Care Home: Drummuir Nursing and Residential Home

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What the care home does well We have seen previously that recruitment practices within the the home are robust and minimise the risk of abuse to people. Social Activities on the day of the inspection provided a positive experience to those who took part. Although it should be noted that this was seen in communal areas only. What has improved since the last inspection? The previous concerns expressed to us included the number, skills and competencies of staff working at the home. This included the clinical skills of the registered nurses. We were, previously, unable to ascertain the clinical skills of the nurses. At this inspection we found that a number of new registered nurses had been employed. The nurses had undertaken a range of training and updates to ensure that they have the skills and competencies to meet the peoples needs. All staff have undertaken some mandatory training. Some training remains outstanding however this has been planned and due to take place in the near future At previous inspections there was a lack of clear documentation so we were unable to see if adequate staff are on duty at all times. Since the last inspection the numbers of people living at the home has temporarily reduced. The home manager has been forwarding us copies of staff rota`s. This has demonstrated that the home now employs adequate numbers of staff. Previously new staff did not currently receive an adequate induction. Since the last inspection the induction process has been reviewed and now meets best practices guidance. The length of induction has been increased from one to three days. Due to the previous lack of suitably qualified staff the health needs of people living at the home were not being met. This included care of people at the end of their lives. In addition we had identified serious concerns with regard to the number of people who had or who were risk of loosing weight and a high number of people with pressure damage. At this inspection we found that the majority of people had put on weight. The number of people with pressure damage has reduced. This is due to staff now providing an increased and appropriate levels of care. At this inspection people looked well hydrated and well cared for. We observed people having a regular change of position, which is required to avoid pressure damage. Charts used to monitor care such as fluid, turn and diet charts are now completed accurately and influence the care given. The standard of meals at the home has improved with a reduction of shop bought processed foods. The care plans in place now give clear guidance to staff on the physical needs of people at the home and how these needs should be met. The home has purchased equipment to meet the needs of people living at the home. This includes hoists used in moving and handling and equipment to accurately weigh people. The environment was not previously of a high standard. There was a problem with recurrent malodours. On this inspection visit we observed that a programme of updating and refurbishment has commenced. This includes some bedrooms and some communal areas. No malodours were noted on this occasion. The home had not had a registered manager for some time and a lack of consistent management for the past few years. The lack of clear lines of accountability or responsibility lead to a lack of leadership and direction within the home. A new manager has been in place for several months now and has had a positive impact on the home with significant improvements noted. The manager is yet to register with us. Staff and people living at the home were very complimentary about the current manager. In addition the company has provide additional managerial support to the home. The service was not previously proactive in identifying shortfalls in the level of service and addressing any shortfalls. This has now been addressed. A number of internal quality assurance audits have now been completed. The management and administration of medication has improved and safe systems are now in place. What the care home could do better: Although the care planning systems have improved and now provide clear guidance with regard to people`s physical needs additional development is required to personalise the plans. This should include details of likes and dislikes such as what time people like to go to bed, get up and personal routines. The plans did not give any details of peoples ability to make decisions or choices. If they are unable to make choices or give consent then the details of relatives, friends or advocates who may be able to provide support in this area should be documented. The care plans should be developed in line with the Mental Capacity Act. Although it was observed that the majority of people at the home has put on weight we could not confirm if food supplements were given as prescribed. Activities, social and recreational opportunities are available within the home. We received comments from people living at the home that these tend to be provided within communal areas. Some people at the home are nursed in bed or choose to spend time in their bedrooms. Comments from people told us that for these people the activities on offer are limited. The management need to ensure that jugs used to serve drinks are appropriate and clean. The kitchen area was seen to be cleaner than on previous visits however there are no fly screens available for the windows in the kitchen area. These should be provided to ensure that the kitchen remains hygienic. All the people at the home were seen to wear clothes protectors at meal times. Staff need to consider how this effects people`s dignity and self esteem. The refurbishment of the home must continue to ensure that the home is a pleasant and clean place in which to live. Although the majority of staff training has now been undertaken some remains outstanding. This needs to be completed. This will ensure that staff continue to develop their skills and knowledge All staff have now received an appraisal however a system of staff supervision has not yet commenced. This