a dementia. She told us that people were encouraged to use the room to listen to the radio, handle and talk about the different items in the room. Mrs Linsely told us that she was still collecting relevant items, which may help people to talk about things that had happened to them and how they had spent their working and family lives. Mrs Linsley told us about the work she was doing to set up life histories with people and their families. She showed us two life histories of people who had lived at the home. The families of these two people had agreed that their details could be shared with others and displayed on the notice board. Mrs Linsley showed us the raised beds in the garden where the garden club were growing flowers and vegetables. One person told us they liked to walk in the gardens each day. One person told us that they enjoyed the films that were regularly shown in the main sitting room downstairs. They also told us they had entered the Christmas card competition that the organisation ran each year. Winning entries would be adopted as their Christmas card. We asked people whether they used the computers located by the front entrance and in the sitting room downstairs. They all said they did not use them. Mrs Linsley told us that she planned for these computers to be more accessible to people following training for staff and people who use the service. She told us that she expected the computers to be used more in the future. Currently only two people used the computers. People told us that their visitors were made welcome at any time and offered refreshments. There is a hairdressing salon by the front entrance where people can have their hair done. There is also a small shop where people can buy toiletries, sweets and drinks. Times of opening were displayed. One person told us they could eat their meals in the dining room or in their bedroom. They told us they preferred to go to the dining room to catch up with the gossip and meet other people. They said there was a board in the dining room which displayed the meals for the day. They went on to say that there was always an alternative to the Care Homes for Older People Page 17 of 34 Evidence: two choices if they did not like the menus. They also said there was a big bowl of fruit in the dining room for them to help themselves to. We looked at the menu board. The writing was quite small and could not be seen from a distance. Mrs Linsely said that she would ask the night staff who wrote up the menu board to ensure that it was more legible. We spoke with another person who described the meals as Great. Its always served on time and plenty of fresh veg, which I like. They make a fabulous chocolate mousse. For tea we have various sandwiches or things on toast. I like to have my meals in my room. We saw that people who had come to the dining room in a wheelchair were offered a dining room chair to sit in, so they could get nearer to the table to eat their meal. We saw people having their lunch in the unit for people with dementia. The lunch was either chicken wrap or bacon and tomato puff with two vegetables and potatoes. People were offered a choice of two juices with their meal. The meal was well presented and looked appetising. People were shown the two dishes from which to make a choice. Staff explained each dish. People who did not choose from either dish were offered soup. People who needed help or encouragement with eating were sensitively supported by staff. We met with the chef who told us about peoples contribution to the menus. Each persons favourite meal had been included as The Dish of The Day. The chef said that care staff had asked those people who may not be able to discuss their favourite meals. Some of the examples the chef gave that were included in the menu were prawn sandwiches, steak and meat loaf. The chef told us that vegetables that people grew would be used in the meals. They said that last year people had grown potatoes, carrots and green beans. The chef told us that they used local suppliers for meat and vegetables. They also made all the cakes. The menus showed two choices for lunch course and for the evening meal, except for at the weekends. People could have bacon and eggs for breakfast on a Sunday. The chef told us that they could prepare eggs for peoples breakfast during the week, at any time during the mornings when people were ready to eat. The chef was made aware of individual dietary needs when people first came to live at the home. They gave an example of liaising with one person and their family to provide a gluten free diet. The chef told us about cooking dishes from around the world for people to try. They gave an example of a recent meal of Mexican food. They also said they had introduced some finger food such as goujons, wraps and scotch eggs. They said this was sometimes easier for people with dementia. The chef had undertaken training in Care Homes for Older People Page 18 of 34 Evidence: dementia care. Each of the different units had a servery where snacks and refreshments were available. The chef told us that full fat milk and yoghurts were used to increase peoples nutrition. Care Homes for Older People Page 19 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are listened to by staff and their views are acted on. There are procedures in place which help to ensure that people are protected from harm and abuse. Evidence: A complaints procedure was included in the information given to people when they moved into the home. We were told in the AQAA that the families of the people who use the service were also told about how to make a complaint. This is important because some people who live at the home would not be able to make a formal complaint without support. The complaints procedure was also displayed in the front hall, so that it could be seen by visitors to the home. We were told in the AQAA that the complaints procedure was available in different languages and formats. We asked people we spoke with what they would do if there was something they were not happy with or needed to make a complaint. One person told us they would speak to their daughter. Another person told us There is a form to fill out. I would go to Mrs Linsley, shes often around at breakfast time. Another person told us that Mrs Linsley was the person to go to. In their surveys, several people who use the service told us that they would be able to talk to the staff or the manager if they were not happy with something. People Care Homes for Older People Page 20 of 34 Evidence: commented that they would Look to see who I know and tell them, Find the girls and say and Tell staff. A number of staff members also told us in their surveys what they would do if somebody