Care Home: Crispins and Loadhams Nursing Homes

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What the care home does well People considering moving into the home can be confident their care and nursing needs will be understood and met owing to thorough pre-admission assessment processes. They receive helpful information about what life is like at the home. Their care is planned with them in a way that takes account of their individual needs and preferences. Health is promoted and they are protected from harm through the safe handling of medication. The home is able to meet the diverse range of needs of the people currently accommodated. Care and support is consistent yet flexible and able to meet their changing needs. The principles of respect, dignity and privacy are put into practice. The activities co-ordinator offers an interesting, stimulating activities programme with input from local entertainers. A local hairdresser visits weekly and social indoor and outdoor events are organised.People using services are supported in maintaining contact with families and friends. The chef visits each person soon after admission to discuss their food preferences and dietary needs. Menus offer a choice of meals and are nutritionally checked. People using services can choose to eat in either of the two dining rooms or in their bedrooms, if they prefer. Both buildings are attractively decorated and comfortably furnished, domestic in character and immaculately clean and hygienic. Suitable adaptations ensure wheelchair access throughout both buildings. The large landscaped gardens are well-maintained. People using services are supported by staff who are trained and competent and protected by robust recruitment procedures. The home`s atmosphere was warm and friendly at the time of the visit. Positive relationships were apparent between some people using services and individual members of staff. There is an open and inclusive management approach and people using services are protected from harm through safe working practices and overall robust quality assurance and quality monitoring systems. Regional and national experts are available within the company for advice and guidance to the home. The manager told us in the AQAA that the two key strengths of the home are its long-serving core group of staff who ensure continuity of services and its ethos which values and respects the views of people using services. Feedback from health professionals in regular contact with the home included comments, " Crispins and Loadhams generate a great atmosphere; friendly and inviting. I find the staff generally happy in their work due to the wonderful Matron who is both authoritative and approachable at the same time". " They try where possible to cater for everybody`s needs and provide a homely and caring environment". Survey comments from people using services and relatives included, " Sometimes they do take care over the smallest things as well as the biggest and it makes a difference". " The level of care is very good, I have a warm relationship with my carers who have taken the trouble to get to know me and my family." "They look after my every need with care and attention. All the staff have become an extension of my family. After living independently and having had a stroke I now need full time care and I am so well looked after here with the help of my family too." Staff comments include, " We provide individual and intelligent care to residents. Friendly relationships with relatives. Staff go about the home singing and laughing as they go about their work. We maintain good standards of care, cleanliness, infection control and safe administration of drugs. Homely setting. Staff retention is good, few have left in the four years I have been here." "The home does very well, I know because I have worked here a long time. Staff I work with are very helpful. The manager is very good, she is the best and I am happy and lucky to work here. " What has improved since the last inspection? Worn carpets on stairs and in corridors have been replaced and there is an ongoing programme of general maintenance and redecoration. The home has managed to acquire good quality furniture and curtains from recently refurbished Bupa homes in the area. This has enabled the home`s management to maintain the environment to an overall satisfactory standard whilst waiting for its own refurbishment and upgrading work. Developments since the last inspection include the practice of giving all new admissions a welcome card from the team and provision of fresh flowers in rooms, on arrival. Care documentation and processes have been standardised and are easier to audit. The AQAA states care planning has improved and staff are more aware of the holistic needs of people using services. The Bupa Menu Master ensures menus meet nutritional needs and the Nite Bite menu offers food and drink 24 hours a day. A new social activities organiser has taken up post. The home strives to promote social inclusion through its activities programme, welcoming people from the local community at some of the home`s social events. What the care home could do better: The registered manager was unable to complete and submit the AQAA when due owing to competing pressures on her time outside of her direct control. These pressures were compounded by delegated responsibilities for overseeing two other Bupa care homes for periods of time. A shortfall in pressure sore prevention practice was identified also medication records. We