Care Home: Culm Valley Care Centre

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What the care home does well Assessment of prospective residents` needs is sufficient to ensure that people will receive the person-centred care they need if they move into the home. People benefit from continued relationships with family, friends and the wider community around them, with good support from the home. They are offered a balanced diet, taken in congenial settings, which promotes their health and social wellbeing. They have homely accommodation that is being improved through ongoing refurbishment and adaptations made in line with people`s needs. The home is being run in the best interests of those who use the service. It`s policies and practises help to ensure people`s concerns are heard, and that they are also protected from harm. Recruitment systems help to protect people from unsuitable staff. What has improved since the last inspection? The home has worked hard since our last inspection to address the issues raised then, to improve the care people receive at the home. No requirements have been made following this inspection. To achieve this improvement, the number of residents was stabilised and kept at a relatively low level, so that necessary changes could be made more easily. Information about the home has been kept up to date, so prospective service users can make an informed decision when choosing a care service. Improvements in care planning and medication management are promoting people`s welfare, with their needs met consistently, in a person-centred way. There is proper provision for meeting the health needs of people living at the home, and they are consulted about their social interests, with efforts made to ensure their life at the home matches their preferences, and satisfies their social and recreational needs. They are looked after by committed staff, who have training to ensure people`s various and changing needs will be met, and so they can fulfil the aims of the home. Staff are caring, respecting people`s dignity and privacy. Unnecessary risks to the safety of people at the home are identified in a timely way and eliminated where possible, to ensure people`s continued welfare. The home has completed improvement work based on the findings of a Health Protection Agency audit, complying with professional guidance to establish good standards of hygiene. What the care home could do better: Continence products should not be visible in people`s rooms, in order to protect their dignity. More action to ensure that staff spend one to one time with people who chose not to participate in group activities would help to reduce some people`s boredom, and reduce the risk of individuals becoming isolated. Improving staff knowledge of the local authority`s safeguarding procedures, especially the agencies with primary safeguarding roles and responsibilities, would help to safeguard people more robustly. All care assistants should undergo an induction of a nationally recognised standard, and a minimum of half of the care assistants should achieve a recognised care qualification (NVQ2 in Care, or higher), to ensure people can be in safe hands at all times. The home would benefit from the registration of a manager, in order to confirm the home will be run by a person fit to be in charge, as well as to to provide longterm stability and direction. We have recently received the application to register Mrs Mantle, the acting manager. Key inspection report Care homes for older people Name: Address: Culm Valley Care Centre 10 Gravel Walk Cullompton Devon EX15 1DA     The quality rating for this care home is:   two star good 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: Rachel Fleet     Date: 3 0 0 9 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 36 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 36 Information about the care home Name of care home: Address: Culm Valley Care Centre 10 Gravel Walk Cullompton Devon EX15 1DA 0188433142 0188432846 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Ashdown Care Limited care home 56 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: On the termination of the placement of any of the named service users the Registered Person will notify the Commission and the particulars and conditions of this registration will be altered. Registered for up to 6 people Intermediate Care (50 years and above) The maximum number of placements including those of the named service users will remain at 56 To admit one named persons outside the categories of registration in the category DE[E] as detailed in the notice dated 31st July 2006 Date of last inspection Brief description of the care home Culm Valley Care Centre is a 56-bedded home, with accommodation over three floors, which provides nursing care for people over 65 years of age. This includes convalescent, respite and continuing care. The home can also offer accomodation to people who need care but who do not have nursing needs. Care Homes for Older People Page 4 of 36 Over 65 56 56 0 0 0 9 1 0 2 0 0 8 Brief description of the care home It is a few minutes walk from Cullomptons high street amenities, being situated just behind St Andrews Church. Besides a car park at the entrance to the home, there is parking elsewhere on site. Each floor has a lounge with a dining area. Of the 44 single bedrooms, most are ensuite. There are also 6 double rooms. Some rooms overlook the spacious and level landscaped garden, with patios accessible from the first floor corridor and some residents rooms. There is a shaft lift between floors, and level access on each floor. The cost of care was 350-700 pounds per week at the time of this inspection, depending on the needs of each individual. Additional costs, not covered in the fees, include chiropody, hairdressing and personal items such as toiletries and newspapers. Our previous inspection reports are available in the reception area. Care Homes for Older People Page 5 of 36 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: two star good 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 key inspection took place as part of our usual inspection programme. Our unannounced visit to the home took place over 8.5 hours on a weekday. Louise Delacroix and Rachel Fleet, Regulatory Inspectors, undertook the visit. A questionnaire (the Annual Quality Assurance Assessment, or AQAA), sent by us to the home ahead of our site visit, was returned by Margaret