had a concern. Their comments included I know the complaints procedure and know I can call my manager at any time including the weekends, If any member of staff had any issues we were always welcome to speak to our manager at any time and go to senior or manager. We were told in the AQAA that the home had received one complaint during the last 12 months, and there were currently no unresolved complaints. Mrs Linsley told us about one other complaint that had been investigated and concluded since the AQAA was completed. We looked at the records that the home kept about complaints. There were reports which showed how these had been investigated. The complainants had been kept informed in writing of the action being taken, and about the outcome. Residents meetings were being held regularly. These gave people who use the service the opportunity to express their views and talk about any issues that concerned them. Mrs Linsley told us about how Independent Mental Capacity Advocates (IMCA) had been involved when needed for peoples protection. Mrs Linsley told us that there was also a Dementia Support Group, which looked at the needs of particular people who use the service, including those people who had rooms in Pearl unit. This helped to ensure that the interests of people with dementia were also represented. The staff members we met told us that they had received training in abuse awareness and the safeguarding of vulnerable adults. These subjects were covered during induction and when undertaking a National Vocational Qualification. The homes training programme also included a module about safeguarding vulnerable adults. The organisation had policies and procedures in relation to reporting abuse and whistle blowing. Staff members told us that they had received the No Secrets booklet, which summarises the local authoritys procedures for safeguarding vulnerable adults. We were told in the AQAA that one improvement during the last year had been the provision of dementia training for a number of staff. This had developed staff awareness of potential abuse with people who would have difficulty in reporting this themselves. Care Homes for Older People Page 21 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well maintained home which provides them with a pleasant and hygienic environment. Features and areas of interest are being well developed, which add to peoples enjoyment of the home. Evidence: Coombe End Court is located close to Marlborough town centre and was purpose built as a care home. The home is in its own grounds and set away from the main road. There is large car parking area at the front, from where people have good access to the homes entrance. The needs of older people were taken into account in the homes design and in the facilities provided. This included ensuring that the home was fully accessible and had rails and other aids fitted which people would need to move around safely. Staff call alarm and other systems were in place to assist the people who use the service. All the bedrooms have en-suite toilets and showers. People had keys to their bedrooms if they wanted. Some people had been assessed as not being able to use a key for different reasons. We asked people we spoke with about calling staff if needed when they were in their bedrooms. They showed us their call bell systems which were within easy reach of where they were sitting. One person told us they used the call bell pull in their toilet which was nearer. Care Homes for Older People Page 22 of 34 Evidence: The layout of the bathrooms and assisted baths helped to ensure that they met peoples needs and could be used safely. People told us they could have a shower or use the bathroom nearby. One person told us they liked to have a shower every day. We saw that bathroom and toilet doors could be taken off to gain access if anyone was to fall inside the room against the door. Upon arrival at the home we saw the central communal areas, which included a large front hall, reception area, lounge and a hairdressing salon. These areas looked welcoming and there was a lot of information displayed which would be of interest to the people who use the service, and to any visitors. The lounge was a light and spacious room, which was known as the heart of the home. It had sitting areas and facilities such as an organ, music centre and large screen television, so that it could be used for a variety of social and leisure activities. The rest of the home was divided into three main units. The units had their own communal areas and were relatively self-contained. This helped to create environments which would meet peoples different needs. The doors between floors and all exit doors have coded keypads. Mrs Linsley told us that only staff have the numbers for security reasons. People can access both floors if they can work the lift. We saw that staff helped others to go to the activities room on the ground floor. There were written instructions on how to use the lift. One of the units, Pearl, was specifically for people with dementia. We looked around the unit and saw that there were different communal areas where people could spend their time. One of the communal rooms was being decorated and furnished in a 1950s style. The room, and the items in it, were designed to be talking points and the focus for reminiscence with the people who use the service. There were some personal touches in the unit, such as photographs on the bedroom doors. Staff said that the people who use the service had chosen the photographs, which would help them to recognise their own rooms. The areas of the home that we saw looked well decorated, and thought had been given to making the environment look homely and interesting. In Pearl unit, we talked to staff about how well the overall environment was meeting the needs of people with dementia. Signs and colour had been used to help people find and identify particular areas, such as the toilets. Some staff thought that more could be done in this area, although other people felt that it was more important to maintain a low key appearance. Care Homes for Older People Page 23 of 34 Evidence: One of the lounges in Pearl unit had access to an area of garden. Staff told us that this was enclosed and a safe area for people to use. The main garden at the rear of the home could be reached from the lounge known as the heart of the home. The garden had seating areas and raised beds, so that it could be enjoyed by the people who use the service. Features have been added during the last year and the home had won awards from the organisation for the quality of its garden. There were plans to further improve the garden. The home was inspected by an environmental health officer