have been informed by the registered manager that heating problems identified during the visit have been resolved. Survey feedback from some relatives and staff highlighted shortfalls in communication across departments, within the home.The organisation of morning routines was also raised as an area of dissatisfaction. Though some staff expressed opinion that staffing levels were not always adequate this was not the opinion of the majority.Opinions varied about catering standards.On the day of the visit the alternative hot dish on the menu was not available. The need to maintain records of changes to the menu for at least three years was discussed. A major works and refurbishment programme was understood to be planned. Office space is at a premium and in Loadhams this compromises confidentiality. Communal space is limited in Crispins, staff facilities are minimal and the location of the kitchen and laundry facilities in separate buildings creates operational challenges. Loose slates on Loadham`s roof were under investigation and safety precautions had been implemented. Though shrubs and trees had been cut back to improve external lighting on pathways and in the car park, observations confirmed these areas were not well lit at night. A concern raised by a nurse about the security of buildings at night was drawn to the manager`s attention. Potential environmental hazards were also discussed. Key inspection report Care homes for older people Name: Address: Crispins and Loadhams Nursing Homes 43/43a Waverley Lane Farnham Surrey GU9 8BH     The quality rating for this care home is:   three star excellent 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: Patricia Collins     Date: 0 6 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 31 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) 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 31 Information about the care home Name of care home: Address: Crispins and Loadhams Nursing Homes 43/43a Waverley Lane Farnham Surrey GU9 8BH 01252710574 01252719007 ashbya@bupa.co.uk www.bupa.com BUPA Care Homes (CFHCare) Ltd care home 37 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 37 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 : Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Crispins and Loadhams is a care home registered to provide nursing care for up to thirty-seven older people. It is situated close to the centre of Farnham and public transport services are nearby. The home was purchased by Bupa Care Homes, part of the Bupa group in September 2005. It is set in large landscaped grounds with a furnished patio and a sensory garden and has ample car parking space in two car parks. Crispins and Loadhams care home was originally two private houses dating back to the 1920s. They have been thoughtfully and tastefully converted, retaining original period features. Each building offers bedroom accommodation on two floors accessible by Care Homes for Older People Page 4 of 31 Over 65 37 0 Brief description of the care home passenger lifts. The majority of rooms have en-suite bathrooms and are for single occupancy. Communal facilities include dining rooms, lounges and wheelchair accessible bathrooms. Weekly fees range between 742 to 1007 pound. Contractual terms apply for commissioning agencies. Additional charges include chiropody, hairdressing, outings, newspapers, aromatherapy and private physiotherapy. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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: Date of last Key Inspection: 7th November 2007. The unannounced inspection visit formed part of the key inspection process using the Inspecting for Better Lives (IBL) methodology. The visit was carried out by one inspector in just over ten hours. The report will say what we found as it is written on behalf of the Care Quality Commission (CQC). All available information has been taken into account in forming judgements about how well the home is meeting the National Minimum Standards (NMS) for older people. This includes accumulated evidence, knowledge and experience of the home since its last key inspection. Also feedback in survey questionnaires received from five people using this service, eight relatives, ten staff and two health care professionals. Each year providers registered with the Care Quality Commission (CQC) must complete Care Homes for Older People Page 6 of 31 a self assessment called an Annual Quality Assurance Assessment (AQAA) and send this to the CQC. It provides quantitative and numerical information about their service. It requires assessment of services against the NMS outcome areas, demonstrating both areas of strength and where improvements can be made. The AQAAs content was clear, validated by evidence and demonstrated awareness of service strength and areas for development. The inspection visit was facilitated by the registered manager. It incorporated one to one and a group discussion with some people using services and staff. We viewed communal lounge and dining facilities in both buildings, also the kitchen and laundry and sampled bedrooms, bathrooms and toilets. We looked at information received by people considering using the service, to inform their choice of home. Additionally at various policies and procedures also records specific to safe working practices, staff recruitment and training. We sampled care plans, risk assessments, medication records and menus. Practice observations included a handover meeting between staff at a shift