Mantle, the home manager. She was not present for our visit, so we were assisted by Marlene Butler, Operations Manager for the company that own the home, and Paula Burtoft (registered manager of another of the companys homes). The AQAA included the homes assessment of what they do well and any plans for improvement, as well as information about the people living at the home, staffing, policies in place, and maintenance of facilities. We had also sent surveys to the home for them to give to 10 people living at the home and to 10 staff, and seperately to 5 community-based health or social care Care Homes for Older People Page 6 of 36 professionals. We received surveys back from 7 people living at the home (4 of who were were helped by relatives to complete the survey), from 5 staff and 3 healthcare professionals. Responses were generally positive. During our visit, we looked at various aspects of the care or support people living at the home receive, and at administrative matters such as health and safety, staff recruitment and training, and quality assurance systems. We spoke in depth with 5 of the 20 people who were living at the home, and chatted with others as we looked around the home, meeting some who were unable to give their views verbally because of their frailty. We also spoke with 2 visitors. We found out what it was like living at the home from them, as well as by talking with 7 staff (ancillary staff, nurses and care assistants), and by looking around the home. We case-tracked 3 people, which meant we looked in more depth at their care. They included men and women, people new to the home, people with complex or changing needs, and people at the home for a short stay. We read their care records and other relevant information - medication records, personal monies records, etc. We met them, observed some of the support they received, spoke to staff about their care and other matters, and looked at the accommodation with regard to their needs. We ended the visit by discussing our findings with Paula Burtoft and Marlene Butler, who had assisted us fully through the day. Information included in this report is from all these sources, as well as from communication with or about the service since our last inspection. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? What they could do better: Continence products should not be visible in peoples rooms, in order to protect their dignity. More action to ensure that staff spend one to one time with people who chose not to participate in group activities would help to reduce some peoples boredom, and reduce the risk of individuals becoming isolated. Care Homes for Older People Page 8 of 36 Improving staff knowledge of the local authoritys safeguarding procedures, especially the agencies with primary safeguarding roles and responsibilities, would help to safeguard people more robustly. All care assistants should undergo an induction of a nationally recognised standard, and a minimum of half of the care assistants should achieve a recognised care qualification (NVQ2 in Care, or higher), to ensure people can be in safe hands at all times. The home would benefit from the registration of a manager, in order to confirm the home will be run by a person fit to be in charge, as well as to to provide longterm stability and direction. We have recently received the application to register Mrs Mantle, the acting manager. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 36 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 36 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. There is current and comprehensive information about the home, assisting people to make an informed decision when choosing a care service. Assessment of prospective residents needs is sufficient to ensure that people will receive person-centred care if they move into the home. Evidence: Information about the home, provided in the Statement of Purpose and Service User Guide, had been updated and kept under review since our last inspection. We had been sent the revised version, as is required by regulation. We saw the Service User Guide was provided in all bedrooms. This ensures that people have access to good, accurate information about the service offered by the home. Of 7 surveys returned to us from people living at the home, 5 said they had enough information pre-admission to help them make an informed choice about living there, with 2 saying they did not. Four people said they had been given written information Care Homes for Older People Page 11 of 36 Evidence: about the homes terms and conditions; 2 said they had not, with 1 answering Dont know, but since some were anonymous surveys, we could not follow this up fully. The AQAA included that prior to making a decision abut moving into the home, people can spend time in the home - for an afternoon or for a trial period, for example. The assessment of prospective residents needs is always undertaken by a qualified nurse, normally the manager or senior nurse, who try to meet people in their current accommodation. If a place can be offered at the home, a letter is sent to them confirming the home can meet their needs and an admission date is agreed. If someone is admitted to hospital after their admission, a re-assessment of their care is carried out by the home while they are still in hospital, to ensure it would still be able to meet their needs. One person admitted due to very difficult circumstances said the manager had been super. They noted a great improvement in the home since they visited it some years ago. Their next-of-kin had been able to choose their room on their behalf. The homes current newsletter welcomed people new to the home. When asked about the sufficiency of the homes assessment arrangements and subsequent planning of a service for individuals, responses in surveys from 3 community health professionals - each in different roles - varied from Always to Sometimes. We looked at the homes pre-admission assessment for someone admitted to the home since our last visit. There was very detailed information about how their particular and various needs were to be met, in line with the individuals personal preferences. Their health conditions were noted, and the equipment they required. We saw the pre-admission assessment form had been updated to include considerations under the Mental Capacity Act regarding individuals decision-making and wishes. There was evidence of close liaison with the persons