in January 2009 and was given a five star excellent rating under the local authoritys Food Hygiene Star Rating Scheme. There were no unpleasant odours at the time of our visit. The accommodation looked clean and hygienic. A number of people who use the service told us that they were happy with the overall cleanliness of the home. There was a room set aside for people to smoke without upsetting others. Risk assessments had been carried out with people who smoked. Mrs Linsley told us that the stained carpet in one of the dining rooms was due to be replaced. We asked people we spoke with about the laundry and cleaning services. One person described the cleaning of their bedroom as very efficient. We saw that bed linen and towels were of good quality. Mrs Linsley told us that fresh stocks were regularly ordered. The chef told us that the kitchen staff did their own laundering of kitchen linens, to avoid contamination. They said they had implemented different coloured linen to use in different areas throughout the home, for example, tea towels. Staff members told us that they received training in infection control. They explained that a colour coded system of laundry bags was being used to reduce the risk of cross infection. They also had access to supplies of disposable gloves and aprons. We saw gels and single use soap and drying facilities which also helped to maintain hygienic conditions in the home. Care Homes for Older People Page 24 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from an effective staff team. They are protected by the way in which staff are recruited. Staff members receive training and undertake qualifications, which help to ensure that they are competent to do their jobs. Evidence: Mrs Linsley said that the number of care staff hours provided had been agreed at the time of registration. We were also told in the AQAA that the home had recruited for extra care support hours during the last year. Mrs Linsley told us that she had recruited two part time care support staff. They worked 9.00am to 2.00pm throughout the week. They were involved in serving meals, making beds and other duties which do not involve personal care. Mrs Linsley told us that she had recruited to all the posts and built up a group of bank staff, which had reduced the reliance on agency staff. The hours worked by the activity co-coordinator had also increased from 30hrs to 36hrs a week. In the main entrance hall there were photographs of the staff who were working that day. Staff planned their work during regular handovers. Staff rotas were being written which showed the deployment of all staff throughout the day. Care staff were allocated to a particular unit, but over time gained experience of working in each of the three units. During the day, there were normally five care staff working in Pearl unit, with the same number working between the two other units. The Care Homes for Older People Page 25 of 34 Evidence: staff we spoke to said that these staffing levels were usually manageable. They felt that the staffing levels in Pearl unit usually worked well, but the use of care support staff (who did not provide personal care) sometimes had an impact in the other two units. One staff member mentioned that the need to complete the drugs round also meant that the staff member who did this was not available to support people in other areas. In their surveys, one person who uses the service commented Staff always friendly, caring and helpful. Lots of demands placed on staff, could do with more staff at times. Another person commented Staff very professional and keep my family well informed. A staff member commented We were fully staffed, but we do have times when staff sickness can reduce our numbers. When this happens we use agency staff. This doesnt happen often. But the care of our clients is paramount and we all pull together to ensure our clients were cared for as they should be. We were told in the AQAA that the home was fully staffed, with no agency staff currently being used. One of the visiting district nurses told us They could do with more staff when it gets heavy. We were told in the AQAA that the home had a good record of staff retention. We were also given information about the staff mix; it was reported that the home benefited from a wide age range joining maturity and experience with energy and youth. Other staff were employed to undertake laundry and cleaning tasks throughout the home. Care staff confirmed that they did not need to be significantly involved in these areas. We looked at the recruitment files for three staff who had been appointed since the last inspection. These records were well organised and contained the required references and documentation in respect of Criminal Record Bureau (CRB), Protection of Vulnerable Adults (POVA) list and other checks. A new staff member did not work in the home before their name had been checked against the POVA list, which includes the names of people who should not be working with vulnerable adults. Day staff could work under supervision, before their CRB disclosure was returned. However night staff did not start working until the outcome of their CRB disclosure was known. New staff members undertook a period of induction, before undertaking their full duties independently. This included shadowing experienced members of staff. The staff members we met said that their induction had mostly covered things well. We looked at three staff members training records. Some details of their training and induction had not been kept up to date on the paper records, although Mrs Linsey said Care Homes for Older People Page 26 of 34 Evidence: that the information was now being kept in electronic form. We were given information in the AQAA about the arrangements being made for staff training. It was reported that there was an on-going programme which was developed from individual staff members training needs. Vocational training was provided alongside mandatory subjects such as fire prevention, moving and handling, first aid and infection control. Some staff were in the role of Champion which helped to promote training and good practice in areas such as dementia care, medication and care planning. We were told that all staff had signed up to undertake e-learning in equality and diversity. We were told that training had improved during the last year in the areas of palliative care, end of life care planning and some health related subjects. A training plan had been produced for 2009 - 2010. Training events were advertised on the staff notice boards. Recent training included mental health, managing catheters and testing blood glucose levels. Staff members generally commented positively about the training