is recommended to ensure that staff received adequate and continued support. The manager needs to submit an application to become registered with us. This will ensure that she had the skills, competencies and knowledge to run the home. Key inspection report Care homes for older people Name: Address: Drummuir Nursing and Residential Home 9-11 Northfield Bridgwater Somerset TA6 7EZ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Justine Button     Date: 0 1 0 7 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Drummuir Nursing and Residential Home 9-11 Northfield Bridgwater Somerset TA6 7EZ 01278422144 01278420397 drummuir@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Caroline Williamson Type of registration: Number of places registered: care home 38 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Elderly persons of either sex, not less than 60 years, who require general nursing care Up to eight places for personal care Up to two persons of either sex, between the ages of 50-60 years who require general nursing care Date of last inspection Brief description of the care home Drummuir Nursing Home is situated in a quiet residential area close to the town centre of Bridgwater. The home is not purpose built. Drummuir is registered with the Care Quality Commission provide general nursing care for up to 38 older people, although the home can only accommodate a maximum of 31 people. This includes up to 8 people who require personal care. The fee range does not include hairdressing, newspapers, toiletries, optician and some activities. Care Homes for Older People Page 4 of 30 Over 65 38 0 0 2 0 2 2 0 1 0 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The focus of this inspection visit was to inspect relevant key standards under the Commissions Inspecting for Better Lives 2 framework. This focuses on outcomes for people and measures the quality of the service under four general headings. These are excellent, good, adequate and poor. This inspection was carried out by one inspector over a one day. During this time we, The Commission, were able to speak with people living and working at the home, tour the building, view records and observe care practices. We were given unrestricted access to all areas of the home and all records requested were made available. A manager, who is providing support to the home, was present over the day of the inspection. Verbal feedback was given at the end of the inspection to the home. Some of the people who live at the home are unable to fully express their opinions, therefore some of this inspection was spent observing care practices and interactions. Feedback was obtained form some people living at the home who were able to give it. This feedback has been incorporated into the report. We have recently received a number of concerns and complaints about the level of care and Care Homes for Older People Page 5 of 30 support people at the home are receiving. These concerns have been made by visiting healthcare professionals including GPs District nurses and healthcare professionals. As a result of these concerns and findings of previous inspection visits, the commission, issued three statutory requirement notices.The notices related to meeting the healthcare needs of people at the home, medication arrangements and care planning. Since the last key inspection and following the issue of the statutory notices we have met with the company and other healthcare professionals under Somerset Safeguarding policy as part of our monitoring procedures. Information obtained from these meetings have formed part of the evidence in this report. Following the last key inspection as part of the safeguarding procedure the company submitted an action plan to address the shortfalls in the care given at the home. This inspection was completed to monitor progress towards meeting the action plan and to assess if the requirements made in the statutory notices and those at previous inspections have been met. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Care Homes for Older People Page 6 of 30 What the care home does well: What has improved since the last inspection? The previous concerns expressed to us included the number, skills and competencies of staff working at the home. This included the clinical skills of the registered nurses. We were, previously, unable to ascertain the clinical skills of the nurses. At this inspection we found that a number of new registered nurses had been employed. The nurses had undertaken a range of training and updates to ensure that they have the skills and competencies to meet the peoples needs. All staff have undertaken some mandatory training. Some training remains outstanding however this has been planned and due to take place in the near future At previous inspections there was a lack of clear documentation so we were unable to see if adequate staff are on duty at all times. Since the last inspection the numbers of people living at the home has temporarily reduced. The home manager has been forwarding us copies of staff rotas. This has demonstrated that the home now employs adequate numbers of staff. Previously new staff did not currently receive an adequate induction. Since the last inspection the induction process has been reviewed and now meets best practices guidance. The length of induction has been increased from one to three days. Due to the previous lack of suitably qualified staff the health needs of people living at the home were not being met. This included care of people at the end of their lives. In addition we had identified serious concerns with regard to the number of people who had or who were risk of loosing weight and a high number of people with pressure damage. At this inspection we found that the majority of people had put on weight. The number of people with pressure damage has reduced. This is due to staff now providing an increased and appropriate levels of care. At this inspection people looked well hydrated and well cared for. We observed people having a regular change of position, which is required to avoid pressure damage. Charts used to monitor care such as fluid, turn and diet charts are now