previous carers to ensure staff could meet their needs as was done previously, helping a smooth transition to the new care setting. We noted that for an emergency admission, an assessment was done over the phone, with further assessment of the persons needs on their arrival. The assessment included their cognitive functioning, medication, risks of falling, malnutrition and pressure sores, as well as their personal needs and how they were to be met. Their dietary preferences were recorded. All this information had been used to produce a very detailed, precise assessment about the persons preferences and dislikes in relation to aspects of their day and care - such as positioning in bed, and use of equipment. There were individualised care Care Homes for Older People Page 12 of 36 Evidence: plans relating to their health needs. Care Homes for Older People Page 13 of 36 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. Improved care planning and medication management promote peoples welfare, with their needs met consistently and safely, in a person-centred way. Peoples dignity and privacy is generally respected. Evidence: Surveys from people who lived at the home were generally positive about the care they received, answering always or usually when asked if they got the care and support they needed, and if the home made sure they got the medical care they needed. One person commented Care, when asked what the home does well; another said I feel I can always ask for help if I need it. Those we case-tracked were aware of their care plan or said that staff discussed their care needs with them. Staff surveys showed staff felt they were usually or always given up-to-date information about peoples care and support needs. Those we spoke with clearly knew the particular needs of people we case-tracked - in relation to their diet, health problems, mobility, etc. - as indicated in their care plans. Care Homes for Older People Page 14 of 36 Evidence: Care plans were very detailed and person-centred in general, giving peoples abilities and usual level of independence, reducing risks that staff would intervene unnecessarily and take away peoples independence. Individuals variable needs and subsequent care were well noted - for example, that someone was to be asked daily if they wanted to wear their dentures, or when someones ability to communicate could vary. However, we noted there was no plan relating to mental health needs or social needs for someone originally admitted in an emergency. There was a Social profile written for another person which listed their interests, hobbies and that they used to go to church before moving into the home. Yet the subsequent care plan did not mention these interests when suggesting what staff might chat to the person about (now they were too frail to physically undertake those hobbies), and there was no reference to meeting any faith needs. For a third person, a care plan identified that they might be at risk of isolation and how this was to be minimised, but it had not been updated since the person lost a close companion. We found Life books in peoples bedrooms, which gave their preferences (including their daily routine and any variations on certain days), dislikes, important facts about their life to date, and had photos of the individual at various activities, outings or events organised by the home. People we met looked well cared for in that their personal care needs were attended to. We saw staff checked on them at intervals when not giving personal assistance. Someone we case-tracked was being cared for in their bedroom. Their fluid and diet intake was being monitored, because care assessments had shown they were at risk of not drinking or eating enough. This was being managed well. Fluid intake totals over recent days showed the person was having a reasonable amount to drink over time. Occasionally staff had recorded information on the fluid chart that wasnt reflected in daily care notes - such as when the person did not want to drink for a reason that might require further action by staff. We saw staff assisting them with their meals appropriately, positioning them well, and using a small spoon for their pureed meal so as not to overfill the persons mouth. They talked to the person, as well as encouraging them to eat. Their care plan included guidance on how this persons weight loss or gain could be measured despite the fact that they were too frail to be weighed. A turns chart had also been completed in the persons room, for recording and monitoring that this particular aspect of care was given as required for that individual. Care Homes for Older People Page 15 of 36 Evidence: We were told by people living at the home that the staff responded promptly when they were in pain, seeming to understand their difficulties with pain, and were available throughout the night. There were clear, very person-centred care plans relating to pain for people we case-tracked. For one person, a measurement scale was used, with descriptions of their medication and what specific pain each medication was for, promoting continuity of care as well as enabling staff to detect any new cause of pain experienced by the person. One person with more complex health needs felt staff were mindful of their difficulties, understanding their condition and how it affected them. People told us that staff were observant, noting if people looked unwell or felt under the weather, and calling the GP accordingly. Surveys from 3 health professionals indicated they thought the home usually monitored peoples needs, reviewed and met them properly, seeking advice and acting on it. The AQAA stated that a GP made weekly visits for non-emergency matters. Visits, advice or other input from community-based health professionals was recorded well, with cross-referencing to care plans and other relevant records, so that staff would be led to full information on any one matter. We saw staff used a very detailed form for assessing peoples wounds, so that any improvement or deterioration could be measured easily. One person who needed a special diet for health reasons said all staff were aware of this. We heard a care assistant arranging to get breakfast for someone who had it later than other people because of their particular health care needs. Asked in a survey what the home did well, one person commented Give me my medication, as they had particular needs. Where someone was partly self-medicating, we saw