that they received. Their comments included I attended induction and many basic training courses over the first month of my employment and Always kept up to date with new training and policies relevant to my role. In relation to working with people with dementia, one staff member told us My manager ensures that I attend training courses to give me the correct knowledge to care for our clients. We have a dementia unit and I go for regular updates on this condition. I also meet regularly with other homes to widen my knowledge. I work in the dementia unit regularly and pass on what I have learnt to other staff. Staff members were expected undertake a National Vocational Qualification (NVQ) as part of their development. We were told in the AQAA that the proportion of permanent care staff with a NVQ at level 2 or above was slightly below 50 per cent. This figure had increased over the last year and was expected to rise to over 50 per cent by the end of 2009. All of those people we spoke with told us about their good relationships with staff. One person described staff as Extremely Nice. We saw that staff introduced themselves to people when they met with them. We saw one staff talk to one person who was about to have their meal. They told the person who they were and what was about to happen. Care Homes for Older People Page 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a home that is well managed. The home is run in peoples best interests. Safe systems are in place for safekeeping of small amounts of money people may wish to keep at the home. Systems to protect peoples health, safety and welfare are in place. Evidence: Mrs Linsley has managed the home for more than three years. She came with a good history of improving a specialist home for people with dementia run by the organisation. During the time she has managed Coombe End Court, Mrs Linsley has demonstrated her ability to improve the service, particularly the environment for people with a dementia and the activities that people are involved in. Mrs Linsley is aware of the need to enhance the way the service is delivered, particularly in light of the planned development to increase the service for people with dementia. Mrs Linsley has over thirty years experience of working with older people in care Care Homes for Older People Page 28 of 34 Evidence: homes and in hospital. Mrs Linsley has NVQ Level 4 in management and care and the Registered Managers Award. She also has a qualification in dementia care mapping and is undertaking a Diploma in Dementia Care. All of the people we spoke with told us that Mrs Linsley visited them everyday to discuss how they were. One person told us She defiantly knows us all. We were told in the AQAA that Coombe End Court, as part of the organisation, held the ISO Accredited Quality Assurance Standard. The organisation had achieved the Investors in People award and also carried out its own internal audit of standards in the home. People who use the service were being given an annual Quality Questionnaire. This enabled them to give feedback about the service they received and rate different aspects of the home. The information was then collated, and action planned in response to the findings. We read that the garden and the provision of social activities had been improved following peoples comments in last years questionnaires. There were also the monthly residents meetings when people who use the service could talk about topics, such as the menus, and make suggestions about what they would like. The Dementia Support Group helped to ensure that the interests of people with dementia were represented. This is important because a number of people will find it difficult to pass on their views, and the use of questionnaires would not always be appropriate. We were told in the AQAA that the manager had also attended courses and events, which had helped to develop an understanding of the needs of people with dementia and how these could be best met in the home. People could keep small amounts of cash in the homes safe. Records and receipts were kept of all transactions. Only the administrator and senior staff had access to the safe. The accounts were regularly checked by the manager and the administrator. Although it was clear from records that staff had been trained in moving and handling, we saw two members of staff move a person from an armchair to a wheelchair by lifting them under their shoulders. This move puts the person at risk of dislocating their shoulder. There is also the risk of staff injuring their backs when using this move. Mrs Linsley told us that she would look into the matter and ensure that staff only used moving techniques that they had been shown during training. We saw that moving and handling care plans gave clear instructions on how people should be moved when transferring to different seating positions. We had previously seen two staff supporting Care Homes for Older People Page 29 of 34 Evidence: another person to stand using an appropriate method. Soon after we visited Mrs Linsley told us that she had commenced a programme to retrain all the staff in moving and handling. There was a health and safety checklist for monitoring different area weekly, monthly and annually. Environmental risk assessments had been carried out and were regularly checked by the manager and the locality manager. Care plans identified individual risks to people in the event of a fire. The organisation contracts for maintenance and repair of services and equipment. Care Homes for Older People Page 30 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 31 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 8 12 Staff must continue to save 31/07/2009 life with first aid treatment unless such a statement had been given to them by the person. Any end of life care must be determined by the person and their healthcare professional or an IMCA, who legally acts in their best interests. Any Advance Statements regarding peoples end of life care must be between the person and their GP. The home has no legal right to determine any advanced care. 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 2 7 22 The full date should be used when completing records. The use of signs and colour schemes to assist people with Care Homes for Older People Page 32 of 34 dementia within the accommodation is kept under review. This is to ensure that their use is consistent with guidance produced by organisations who undertake research in the field of dementia. 3 33 The homes system of quality assurance is developed, with the aim of being able to assess the outcomes for people with dementia in a more individual and direct way. 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