changeover, the presentation and serving of lunch in Crispins dining room and medication administration in Loadhams. We sampled a meal and looked at arrangements for meeting the social, cultural, religious and recreational needs and interests of people using services. Care Homes for Older People Page 7 of 31 What the care home does well: People considering moving into the home can be confident their care and nursing needs will be understood and met owing to thorough pre-admission assessment processes. They receive helpful information about what life is like at the home. Their care is planned with them in a way that takes account of their individual needs and preferences. Health is promoted and they are protected from harm through the safe handling of medication. The home is able to meet the diverse range of needs of the people currently accommodated. Care and support is consistent yet flexible and able to meet their changing needs. The principles of respect, dignity and privacy are put into practice. The activities co-ordinator offers an interesting, stimulating activities programme with input from local entertainers. A local hairdresser visits weekly and social indoor and outdoor events are organised.People using services are supported in maintaining contact with families and friends. The chef visits each person soon after admission to discuss their food preferences and dietary needs. Menus offer a choice of meals and are nutritionally checked. People using services can choose to eat in either of the two dining rooms or in their bedrooms, if they prefer. Both buildings are attractively decorated and comfortably furnished, domestic in character and immaculately clean and hygienic. Suitable adaptations ensure wheelchair access throughout both buildings. The large landscaped gardens are well-maintained. People using services are supported by staff who are trained and competent and protected by robust recruitment procedures. The homes atmosphere was warm and friendly at the time of the visit. Positive relationships were apparent between some people using services and individual members of staff. There is an open and inclusive management approach and people using services are protected from harm through safe working practices and overall robust quality assurance and quality monitoring systems. Regional and national experts are available within the company for advice and guidance to the home. The manager told us in the AQAA that the two key strengths of the home are its long-serving core group of staff who ensure continuity of services and its ethos which values and respects the views of people using services. Feedback from health professionals in regular contact with the home included comments, Crispins and Loadhams generate a great atmosphere; friendly and inviting. I find the staff generally happy in their work due to the wonderful Matron who is both authoritative and approachable at the same time. They try where possible to cater for everybodys needs and provide a homely and caring environment. Survey comments from people using services and relatives included, Sometimes they do take care over the smallest things as well as the biggest and it makes a difference. The level of care is very good, I have a warm relationship with my carers who have taken the trouble to get to know me and my family. They look after my every need with care and attention. All the staff have become an extension of my family. After living independently and having had a stroke I now need full time care and I am so well looked after here with the help of my family too. Staff comments include, We provide individual and intelligent care to residents. Friendly relationships with relatives. Staff go about the home singing and laughing as they go about their work. We maintain good standards of care, cleanliness, infection control and safe administration of drugs. Homely setting. Staff retention is good, few have left in the four years I have been here. The home does very well, I know Care Homes for Older People Page 8 of 31 because I have worked here a long time. Staff I work with are very helpful. The manager is very good, she is the best and I am happy and lucky to work here. What has improved since the last inspection? What they could do better: 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. Care Homes for Older People Page 9 of 31 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 31 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people using services and their representatives receive sufficient information to enable an informed choice of home. Their needs are fully assessed before admission to ensure these can be met. Evidence: The home has a comprehensive statement of purpose and service users guide specific to people for whom services are intended. They provide helpful information about what life is like in the home and describe the facilities and services available.The statement of purpose had been recently updated and the service users guide was being updated at the time of the visit. An information pack is given to people enquiring about vacancies.This included a summary of the statement of purpose and service users guide. Inserts included a sample menu, a leaflet about the regulators role and explanation about the national quality star rating system. Information is also provided on how to access a copy of the homes latest inspection report. The pack contains an innovative checklist of what to look at and consider when choosing a care Care Homes for