a risk assessment had been carried out to ensure they could manage this appropriately and safely. We noted staff had left peoples prescribed skin creams on bedroom radiators, exposing them inappropriately to heat. Senior staff said they would ensure this issue was addressed promptly. The temperature of the fridge used for storing medication had been monitored, including minimum/maximum temperatures, showing correct storage temperatures were being maintained. Since our last visit, the home has introduced excellently used, clear charts for the recording of skin cream applications. These stated what the particular prescribed preparation is for, where it is to be applied in relation to each individual, how much, and for what period of time. These creams and other items had been dated on Care Homes for Older People Page 16 of 36 Evidence: opening, enabling staff to monitor their shelf-life thereafter as recommended by manufacturers. Medication stock levels were more appropriate than at our last visit. We found controlled drugs were being stored securely, with relevant records kept of receipts and administration, and stock levels correlating with the records. Handwritten directions on medication administration charts had been signed by two staff to verify the accuracy of what was written. Peoples allergies were also recorded on these sheets. No issues were found in relation to recording of medication given where a variable dose had been prescribed. Staff we asked confirmed that their practise was observed as part of routine staff supervision, to ensure that they were using correct procedures. We noted one persons care plan said they might refuse their medication. It would be good practise to include clear guidance as to what staff should do if the person refuses, including when the GP should be contacted, etc. Surveys from 3 health professionals indicated they thought the home usually or always respected peoples privacy and dignity. People that we met during the day looked appropriately dressed and well cared for, with clean nails and brushed hair, for example. People were supported discretely to use the toilets. We heard staff addressing people as they entered their rooms. People told us that staff respected their privacy. We discussed with senior staff whether Do not disturb signs on bedroom doors would be useful, as some people in their bedrooms could not make their response heard if someone knocked on their door. We also discussed that packs of incopads were still very visible in some peoples rooms, which does not promote dignity. Care Homes for Older People Page 17 of 36 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. Arrangements are being established to meet peoples social and leisure needs on a regular basis. They benefit from continued relationships with family, friends and the wider community around them, which are supported by the home. They are offered a balanced diet, taken in congenial settings, which promotes their health and social wellbeing. Evidence: Of 7 surveys from people who lived at the home, 5 said there were always or usually activities, arranged by the home, that they could take part in; 1 said sometimes, and 1 person didnt answer. Since our last visit, the home has employed a regular activities person, who has shown a strong commitment to meet the interests of the people living at the home. For example, supporting someone to write a letter, playing peoples preferred music, and - as someone who lived at the home told us planning a gardening club. Records show how peoples interests are recorded, and the work done to try and meet these interests. Records were well worded, with good summaries of peoples responses to activities. We saw that the home is visited by external groups, such as the Donkey Sanctuary. There has also been a focus on creative activities within the home, such as making Care Homes for Older People Page 18 of 36 Evidence: chutney. On the day of the inspection, people were offered a taste of the different chutneys and discussion took place about the labelling and style of the pots. These type of discussions showed that carers held information about peoples past lives, which they could relate to current events. When we spoke with the activities person, they could describe peoples personal preferences, and we observed people making these choices during the day. For example, a person who enjoyed watching the activity but chose not to participate. We saw other staff members involved in playing bowls with a group of people, and the atmosphere was light hearted and encouraging. Generally, time was spent on group activities. Some people chose not to come out of their rooms, some giving health reasons for this. We saw from records that the activities person greeted them each day. One person said the activities organiser came to see them in their room, bringing puzzles that the person enjoyed doing. They said they had enough to do with their time, but another person remaining in their room said they got bored. Staff we spoke with referred to volunteers visiting people in their rooms, etc. Senior staff said that there were no volunteers as such, but a visiting lay preacher chatted to people whilst visiting those with faith needs. Dates of church services to be held at the home in coming months were displayed on a notice board. We found a newsletter, which included the current Activities programme, in peoples bedrooms, which was in large print and clearly presented. It gave news of the homes Summer fete, and that items made by residents would be on sale at the harvest celebration. We discussed trips outside of the home with the staff. We were told that these did take place but not on a regular basis as people often chose not to participate. One person we spoke with said they would like to go on outings but just for a ride rather than to go to a specific place. One person commented, when asked what the home did well, that they make visitors feel welcome. People told us that there was no restriction on visiting times, that their visitors were made welcome, and given a cup of tea, etc. This confirmed information given in the AQAA. One person wasnt aware that the home had invited visitors to the harvest celebration, but they correctly thought this information was in the newsletter they had not read yet. We noted that photos and flower arrangements were positioned within the sight of people sitting in their rooms or cared for in bed, so that they could