completed accurately and influence the care given. The standard of meals at the home has improved with a reduction of shop bought processed foods. The care plans in place now give clear guidance to staff on the physical needs of people at the home and how these needs should be met. The home has purchased equipment to meet the needs of people living at the home. This includes hoists used in moving and handling and equipment to accurately weigh people. The environment was not previously of a high standard. There was a problem with Care Homes for Older People Page 7 of 30 recurrent malodours. On this inspection visit we observed that a programme of updating and refurbishment has commenced. This includes some bedrooms and some communal areas. No malodours were noted on this occasion. The home had not had a registered manager for some time and a lack of consistent management for the past few years. The lack of clear lines of accountability or responsibility lead to a lack of leadership and direction within the home. A new manager has been in place for several months now and has had a positive impact on the home with significant improvements noted. The manager is yet to register with us. Staff and people living at the home were very complimentary about the current manager. In addition the company has provide additional managerial support to the home. The service was not previously proactive in identifying shortfalls in the level of service and addressing any shortfalls. This has now been addressed. A number of internal quality assurance audits have now been completed. The management and administration of medication has improved and safe systems are now in place. What they could do better: Although the care planning systems have improved and now provide clear guidance with regard to peoples physical needs additional development is required to personalise the plans. This should include details of likes and dislikes such as what time people like to go to bed, get up and personal routines. The plans did not give any details of peoples ability to make decisions or choices. If they are unable to make choices or give consent then the details of relatives, friends or advocates who may be able to provide support in this area should be documented. The care plans should be developed in line with the Mental Capacity Act. Although it was observed that the majority of people at the home has put on weight we could not confirm if food supplements were given as prescribed. Activities, social and recreational opportunities are available within the home. We received comments from people living at the home that these tend to be provided within communal areas. Some people at the home are nursed in bed or choose to spend time in their bedrooms. Comments from people told us that for these people the activities on offer are limited. The management need to ensure that jugs used to serve drinks are appropriate and clean. The kitchen area was seen to be cleaner than on previous visits however there are no fly screens available for the windows in the kitchen area. These should be provided to ensure that the kitchen remains hygienic. All the people at the home were seen to wear clothes protectors at meal times. Staff need to consider how this effects peoples dignity and self esteem. The refurbishment of the home must continue to ensure that the home is a pleasant and clean place in which to live. Although the majority of staff training has now been undertaken some remains Care Homes for Older People Page 8 of 30 outstanding. This needs to be completed. This will ensure that staff continue to develop their skills and knowledge All staff have now received an appraisal however a system of staff supervision has not yet commenced. This is recommended to ensure that staff received adequate and continued support. The manager needs to submit an application to become registered with us. This will ensure that she had the skills, competencies and knowledge to run the home. 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 30 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 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. These standards were not assessed on this occasion. Evidence: Due to the previous concerns raised to us with regard to the care and support provided at the home no admissions have been accepted in recent months. These standards were therefore not reviewed on this occasion. Please see previous inspection reports for more details. Care Homes for Older People Page 11 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning systems have improved although additional developments are required. The health care needs of people living at the home are now being met. The arrangements for the storage, administration and disposal of medication has improved. Evidence: At the last key inspection concerns were identified with regard to the homes ability to meet the healthcare needs of people living at the home. In addition we had received concerns from Somerset Primary Care Trust and Somerset Adult Social Care. The concerns expressed to us and finding from the last key and random inspections related to the number of people that had lost weight, the relatively high frequency of people with pressure damage, and the homes ability to support people with complex healthcare needs including those who required end of life care and those with diabetes. Due to these ongoing concerns we issued three statutory requirement notices on 1st June 2010. The notices related to meeting peoples healthcare needs, Care Homes for Older People Page 12 of 30 Evidence: care planning and medication administration. This is inspection was primarily conducted to ascertain compliance with the statutory notices and additional requirements made at previous inspection. During the inspection we reviewed the care plans and care given to three people living at the home, In addition we reviewed aspects of the documentation (such as weight records) for a number of other people. We reviewed the care plans and ongoing care and support offered to one individual throughout the day. At previous inspection visits this individual had looked dehydrated and