Older People Page 12 of 31 Evidence: home. A copy of the service users guide and statement of terms and conditions of residency is available in each bedroom. The home has a comprehensive care needs assessment document. This provides detailed information about peoples care and nursing needs, daily activities of living and personal preferences. All people using services have the benefit of a preadmission assessment prior to admission, to ensure their needs can be met. For people already in touch with social services or social work departments the initial assessment is undertaken as part of the care management process. The homes management ensures the homes suitability to meet the needs of these individuals before admission. The homes assessment is person centred and shows understanding and respect for diversity. Policies and procedures ensure equal access to services, non-discriminatory practice and respect the rights and beliefs of people using services. Needs assessments are carried out by the manager, deputy manager or other suitably trained nurses. Four care needs assessments were sampled and found to provide a comprehensive overview of individual needs. The assessment process is inclusive, involving people considering using this service and/or their relatives. It is focused on achieving positive outcomes for each individual. Standard 6 was not inspected on the basis that intermediate care services are not provided by the home. Care Homes for Older People Page 13 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people using services receive is based on their individual needs. Medication practice is safe. The principles of respect, dignity and privacy are put into practice. Evidence: On arrival at the home we observed a handover meeting on Crispins.The same process was stated to be replicated in Loadhams. The night nurse sat with the day staff in the dining room and a comprehensive exchange of information took place. None of the people using services were using communal areas at the time. Staff said some people were up and dressed in their rooms, assisted by night staff and were either eating breakfast or waiting for breakfast to be served by day staff. All areas of the home were clean and odour free and the atmosphere calm. The Quest assessment and care planning system used by Bupa homes supports a person-centred approach to care planning. It is based on a comprehensive assessment of needs and risks. People using services and their representatives are requested to complete a Map of Life so staff can get to know each person as an individual. This Care Homes for Older People Page 14 of 31 Evidence: enables them to respond to emotional and social needs as well as physical needs. The standard for completing the Map of Life and Lifestyle plan is within three days of admission. The four care files examined demonstrated an inclusive approach to the care planning process. People using services can be confident their needs are overall understood. Needs and preferences are mostly taken account of. The registered manager is aware of some dissatisfaction with morning routines and is planning to review this to try to accommodate the wishes of people who prefer to get up earlier. Survey comments highlighted this is an issue. A person using services commented during the visit, You cant ask for more but need to be careful not to raise things that arent quite right in the home in case the bosses think its the girls which it definitely is not. You might have noticed they are short of staff so sometimes they get us up late. I dont mind but others do. A relative commented, Getting people up from 10 a.m. will not do, for some their day starts much earlier. All of the care plans sampled were signed and dated by staff and reviewed at least monthly. The registered manager audits a small sample of care plans each month as part of the homes quality monitoring system. The Quest assessment tool offers people using services opportunity to sign their care plans signifying their involvement and agreement. Some care plans were signed others were not, either because individuals didnt wish to be involved in the process or did not have capacity. Practice in the home reflects individual needs under the six strands of diversity. Staff were observed to be professional, respectful and sensitive to the privacy of people using services, in their practice. Their personal appearance demonstrated time and attention to the delivery of personal care, respecting individuals dignity. Healthcare support is effective ensuring access to primary and specialist healthcare and other professionals and services, meeting individual needs. The company has its own specialist nurses and staff can access specialist nursing advice from the local Primary Care Trust. Aids and equipment maximise independence and accommodate changing needs. Mostly the records viewed demonstrated diligent practice relating to pressure sore prevention. The standard is for risk of pressure sores to be assessed within two to four hours of admission. People using services assessed at risk were mostly supplied with suitable pressure relieving equipment. It was concerning however to find nurses had not informed the registered manager that a faulty air flow mattress essential to the health of a vulnerable person at high risk of developing pressure sores, sent for repair three before the visit had not been replaced. When this was drawn to the managers attention during the visit she immediately replaced the mattress with one