appreciate and benefit from them. Care Homes for Older People Page 19 of 36 Evidence: Surveys from people who lived at the home indicated staff always or usually listened and acted on what they said. Surveys from 3 health professionals indicated they thought the home usually supported people to live the life they chose wherever possible, and responded to their diverse needs. We spoke to people living at the home about how they exercised choice in their daily lives. Several told us that they preferred to spend time in their own rooms rather than participating in the organised activities. They told us staff respected this choice, but that generally they were informed of events in the main lounge in case they changed their mind. Staff we spoke with reflected this flexible approach. Throughout the day, we saw good practise from staff who listened to people and their preferences. For example, enabling people to choose what they ate and drank, where they sat and who they sat with, as well as how they spent their time. Staff offered people the biscuit tin, rather than just giving them biscuits with their drink, so that they could choose for themselves. People told us that they were offered choice regarding the meals they ate, and we saw staff taking time to ensure that people were clear about the choices on offer. We saw a member of staff asking if a person with dementia wanted help with cutting their meat. When this was not understood, they changed the words they used and then mimed the action of cutting. The person then understood their offer of help and thanked them. We saw that staff took time to check peoples choices, and staff would make choices for those people who were unable to specify, by giving suggestions based on their observations of peoples preferences. Staff told us about a few people who were assisted to get up by the night staff, being clear with us that this was the individuals choice and not for staff convenience. One of these people confirmed they liked to get up very early, telling us that night staff brought them a cup of tea first. We noted that staff ensured people in their bedrooms had their call-bell within reach, asked if they wanted their TV on, and checked people were ok before they left them. One person cared for in bed confirmed that staff remembered to leave things the person might want within their reach. We sat in the dining area when lunch was served. The meal was well presented, and we heard somebody commenting on the quality of the beef - saying that it melts in the mouth. Staff went round to individual tables with serving dishes, so that people could choose the quantity of vegetables they wanted. The tables were attractively set, and we saw some people choosing who they sat with, laughing and joking with them. The atmosphere was calm and relaxed. Care Homes for Older People Page 20 of 36 Evidence: Staff were attentive, discretely offering help and picking up on peoples verbal requests or their body language. Some people were assisted with their meals and staff maintained good eye contact whilst sitting with them; they ensured that they offered support at the individuals pace, which is good practise. We saw that people were provided with suitable equipment such as plate guards to promote independence. We heard senior staff being informed about concerns that someone had not eaten well and the seniors recognition that the person was tired and not their normal self. Surveys from people living at the home said they always or usually liked the meals at the home; 2 people responded Food when asked what the home did well. Four people that we spoke to said that the food was generally good, but one person said that it would be helpful to have a menu for people who spend more times in their room. One person who ate in their room said their food was often cold. Another person said that they were a fussy eater and that the cook had understood, providing suitable alternatives to the general menu. We were told that the menu is being reviewed, and we saw from surveys and the minutes from a meeting that people have been asked for their opinions on the food served with request for ideas. Someone said they hadnt had a response to their survey yet, but they had also spoken with the cook, and were now being given things that suited them better. The cook also told us that someone who often changed their mind was now asked what they wanted to eat on the day rather than the day before. Lunches for the week of our visit included liver & onions, spaghetti bolognaise, and fish & chips on Friday. The light snack at teatimes included scrambled eggs, jacket potato, cheese scones, fishfingers, omelettes. We were told that the cook was on duty until 7pm, so people didnt have to choose what to have for tea in advance, choosing at the meal itself what they wanted. At the bottom of the menu on display, it was written that people could request a salad for lunch or tea instead of what was listed. One person told us they were given a choice at meals but also knew they could have an alternative if they wished. Care Homes for Older People Page 21 of 36 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. The homes policies and practises help to ensure peoples concerns are heard and that they are also protected from harm, although improving staff knowledge of local procedures would help to safeguard people more robustly. Evidence: Of 7 surveys from people living at the home, 5 said they knew how to make a formal complaint, with 2 saying they did not. The 3 surveys from health professionals said the home usually or always responded appropriately if they or others raised any concerns. All staff surveys indicated they knew what to do if someone had concerns about the home. One person we spoke to said they knew how to make a complaint and felt they could speak to staff about their concerns, but was unclear who the manager was if they wished to take the complaint higher. Other people told us that the manager was approachable and they would tell her if they had any complaints, adding she would listen to them. We saw that the home had a well displayed complaints policy, which was clearly worded and included contact phone numbers for senior staff as well as the responsible individual for the company who owned the home. The AQAA stated the home had received 2 complaints in the last year, 1 of which was Care Homes for Older People Page 22 of 36 Evidence: still being dealt with. It also included