unkempt. On previous inspections it was noted that the individual had some pressure damage caused by losing weight and an infrequent change of position. On this occasion the individual was seen to be sitting in the lounge area. On previous visits we had been told by staff that the individual was unable to get out of bed. The individual looked clean tidy and comfortable. We were informed by staff that the pressure damage had now healed and that the individual had put on weight. This was confirmed by reviewing the care plans that were in place. On previous inspection visits charts that there in place to monitor the care and support provided to the individual had not been completed. It was therefore difficult to see how these influenced the care that was provided. On this occasion charts were completed. The charts demonstrate that staff were now supporting the individual to have over a litre of fluid a day and as such the individual did not look dehydrated. Charts were also completed to show that staff were now supporting the individual to have a regular change of position in line with the plan of care that had been developed. The increase in amount of diet, fluids and a change of positing had shown in a significant improvement in the individual pressure area damage. We reviewed the charts for other individuals at the home and found that these had also been completed as required. We reviewed the Medication Administration Records (MAR) for this individual. The MAR showed us that the GP had prescribed twice daily food supplements. The MAR, however, did not demonstrate that these had been given on all occasions required. We compared the MAR and the times that the food supplements were given to the charts held in the individuals bedroom. These did not correlate. It was difficult to ascertain therefore if the food supplements had been given as prescribed by the GP. Given that the individual had put on weight since the last inspection visit it could be argued that the food supplements were no longer required or if the individual had eaten well that day that these had not been given by staff. Food supplements are a prescribed treatment and if they are not given then staff need to document the reason for this. If the food supplements are no longer required then Care Homes for Older People Page 13 of 30 Evidence: this should be discussed with the GP and they should be discontinued. Similar issues were identified for other individuals on food supplements. We discussed this with the management at the home on the day of the inspection visit. The manager agreed to review this. We reviewed the care records for two individuals who was a diabetic. Previous inspections and concerns from Somerset Primary Care Trust had identified that staff at the home did not have the skills or competencies to meet the needs of people with diabetes. This had placed people at risk. In response to this the local district nursing staff have been visiting the home to complete blood sugar monitoring and insulin injections. This support currently continues. On this inspection visit we noted that care plans for people with diabetes had been developed and now gave clear instructions to staff on the needs of the individuals with regard to their diabetes. It was also noted that staff have received some training in this area. Additional training has been organised and will be completed in the near future. It is envisaged that the support from the district nurses will be withdrawn once this training has been completed. We reviewed the weight records for a number of people at the home. The majority of people who had previously been identified as having some weight loss had put on weight. For one individual who had continued to lose weight there was evidence in the care records that this had been discussed with the GP and an appropriate agreed plan of care had been formulated. The number of people at the home with pressure damage has significantly reduced. Pressure damage can be an indicator that people are not receiving the care and support that is required. This is therefore a significant improvement on previous inspection findings. We reviewed the arrangements for the storage, administration and disposal of medication. significant improvements were noted. The medication for all people living at the home has been reviewed by staff with the individuals GP. The home now has a Homely medication policy in place. All old stock has been removed. Identification was seen for all people living at the home. Policies and systems are now in place for the removal / disposal of medication. We observed a Registered Nurse completing a medication round and safe practice was seen. We reviewed all the Medication Administration Records. These are now completed to a good standard although the comments made earlier in the report with regard to food supplements should be noted. It was also identified that not cream and lotions held in peoples rooms had a date of opening. This needs to be completed as creams only have short shelf life when opened. One medication error was identified during the inspection visit however this Care Homes for Older People Page 14 of 30 Evidence: had also been identified prior to the inspection by the staff at the home. Staff at the home had taken appropriate action in response to the error. This is a significant improvement from previous inspections when there was no systems in place to audit and identify any errors. At the end of the inspection visit it was concluded that the requirements laid out in the statutory notices had been complied with. This includes those with regard to care planning. The care plans now detail the physical needs of people living at ht home and the actions staff should take in response to these needs. The plans however now need continued development and to become more personalised. For example there is no reference in any of the plans seen with regard to mental capacity and how people are able to make choices. If people are not able to make choices then the plans should detail family, friends or advocates to support the staff in ensuring that they act in the individuals best interest. The plans need to