in a vacant room. The records for this individual did not include a turning chart and though the care plan stated that fluid intake and out put must be monitored, these records were also not evidenced in recent weeks. Care Homes for Older People Page 15 of 31 Evidence: The home has a good record of compliance with its medication policy and procedures. On this occasion however medication prescribed for an individual on Loadhams, for administration as required, could not be found by the nurse in charge. She speculated this could have been discontinued and destroyed and the records were not updated. She stated her intention to immediately follow up. Otherwise the storage, recording and administration of medication was observed to be satisfactory at the time of the visit. Feedback in surveys received from people using services indicated overall good levels of satisfaction with their care. Comments included, They do most things well. They are friendly and look after me well. They used to take me out in the garden when I was able to go out. The home has a nice friendly atmosphere and the environment is very homely. It doesnt have the sterile appearance of other nursing homes. You can always look to find fault but generally they do their best for everyone. Care Homes for Older People Page 16 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using services are treated as individuals and are encouraged to keep in touch with family and friends. They are offered nutritious meals and can engage in a stimulating activities programme. Evidence: Routines are flexible, there is a warm, relaxed atmosphere and staff respect the rights and autonomy of the people they support. One person continues to use local community amenities independently. People using services are encouraged to maintain relationships with family and friends. They have opportunity to engage in meaningful daytime activities of their choice and according to their individual interests, diverse needs and capabilities. Discussion took place with the activities coordinator who is relatively new in post and very enthusiastic and motivating. An activities assistant is also employed. The November activities programme was displayed in both buildings. The broad range of group activities on offer included gentle exercises to music, newspaper discussions, reading groups, religious services including Holy Communion and clothing shows. External input to the programme in November included provision of a Golf activity and singing and dancing entertainers. The home has a collection of reminiscence materials enabling this type of activity. A Pat Dog visits and in the summer outdoor activities are organised, for example, a Care Homes for Older People Page 17 of 31 Evidence: strawberry tea and fete. A mobile library service visits. Photographic evidence of social activities enjoyed this year were displayed in public areas in both buildings. The home works hard to promote community inclusion by inviting the local community to some social events. Activities take place in communal lounges in both buildings. On the day of the inspection a sherry morning and a stimulating quiz was enjoyed by a small group of people using services in Crispins lounge. People using services who responded to our survey said there was always or usually social activities they can take part in. A relative of a person who spend her time mostly in her room owing to her medical condition said occasionally her mother is taken to musical recitals in the home. Staff or family were said to be always on hand to help her.A number of staff expressed opinion that more opportunities for stimulation should be available to people unable to join in group activities, for example those nursed full time in their rooms. Comments included, As in all homes and hospitals more staff would be a bonus as we could spend more time talking with residents. Alas this is financially impossible. We need more staff to spend more quality time with residents. The registered manager said a bank worker does go round spending one to one time with these individuals. She was stated to talk with a read to them and assist them with their correspondence. Records sampled demonstrated the activities organiser also provides one to one stimulation for people unable to join in group activities. It was good to see that staff had thoughtfully seated one person in her room by the window overlooking the attractive garden. She was observed to take pleasure in watching the wild birds feeding on a bird-table. The homes marketing information states regular visits are organised to local places of interest and for shopping. People using services said this was not the case however. This was due to not having any staff drivers for the mini bus the home shares with another Bupa home. The activities coordinator and maintenance person were noted to be imminently about to take a test to be able to drive this vehicle and reinstate community based activities. The home carries out nutritional assessments and monitors the weights of people using services. Records evidenced professional dietary advice and swallowing assessments had been sought for individuals, as necessary.The chef meets with people using services soon after admission to establish food preferences and dietary needs; also times they would like breakfast served in their rooms. People using services can choose to eat their meals in dining rooms or in their bedrooms. At the time of the visit the kitchen assistant prepared the meals. The