Management appreciates that occasions arise when service users and their relatives may not be satisfied with the service provided. Such instances are viewed in a positive manner and used as a means to reflect on the services provided and as an opportunity to develop. No-one who returned a survey opted to speak with us. We have received one anonymous complaint since our last visit, which related to staffing levels, how staff arrangements were being managed and the effects of these on aspects of care or support people received. The provider provided us with a full report of their investigation into the complaint, as we requested, and which we thought was done thoroughly. The complainant told us that they would contact us again if they felt matters did not improve, and we have heard nothing further. One safeguarding alert has also been made, by senior staff at the home. This was dealt with under the local authoritys safeguarding procedures, with full co-operation from the home. We saw that the home had an appropriate policy in place for promoting good safeguarding practise. We discussed the content with the Operations Manager who confirmed that the style of the wording was to ensure that staff raised safeguarding concerns immediately to people higher in the organisation to ensure that the right approach was taken. Staff we spoke with could identify different forms of abuse and situations when it could occur. They were less clear on what external agencies any concerns should be reported to if necessary, not certain where they might find such information, with some suggesting they would speak to a nurses union or ourselves, for example. One person confirmed they felt safe with the staff, regarding both their skills and the staff members as individuals. They also confirmed they had a lockable facility in their room, for safekeeping of valued items. We saw records were kept in lounge areas that showed staff checked these areas regularly to see that people there were safe and comfortable when no staff were based there. Senior staff told us that where someone was unable to use a call bell because of their frailty, the turn chart was used also as a way of monitoring that staff checked on the person regularly. Care Homes for Older People Page 23 of 36 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 benefit from homely accommodation that is being improved through ongoing refurbishment and in line with peoples needs. Evidence: People we case-tracked were generally satisfied with the facilities in their bedroom such as lighting, heating, etc. We discussed an issue with ventilation in one persons room with senior staff, which they said they would get the handyman to look into. A couple of occupied rooms had curtains that needed some re-hanging. A vacant bedroom was being refurbished, indicated by the AQAA as customary practise. Some bathrooms and toilets were still quite clinical and not very welcoming, being used for storage of equipment also. Senior staff said they would look at this in the ongoing refurbishment plans. A quiet room has been created since our last visit, and grab rails have been fitted along corridors. Staff felt they had the equipment, adaptations and aids needed to care for current needs of people living at the home. They told us that when a new piece of moving equipment was needed by someone, the home obtained it quickly. Staff also told us that repairs were addressed quickly, and that breakdowns were rare. We saw that the home carried out regular safety checks, which were up to date and Care Homes for Older People Page 24 of 36 Evidence: well recorded, such as checks for Legionella. People who lived at the home felt it was kept sufficiently clean, as we also observed generally during our visit. Asked in a survey what the home did well, one person commented Keep the rooms clean. All bedrooms had clean glasses and jugs of water. We noted that commode pans we saw in bedrooms werent always thoroughly clean, or emptied promptly, possibly contributing to malodours in certain rooms. Senior staff said they would follow this up. The laundry area was orderly. The 2 washing machines had appropriate programmes for thorough cleaning of soiled laundry, and staff working there indicated they knew which to use. Specialist bags were used for transporting and washing of particularly soiled items. At our last visit, the home were still taking action to address a Health Protection Agency report on the home, a report that the service had requested be compiled. Senior staff confirmed they had been in contact with the agency in June 2009, with regard to this and that all recommended actions had been completed. Monthly audits were carried out for infection control matters, including staff knowledge, and regarding fixtures and fittings. Staff we spoke with described appropriate measures that they used to minimise cross-infection risks. Care Homes for Older People Page 25 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements have recently been made to staff numbers and staff development, but aspects of training are not yet sufficient to ensure people receive safe and appropriate support or care at all times. They are protected from unsuitable staff by the homes robust recruitment systems. Evidence: When we arrived, there was a nurse on duty with 4 care assistants for the morning shift, with the visiting manager also assisting and available, looking after 20 people (18 of who had nursing needs). The care staff were supported by a cook, a laundry assistant and a domestic staff member; we were told there were usually 2 domestic staff on duty. During the afternoon, there were 3 care assistants with a nurse, rising again to 4 care assistants for the evening. Overnight there would be a nurse with 2 care assistants. The weeks rota showed these levels were maintained on all but one occasion when no-one was rostered for the new twilight shift. The AQAA stated that no agency staff had been used in the previous 3 months. We observed staff in communal areas providing good quality care and responding to people in an individual manner so that they changed their approach to suit the persons needs and personality. Staff showed that they were skilled at providing reassurance and listening to people living at the home. The majority of the time, we saw that staff took time to ensure that people understood what was happening around Care Homes for Older People Page 26 of 36 Evidence: them, although on two occasions