be developed to inform staff of likes dislikes and individual preferences. Care Homes for Older People Page 15 of 30 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. Social and recreational opportunities are available. visitors are made welcome at the home. People are not able to exercise autonomy and choice in all areas. Improvements have been seen with regard to meals served. The kitchen was clean and tidy with appropriate health and safety checks now being completed. Evidence: There were no activities on the morning of this inspection visit. We were informed that the activities organiser was attending the funeral of a person who had lived at the home. At the last key inspection it was reported that On the day of the inspection the activities organiser was on duty. A range of activities were on offer including some arts and crafts, connect 4 and reminiscence. People who were involved in the activities appeared to have be having a positive experience. A number of other people either those who remained in their rooms or those in the main lounge area appeared to have little or no interaction. Care Homes for Older People Page 16 of 30 Evidence: During the inspection we reviewed the complaints made to the home. One of the complaints received by the home related to the lack of activities to people for people who remained in their rooms. These comments need to be considered by the activities organiser. Feedback on this inspection visit from people who live at the home was good with regard to the activities that take place in the communal areas. People living at the home may not have choice and autonomy. Choice with regard to meals has improved for those people who require a specialists diet (see below). Choice is limited for some people with regard to the choices they make about how to spend their time and lifestyle choices for example what time they get up or go to bed. Developments in the care planning process (see outcome area 2) may help staff consider how to support individuals to make choices. At the last inspection it was identified that a number of people at the home had lost weight. In addition the majority of the foods served were processed, shop bought products. Choice of meals was limited with people who required specialist diets having no choice at all. No snacks were available between meals which is especially important for those who have or are at risk of loosing weight and those who require specialist diets for example to aid wound healing. At the last inspection visit the kitchen was not seen to be clean and checks had not been completed for example temperature checks to hot foods. At this inspection we were told that the menus had been reviewed and updated. We reviewed the documentation of food served to confirmed this. A choice of homemade meals are now available. On the day of inspection sausages or homemade quiche with mashed potatoes or chips was available. Rhubarb crumble and cream or yoghurts were available for pudding. We tasted the quiche and found this to be of good quality. We viewed the support given to people at the home over the lunch time period. Some people require a soft or pureed diet due to difficulties in swallowing or chewing. At the last inspection the pureed diets were seen to mixed together. Soft diets were observed to be served separate on this occasion. This allows people to taste the the constituent parts of the meal and the presentation of the meal is more appetising. Despite these improvements it was still noted that people who require a soft diet still have their meals served in bowls. Staff were observed to support people sitting down. The number of people who were supported to go to the table for their meal has increased since the last inspection. It was noted during the meal that all people living at the home were wearing food protectors. Whilst it is appreciated that this may be required for some people the use of this equipment for all did have add a rather institutional feel to the meal. Staff need to consider how this impacts on peoples Care Homes for Older People Page 17 of 30 Evidence: dignity and self esteem. Any soiled clothing could be changed following the meal. At the last inspection it was noted that squash was the only drink available. At this inspection water is was also on offer. Sherry was also offered prior to the meal. This was enjoyed by a number of people. All drink were now served in glasses rather than plastic beakers. We viewed the drinks trolley which was used to serve the morning and afternoon drinks. Biscuits were available on the trolley in the morning. These would not be suitable for those people requiring a specialist diet. Donuts were on the trolley in the afternoon again these may not be suitable for all people. The management need to ensure that a range of snacks are available at all times. Food supplements were seen to be available on the drinks trolley although these were not seen to be used. It should be noted however that the majority of people have put on wieght since the last inspection visit. It was noted that the hot drinks were served from a plastic jug which appeared stained. This was not very appealing. The manager in charge of the home on the day of the inspection stated that he would review this and if necessary purchase a tea pot. During the inspection visit we visited the kitchen. The cook on duty told us that she thought improvements had been made and that staff were now cooking more homemade foods. The cook told us that she had enrolled on an National Vocational Qualification in order for her to increase and develop her skills. An evening cook is now employed. This enables fresh evening meals to be prepared rather than heated up. This now enables the care staff to concentarte on supporting people within the home and not having to prepare the evening meal. The kitchen was clean and tidy on the day of the visit. An increase in fresh products including fruit and vegetables was seen. A probe has been purchased in order that the temperature of hot foods can be monitored. Documentation is now kept of cleaning schedules, food temperatures, fridge and freezer temperatures and the food served on