chef was on leave and the housekeeper who usually covers when the chef is off had reported sick. Catering staff work from 07:00 to 16:00 and supper staff are employed from 16:00 to 19:00 daily. The chef prepares soup and meals for supper before going off duty for supper Care Homes for Older People Page 18 of 31 Evidence: staff to reheat, serve and wash-up afterwards. Though a carer in Loadhams said they sometimes have to wash-up after meals, a nurse said this was not regular, only when the housekeeper is off or covering the chefs duties. The kitchen was clean and organised. It was last inspected by the Environmental Health Department in November 2008 at which time no requirements or recommendations made. The chef prepares a four weekly cyclical menu which offers a choice of hot and cold meals. The menu planning process includes consulting people using services to obtain their suggestions. The Bupa Menu Master points system is used to ensure menus meet nutritional standards. The implementation of the Nite Bite menu is a new development since the last inspection. This ensures food and drink is available throughout the 24 hour period. Water is delivered to bedrooms daily and wine and sherry is served with meals. We joined a group of people using services for lunch in Crispins dining room. The presentation of the dining room was of a high standard and care staff served meals and discretely supported individuals in need of assistance. The meal of frozen fish and chips was served with fresh vegetables in accordance with the menu followed by tinned fruit with cream or ice cream. The hot alternative dish was not available, only the cold option of a ploughmans lunch. Observations confirmed a person on Loadhams whose care plan stated she was on a soft diet was served a pureed meal in error. A record of any changes to the menu was stated to be made however when requested to see past records we were informed these were not kept. The requirement to keep these for three years was discussed with the registered manager. Survey feedback about food was variable. Four people using services said they always like the food, five said they usually did and four said sometimes. Comments included, Our mother has regained her appetite after only having pureed food for so long in hospital. She is on soft food diet plan and eats well. The food is of excellent quality. Meat is tough and sometimes indigestible. Bupas 2008 survey of the views of people using services found 82 overall satisfaction with food. Care Homes for Older People Page 19 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using services are listened to and protected by the homes policies and procedures. Evidence: The complaint procedure in included in the service users guide a copy of which is accessible in all bedrooms and displayed in public areas. The majority of people using services who responded to our survey were aware of the procedure. A group of service users consulted during the visit said they felt listened to and knew who to speak to if unhappy with anything.The home keeps a complaints and compliments log. Four complaints were investigated by the registered manager in the past twelve months. None were upheld. The Quest assessment tool includes a section in which information about capacity is recorded. There are procedures for staff to follow to ensure the homes obligations under the Mental Capacity Act deprivation of liberty safeguards are met. The home has robust policies and procedures for the protection of people using services. These include staff recruitment and training practice, those relating to risk assessment and risk management and for handling the personal finances of people using services. Though the home has a copy of the Local Authority safeguarding procedures the latest edition needs to be obtained. Bupa has a national team of quality and compliance experts available to provide advice and support to the home, where needed. Two safeguarding adults referrals have been received by the Local Authority about the Care Homes for Older People Page 20 of 31 Evidence: home in the last twelve months. The outcome of investigations in these matters is not yet known. Bupa was tasked with carrying out the investigation by the safeguarding team. During the visit a night nurse expressed concern about the security of the building which was communicated to the registered manager, for review. Discussions with the manager confirmed measures in place to minimise risk of intruders. Discussions with night staff confirmed they do not routinely leave the building where they are deployed, during the night. Though effort has been made by management to improve external lighting on pathways and car parks these areas were observed to be not well - lit. Care Homes for Older People Page 21 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using services benefit from a comfortable, suitably equipped environment that is clean and hygienic and has a planned maintenance programme to ensure it is safe. Evidence: Crispins and Loadhams was originally two private houses and both have been tastefully converted and modernised whilst retaining period features. Bedroom accommodation in both buildings is on the ground and first floor, accessible by passenger lifts. Bedrooms are mostly single occupancy with en-suite facilities. Those sampled were nicely personalised and comfortable. Lounge space is limited in Crispins and when activities are in progress in the lounge this can impact on those who prefer to sit quietly