a staff member moved somebody quickly and without giving eye contact, which resulted in the person calling out Where am I going?. However, generally people were moved in a careful and considered way. We saw several cards and letters of thanks displayed on a notice board. People that we spoke to praised the staff and their approach. As we walked around the home, we overheard conversations of staff with people in their rooms, and we could hear that there was a good rapport between them. Feedback from surveys stated that staff were friendly and welcoming, and someone said that staff were kind and caring. One person felt staff didnt have time to stop and chat; another told us that they felt they were looked after as well as possible given staffing levels. One person we spoke to said that staff responded promptly to their call bells. But another person, who needed 2 staff to assist them, said that if staff were already assisting someone else who needed 2 staff to help them, they could wait a while to receive assistance. A second person who needed help from 2 staff for moving felt they had to wait for assistance, even when they only wanted something that could be done by one person. When asked what the home could do better, one person commented in a survey that staff could check on people in their rooms more often, and that call bells could be answered more promptly. Of 5 surveys returned by staff, 3 said there were usually enough staff to meet peoples individual needs, 1 said sometimes, and 1 said Never. Someone who lived at the home commented that staff seemed shattered, and felt 1-2 more staff would be beneficial. Another comment was that it would be particularly appreciated if staff could go to people punctually at any previously agreed times. However, we were also told by one of these people that they were rarely cared for by agency staff, and that staffing levels had been increased recently. Staff confirmed that there was now an extra staff member on duty - in the evening usually, although it might be a morning shift if the need was greater on a particular day. They said this had been organised in response to staff suggestions, and was working well. One staff said afternoons were relatively short-staffed, but then added this meant that the nurse in charge had to help with hands on care. They also told us that there were enough staff to assist people at meals in a timely way, especially as the Activities organiser also helped. We saw that different staff groups worked alongside one another and the people living at the home. For example, the staff that work in the reception and office are at ease with the people living at the home and conversed with people as they worked. Care Homes for Older People Page 27 of 36 Evidence: Some staff we spoke with had worked at the home for several years, with only a few recruited in the last year - we were told by several staff that only two people have been recruited since our last visit. Recruitment records were well kept, with all the required information in place before people started work, such as written references, full employment history and police checks. We also saw evidence that professional visitors to the home, such as the hairdresser, have had police checks to confirm their suitability. A new staff member confirmed they had shadowed colleagues initially, and felt well supported. However, there was little evidence that they had completed the recommended induction, of a nationally recognised standard. Of 3 health professionals surveys (- all being in different roles), 2 said the staff usually had the skills and experience to support peoples needs, with 1 saying sometimes. Of 5 staff surveys, 3 said they usually or always had the support, experience and knowledge to meet peoples diverse needs, whilst 2 said sometimes. All 5 thought they had training relevant to their role, that helped them understand and meet the needs of people they were looking after and which kept them up to date. Of 20 care staff, 9 had a recognised care qualification, and the rest were undertaking the course, according to the AQAA. The Operations Manager told us that one company provides training for staff and that this arrangement worked well. This includes mandatory training, and additional training such as caring for people with dementia, which staff we spoke with confirmed they had undertaken. Six staff had undertaken an accredited course on dementia, with more booked to undertake it. We also saw that health professionals have provided training for working with people with a swallowing difficulty. We looked at the training records for three staff who have different roles in the home and saw that they had training appropriate to their job. We also saw that staff have access to one to one moving and handling training for specific types of equipment. Some staff told us they had had training or updating on safe working practises, but not on conditions relating to people they cared for. One care assistant, however, told us that the nurses would discuss health conditions such as diabetes or multiple sclerosis, and go through the individuals care plan, to help other staff care for people with such conditions. Mental Capacity Act training is provided, and the Operations Manager showed us policies linked to this area of care. She was clear that currently nobody at the home Care Homes for Older People Page 28 of 36 Evidence: required an assessment under the Deprivation of Liberties Safeguards, but was also clear about when this would be appropriate. Nurses that we spoke with confirmed that they were enabled to undertake the training necessary for maintaining their nursing registration. One had had an update on diabetes on an NHS-run course, for example. They also told us that the home checked their registration was still current, with the registering body for nurses. Care Homes for Older People Page 29 of 36 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is being run in the best interests of those who use the service, although it would benefit from the registration of a manager for longterm stability and direction. Evidence: Mrs Margaret Mantle was appointed as home manager in December 2008, and we have recently received her application to become the homes registered manager. She has been the registered manager of another home for older people in the past. The majority of people who lived at the home that we spoke with knew who the manager was, and were positive about