a daily basis. Te cook now keeps a list of those people on a specialist diet. The cook told us that this is updated regularly by the nurses and care staff. The weather during the inspection visit was warm and as such the windows in the kitchen were open. No fly screens were available at the windows. This is recommended to ensure that the kitchen remains hygienic. Care Homes for Older People Page 18 of 30 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 home has a complaints procedure It could not be confirmed that all staff have received training in protection. Evidence: As previously stated we have received a number of concerns and complaints about the care and support provided at the home. This has resulted in a meeting being held under Somerset Safeguarding procedure. As a result the home has been monitored both by CQC and commissioners. The numbers of concerns and complaints about the home has reduced in the last few months. This is as a result of the improvements to the care and support afforded to people living at the home. Work by the company, home manager and staff needs to continue to ensure that the improvements are maintained and continued. The home has updated the complaints policy to include the correct contact details and is displayed in the home to enable access to all. It is also available in the homes Statement of Purpose/ Service user Guide provided in each persons bedroom. Both people using the service and staff told us that if they had any concerns they would raise them with the manager designate and would be confident that appropriate action would be taken. People told us that they had more confidence that complaints would be dealt with appropriately due to a consistent manager and staff team. Care Homes for Older People Page 19 of 30 Evidence: Three complaints have been made to the home since the last inspection. These related to activities, food intake and clothing. All complaints have been dealt with by the home manager in line with homes complaint procedure. The home now has an induction programe for new staff which covers protection of adults. It was noted by viewing the training matrix that not all existing staff have completed Prevention of abuse training. 21 have yet to complete this training. Care Homes for Older People Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is in the process of updating and refurbishing some bedrooms and communal areas. Specialist equipment is now provided to meet the needs of people living at the home. Evidence: At previous inspections it was reported that a programme of refurbishment and decoration was being undertaken. At this inspection it was noted that this programme appears to have commenced. Some of the bedroom are in the process of redecoration and refurbishment. One of the communal lounges is also being updated to provide a quite space for those who do not want to use the larger noisier lounge. These improvements are currently ongoing At previous inspections it has been noted that the home did not always smell clean and fresh. Visitors to the home had also commented on this. During this inspection visit no malodours were noted. The kitchen was viewed and improvements to the cleanliness of this area noted. Fly screens need to be provided to the windows. New equipment has been purchased including scales to ensure staff can monitor peoples weight and new slings for the hoists used to aid peoples moving and handling. The purchase of this equipment now means that staff can provide appropriate care Care Homes for Older People Page 21 of 30 Evidence: and support and maintain health and safety with in the home. Care Homes for Older People Page 22 of 30 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. Staffing levels may not be adequate to meet the needs of people living at the home. Staff at the home have the skills to meet the needs of people at the home. The induction of new staff is now adequate Staff requirement procedures are robust. Evidence: A number of the previous concerns raised with us relate to the skills and competencies of the Registered Nurses working at the home. Concerns related to the staffs ability to care for people with diabetes, those at the end stages of life including the use of syringe drivers and subcutaneous fluids, those who require blood monitoring and catheterisation. At a previous safeguarding meeting we requested that Southern Cross Health care complete and forward to us a skills audit for the nurses at the home. The management then needed to organise any training required to ensure that staff could meet the needs of people at the home. Since this time a number of the Registered nurses have left the home and new nurses have been employed. Training for the staff has been organised and whilst a small amount of is is still outstanding the majority has been completed. This will now ensure that staff have the skills to meet peoples needs. Care Homes for Older People Page 23 of 30 Evidence: We requested a copy of the most recent staff training matrix. A copy of this was reviewed following the inspection visit. A significant amount of training has been undertaken in the last few months. This has enabled staff to develop their skills in order that they can meet the needs of the people living at the home. During the inspection visit we noted that additional training with regard to tissue viability, fire training and food hygiene had been organised in the month of July. The training matrix told us that some staff have not completed all the mandatory training. The manager on duty on the day of the inspection told us that training will continue to be organised until all staff had completed all required training. We had received concerns previously from both GPs and social workers with regard to poor staffing levels. Both stated that staffing levels have impacted on the standard of care and support afforded to people at the home. As a result of this we have requested that the company forward us weekly staffing rotas. These have been supplied. There is currently has a reduced number of people living at the home as no admission have been made over the last few months. In view of this the staff