in this area. Lounge and dining facilities in both buildings are comfortable. The main kitchen is located in Crispins serving both buildings by transporting meals in a heated trolley. The laundry is located in Loadhams. Bupa is currently consulting architects about the possibility of joining both buildings, enhancing office facilities, providing a staff rest room and new shower room in Crispins. There is currently an ongoing programme of general maintenance and decoration. Through other Bupa homes upgrading programme, Crispins and Loadhams has acquired new furniture and curtains. Since the last inspection carpets have been replaced in corridors and on Care Homes for Older People Page 22 of 31 Evidence: stairs and a shower spray fitted to the washbasin used by the hairdresser. Two wide screen televisions have been hired for the lounges in both buildings. A survey was stated to have been carried out of loose tiles on Loadhams roof and the area directly below was cordoned off for safety. Survey feedback and direct feedback during the visit from people using services and observations highlighted recurrent problems with room temperatures in both buildings. A person using services said in one part of the building in Crispins it is too hot and on the other side of the building the heating can at times be inadequate, particularly in the morning. When the bedroom of this person was visited later with the registered manager the temperature was low and the radiator could not be adjusted. The heating was off in another bedroom where a person was nursed in bed in Loadhams and the room not at a comfortable temperature. The registered manager has since reported the heating has been adjusted throughout the home. Bathrooms, toilets and sluice rooms were hygienic. Throughout both buildings odour management was well controlled and the standards of cleanliness high. Attention was drawn to an offensive odour in an en-suite toilet in Loadhams however which has a recurrent problem with drainage. The home appeared suitably equipped. The registered manager anticipates being shortly supplied with another hoist more compatible with the homes carpets. The large landscaped grounds with patio area and a sensory garden were observed to be well maintained. Care Homes for Older People Page 23 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are trained, skilled and in sufficient numbers to meet the needs of people using services, who are protected by robust recruitment procedures. Evidence: People using services are protected by robust staff recruitment and induction procedures. The files of two new employees were sampled and had all required documentation in place. Vetting procedures had been thorough and included checks with the Criminal Records Bureau. Records evidenced a comprehensive induction for new staff. Staff files contained evidence of all statutory and service specific training relevant to their roles and responsibilities.The homes training coordinator, who was not on duty at the time of the visit, audits the teams training records, ensuring staff are trained and competent. The home exceeds the standard of numbers of care staff with relevant National Vocational Qualifications (NVQ) in health and social care at NVQ Level 2 or equivalent. The staff training programme included specialist training in dementia and management of challenging behaviours. Staff also receive customer services training which develops empathy and understanding of how it feels to live in the home and be the recipient of its services. The organisation demonstrates a high level of commitment to staff training and continuing professional development and has achieved Investors in People status. It was noted during the visit that a number of people have high dependency needs Care Homes for Older People Page 24 of 31 Evidence: and some have communication difficulties. Staff were caring in their approach to these individuals and provided support in a way that promoted privacy and dignity. Comments from people using services about staff included, They provide for all necessities cheerfully. Most things done well. They are friendly and look after me well. The staff skill mix provides a nurse in charge of all shifts in both buildings. Discussions with staff during the visit identified most were of the view that staffing levels are usually satisfactory. Staff comments included, The home has good management, good staff ratio, we see residents receive good care according to their choice. Most carers have NVQ 2 and 3. Anytime we can approach our manager. I am happy with my manager, colleagues, relatives and residents and with my work. We provide care and kindness to residents and keep up with training as far as possible. We workers try very hard to make the residents happy and do our best with help from management. Nurses and care staff consulted during the visit said they did not feel coerced into working overtime to cover shifts, though this comment was made by a staff member who took part in our survey. Whilst some staff do work long hours by choice, those consulted felt their competency was not affected by the additional hours they work. They were aware of how this could affect their health and the safety of their practice and were clear they knew when they needed to take time off. There was evidence of agency staff on duty at the time of the visit. Agency staff reported they felt their induction to the home the first day of working there had been adequate and said they were supported by