her. They said she was out and about around the home, working some week-ends, and always willing to listen. One said she always asked if there were any problems or how things were going. Staff surveys indicated that most met with the manager often or regularly, and had enough support; 1 said this applied only sometimes. All thought communication within the home worked reasonably well. Staff we spoke with also said the manager was approachable and available, working hands on shifts with them occasionally. Care Homes for Older People Page 30 of 36 Evidence: They said that other senior staff such as the acting manager helped practically too, and this, with the recent increase in staffing in response to increased demands on staff, had improved staff morale. Staff meetings were felt to be useful, with two-way communication between staff and management, and minutes kept. One staff member pointed out that as they were held in what was work time for some staff, the quality of meetings could vary as some staff would have to go to answer call bells, etc. We were told that staff have yearly appraisals and that the majority of staff have had three sessions, plus meetings. Staff confirmed that work is being completed to monitor and cut down on staff sickness. The home sent us their AQAA when we asked for it. It was clear, and gave us all the information we asked for. There was no-one living at the home who was subject to a deprivation of liberty authorisation, and we did not find that anyone was having their liberty deprived without an authorisation. The home has shown a commitment to quality assurance, demonstrated through meetings and surveys for people both living and visiting the home. We saw the minutes for meetings with staff and the action plans that resulted from the discussions. The Operations Manager confirmed that action had been taken to address concerns. We saw that different staff groups have each had meetings to discuss their individual requests and roles. We saw that there had been a residents meeting in March 2009 and the minutes confirmed that choice is promoted at the home. Staff told us and the minutes confirmed that people who did not attend the meeting are visited in their rooms to ensure they are included. A relatives meeting provided reassurance to visitors regarding the running of the home and also detailed compliments, such as the cleanliness of the home and the quality of the laundry. We also saw that the acting manager had contacted health and social care professionals to build relationships and promote the improvements that we noted have happened at the home. We discussed the types of surveys that have been sent out by the home both to visitors, health and social care professionals and people living at the home. The Operations Manager told us how the sample is chosen and we saw that there was a good range of topics. Two health professionals had commented positively on the service provided by the home, and we saw that people living at the home had responded positively, including surveys that are sent to people two weeks after they Care Homes for Older People Page 31 of 36 Evidence: had moved in. We were told that the home does not hold personal allowances for people. Instead, people or their representatives are billed on a monthly basis, being sent a breakdown of costs. We saw that receipts are kept, and that there is a clear audit trail. Accident records had been completed fully and related to individuals risk assessments for falls and related care planning, where daily care records showed people had had accidents. We saw that the Fire and Rescue service had visited in July 2009 and requested that two areas of work should be carried out. We saw from written records that the acting manager had been prompt in organising this work and responding to the regulator. The laundry doors fire safety closure was in place and effective - an issue addressed since our last visit. There were individualised fire evacuation plans in each persons care plan records. Staff we spoke with felt they had a safe working environment. We saw they had clear instructions as to what to do if tap water was too hot, which the Operations Manager said was an area being addressed for some rooms; valves had been ordered and would be fitted in the week after our inspection. The Operations Manager said that the situation had been risk assessed and that the people in affected rooms did not use hot water independently. The kitchen areas were orderly and clean. Leftovers in fridges were covered and dated. Separate hand-washing facilities were available for catering staff. Senior staff confirmed that they completed an Environmental Health Department monitoring questionnaire every 6 months. Someone newly admitted to the home confirmed that their portable electrical appliances had been checked for safety by the homes handyman when they first moved in. We saw a risk assessment in someones care records relating to use of a free-standing heater that was placed in their room on one occasion, when the heating system broke down. Care Homes for Older People Page 32 of 36 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 33 of 36 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 1 2 10 12 It is recommended that continence products are not visible in peoples rooms, in order to protect their dignity. It is recommended that more action is taken to ensure that staff spend one to one time with people who choose not to participate in group activities but who get bored or are at risk of becoming isolated. It is recommended that all staff are familiar with the local authoritys safeguarding procedures, especially the primary agencies in the community with safeguarding roles and responsibilities, to who they should report concerns if it becomes necessary. It is recommended that a minimum of 50 of care staff should be trained to NVQ Level 2 or above. (Unmet from previous 3 inspections) It is recommended that all care assistants undergo an induction in line with the Common induction standards/Skills for Care specifications, within recommended timescales, and with evidence kept of this. You should ensure that a manager is registered for the care home, in order to confirm the home will be run by a person Page 34 of 36 3 18 4 28 5 30 6 31 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations fit to be in charge. Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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