duty rotas have shown that there are adequate number so of staff on duty currently. If admission are to recommence then the management need to ensure that they keep the staffing numbers under review to ensure that there are sufficient staff to meet the needs of people at the home. We have reviewed the files of three staff who had recently been employed at the home at previous random inspections as part of our monitoring of the home. These showed that robust recruitment procedures were in place. All checks including two written references and Criminal Record Bureau checks. At this inspection we spoke to one person recently employed. The individual told us about the induction that they had undertaken. The induction is now in line with best practice guidelines and has been increased from one day to three days. The staff member told us that she felt well supported through this process and felt that the induction gave her sufficient knowledge to meet peoples needs. This is an improvement on previous inspection findings. Care Homes for Older People Page 24 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is now a clear management structure resulting in clear of leadership and direction at the home. Quality Assurance monitoring is now robust and effectively addresses areas that require improvement. Health and safety at the home has improved. Evidence: Since the last key inspection an manager has been employed at the home. This is the first time the home has had a consistent manager for a significant period of time. In addition a deputy and a number of new registered nurses have been employed. This has reduced the amount of agency staff working at the home. In addition senior managerial support has been provided by the company. Staff told us that this had improved the leadership at the home and that they felt more confident now that a consistent management structure was in place. This has had a positive impact on the Care Homes for Older People Page 25 of 30 Evidence: services provided at the home. The new manager has yet to register with us. This is required to ensure that the manager has the skills and competencies to run the home. The company has its own quality assurance systems to monitor the quality of care. Monthly visits to the home in line with regulation 26 and numerous monthly audits, based on the National Minimum Standards, are undertaken. This are now more robust than those previously seen and include discussions with people living at the home and staff. It was clear that the internal audits are now identifying any shortfalls and action is being taken in a timely way. An example of this was seen when auditing the Medication Administration Records (see outcome are 2) . The manager had recently conducted a survey for people living at the home and their relatives. These confirmed that people thought that the care support and services provided at the home had improved. Some issues still remain and it is envisaged that the management team will act on comments made. In addition to the internal surveys relatives and full staff meetings have been conducted. This has enabled people to express their views and influence the running of the home. Under Regulation 37 of the care home Regulations care homes should inform us of any event which may adversely effect people living at the home and the absence of the manager. These are now being received by us on a regular basis. At previous visits it was noted that the staff did not receive regular supervision or appraisals. At this inspection the manager on duty told us that staff supervision arrangements were still not in place however all staff have now received an appraisal. The manager told us that this will now act as a base line and that staff supervision will commence on the basis of this. We viewed some of the appraisals completed to confirm this. We found no evidence on this occasion that health and safety at the home was not being maintained. Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 31 8 The responsible individual is required to ensure that a manager is registered with the Commission. This is required to promote the stable management of the service. 08/04/2009 Care Homes for Older People Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Care plans now need 18/08/2010 additional development to ensure that they are personalised and reflect peoples wants and wishes. This should include details of individuals capacity in line with the mental capacity act. This will ensure that people are support by staff in line with personal preferences 2 9 13 Creams and lotions must be marked with the date of opening This will ensure that they are used in line with manufacture guidelines 16/08/2010 3 9 13 Any prescribed food supplements given should be recorded on the Medication Administration Record. If not given then reason for this should be recorded. 17/08/2010 Care Homes for Older People Page 28 of 30 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 This will ensure that people are support to have any supplements that are prescribed and that a clear auditing system is in place to ensure that care needs and requirements can be monitored 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 12 Activities must be made available to all people at the home including those who remain in their rooms. Activities should be provided in line with the plan of care. The management must ensure that the use of clothes protectors do not impact on peoples dignity and self esteem The management must ensure that snacks are availble to all peole when required. The management must ensure that drinks are served in clean appropriate containers and pots. The refurbishment of the building must continue to ensure that the home is a clean and pleasant place in which to live. All staff mandatory training must continue to be provided until all staff have the skills and competencies to meet the needs of people living at the home . A system of regular staff supervision should be developed 2 15 3 4 5 15 15 19 6 29 7 36 Care Homes for Older People Page 29 of 30 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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