colleagues. Individuals using services however said not all agency staff were able to meet their needs. This was owing to being unfamiliar with equipment as well as their care plans and personal preferences. One person recalled an agency carer during the night unable to operate her bed-rails. She said she had to wait to use the toilet whilst the carer went away again to request assistance from the nurse in charge. At the time of the visit one nurse was on long term sick leave. Interviews were scheduled the following week for a nurse vacancy and care assistant posts. Whilst turnover of nurses and care staff appeared high the registered manager explained vacancies had been mainly generated when university students employed move on. Recent staff appointments included a weekend cleaner, a weekend kitchen assistant and supper assistant. Care Homes for Older People Page 25 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is effectively managed in the best interest of people using services, providing a safe environment in which to live and work. Evidence: A receptionist works 09:00 to 15:00 during the week in the reception area based in Crispins which is clearly signposted. The registered manager is a qualified general nurse with extensive nursing and management experience and a relevant management qualification. She managed the home between 1995 to 1999 and after a break in service returned to again manage the home in 2003. The management structure includes a deputy manager. At the time of the last inspection this post was vacant and the registered manager fulfilling both roles, supported by senior nurses. The deputy manager who is also a qualified nurse has been in post just over a year and is currently undertaking the Leadership and Management Course. She was on leave at the time of the visit. The registered manager works supernumerary to staffing levels and the deputy manager has some Care Homes for Older People Page 26 of 31 Evidence: supernumerary time. Both managers have clearly defined areas of responsibility. Discussions with staff and feedback in their surveys confirmed the registered manager is held in high regard. She achieved Bupas Business Manager of the Year Award in 2008 for homes under 60 beds. The registered manager is supported by external teams within the organisation; also by internal departments comprising of the care team, administration, activities, catering, housekeeping, laundry and maintenance. Survey feedback from staff highlighted some shortfalls in communication between departments. The manager confirmed regular formal meetings are held with nurses and care staff and informal systems operate for communicating with other departments. She demonstrated willingness to take on board this feedback and plans to strengthen the homes communication systems. For some months prior to this inspection the manager has had significant workload pressures related to safeguarding issues currently under investigation. This problem was compounded by delegated management responsibilities for overseeing two other Bupa care homes for periods of time. This had delayed submission of the homes Annual Quality Assurance Assessment on time. When received, this document was found to be clear, validated by evidence and demonstrated awareness of service strength and areas for development. The organisation has produced clear procedures and there is a training programme to ensure staff are aware and comply with their duties and responsibilities under the Mental Capacity Act 2005s deprivation of liberty safeguards. The homes management is aware of the need for improved office facilities. Lockable storage had recently been obtained to improve confidentiality of records in Loadhams. The need for other records in this office to be securely stored was discussed. Staff need to be very careful about confidentiality when using the phone and speaking with each other in the office area in Loadhams. This is because a bedroom accessed through the office area is left ajar to meet the preference of the bedrooms occupant nursed full time in the room. Effective quality assurance systems ensure people using service receive a quality service. Monthly internal audits are carried out also external audits during statutory visits to the home by the regional manager. The home is supported by a national team of quality and compliance officers whose role also entails carrying out audits, providing guidance on policies, procedures and practice and supporting quality issues. There is a regional health and safety team providing health and safety and fire management leadership.Regular health and safety meetings were also evidenced. The home has an annual internal and external customer satisfaction survey. The Personal Best customer Care Homes for Older People Page 27 of 31 Evidence: service programme encourages a person centred approach to all tasks. The administrator manages any personal allowance accounts on behalf of people using services. Records are made of all transactions which are receipted. A new development in the past twelve months is the open door policy for relatives and people using services to discuss financial issues or documentation with the administrator. Care Homes for Older People Page 28 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 29 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 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 30 of 31 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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