Care Home: Flaxen Road

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What the care home does well We received a range of positive feedback about the home. One relative told us; "I feel very fortunate, and have great peace of mind, knowing how well (my relative) is looked after". The new manager and her staff are working hard to meet the needs of the residents, all of whom have significant needs relating to their diagnosis of dementia. The home has a range of up to date information to assist prospective residents, their relatives and others involved with them, to help them decide if the home can meet their particular needs and preferences. The home also has effective assessment and admission procedures that help with this process. What has improved since the last inspection? At the last key inspection three requirements were made and we were pleased to see these had been complied with. The three requirements were in the following areas: to ensure that initial reviews are always undertaken following the admission of a new resident so that all concerned can be assured that the person`s needs are being properly addressed; to replace a faulty fridge that was a potential health and safety hazard and to ensure that the home`s allocated smoking area met the new environmental health legislation that had come into force at that time. Two good practice recommendation were also made. These were in relation to employing a permanent cook instead of using agency staff, to assist in maintaining good personal and professional relationships with other staff and to review the home`s policies and procedures in the light of changing legislation and good practice advice from the Department of Health. Both of these had, or were in the process of being acted on. What the care home could do better: At this inspection seven requirement are made in the following areas: to make sure that care plans are up to date so that staff have the most recent information on how to meet people`s needs and preferences; to make sure that information about people`s health needs, particularly after appointments with health care professionals, are properly recorded and up to date so that staff are aware of any changing health needs and how to address these; to make sure that information about any complaints and more minor concerns that are raised with the home are recorded in order to evidence that these have been properly addressed and that any action necessary to rectify the situation has been taken; to make sure that that the physical environment can meet the health and safety needs of residents and that they have a comfortable place to live that can meet their needs and preferences; to make sure that staff receive formal supervision to enable them to do their jobs properly and two health and safety issues to help keep people safe. Five good practice recommendations are made in the following areas: that allocated key workers write monthly summaries of their work to assist in reviewing care plans; to record which activities each resident takes part in each day to help develop more activities that residents like; to recruit to vacant posts to help improve consistency of care for residents; to appoint and consolidate a permanent senior staff team and for the new manager to register as such with the Commission, to help strengthen the home`s lines of accountability and to improve the home`s quality assurance systems to help the home to continue to improve the service it offers. Key inspection report Care homes for older people Name: Address: Flaxen Road 1 Flaxen Road Chingford London E4 9TF     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: Peter Illes     Date: 2 3 0 7 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 37 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 37 Information about the care home Name of care home: Address: Flaxen Road 1 Flaxen Road Chingford London E4 9TF 02085244422 02085249656 mary.lee@walthamforest.gov.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: London Borough of Waltham Forest care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: The maximum number of service users who can be accommodated is: 24 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE(E) (of the following age range: 65 years and over) Date of last inspection Brief description of the care home 1 Flaxen Road is registered to provide care to 24 older people who have a diagnosis of dementia. The home is managed by L.B. of Waltham Forest as part of the boroughs in-house residential care resources for older people. The home was purpose built in 1989, and is a single storey bungalow style building with wheelchair access. Access to the grounds is through electric gates with an intercom system. There are 24 single rooms each with its own sink unit, and two with en-suite facilities. The home is divided into two units, each with 12 bedrooms, a lounge, dining area, kitchenette, bathroom, 3 toilets and a shower room. A large bright entrance foyer connects the two units and the home also has a separate main kitchen, laundry, office accommodation, staff Care Homes for Older People Page 4 of 37 Over 65 24 0 Brief description of the care home facilities and attractive gardens. The home is situated in a quiet residential area in North Chingford and is near local bus routes, shopping facilities, library and a leisure centre. The statement of purpose describes that the core purpose of the home is to: Provide quality care and support for people in the community by empowering service users. We will support older people with dementia. The provider organisation makes information about the service, including CSCI inspection reports, available on request to people living at the home and other stakeholders. The current weekly charge is £659 per week. Care Homes for Older People Page 5 of 37 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 last key inspection of this service took place on 12th November 2008. This key inspection took approximately eight hours and was undertaken by the lead inspector. However, terms such as we, our and us are used where appropriate within this report to indicate that the inspection activity was undertaken on behalf of the Commission. The registered manager had retired in 2008 and a new manager appointed who was available to assist throughout this inspection; twenty two residents were living in the home on the day and there were two vacancies. The inspection activity included: meeting and speaking to the majority of the residents present although conversation was limited due to their communication needs; detailed discussion with the new manager; independent discussion with a number of care staff and the cook; independent discussion with a visiting community nurse; independent discussion with a number of relatives that visited on the day and a discussion with the Care Homes for Older People Page 6 of 37 L.B. of Waltham Forests nominated responsible individual for the home, who attended for feedback toward the end of the inspection. Further information was obtained from a tour of the building, documentation kept in the home and from survey forms returned to us by relatives, social work staff who had referred people to the home and from staff working at the home. The new manager sent us an Annual Quality Assurance Assessment (AQAA) when we asked for it. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: At this inspection seven requirement are made in the following areas: to make sure that care plans are up to date so that staff have the most recent information on how to meet peoples needs and preferences; to make sure that information about peoples health needs, particularly after appointments with health care professionals, are properly recorded and up to date so that staff are aware of any changing health needs and how to address these; to make sure that information about any complaints and more minor concerns that are raised with the home are recorded in order to evidence that these have been properly addressed and that any action necessary to rectify the situation has been taken; to make sure that that the physical environment can meet the health and safety needs of residents and that they have a comfortable place to live that can meet their needs and preferences; to make sure that staff receive formal supervision to enable them to do their jobs properly and two health and safety issues to help keep people safe. Five good practice recommendations are made in the following areas: that allocated key workers write monthly summaries of their work to assist in reviewing care plans; to record which activities each resident takes part in each day to help develop more activities that residents like; to recruit to vacant posts to help improve consistency of care for residents; to appoint and consolidate a permanent senior staff team and for the new manager to register as such with the Commission, to help strengthen the Care Homes for Older People Page 8 of 37 homes lines of accountability and to improve the homes quality assurance systems to help the home to continue to improve the service it offers. 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 37 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 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that are considering living in the home, and their representatives, are provided with a range of up to date information to help them decide if the home is likely to meet their needs. Peoples needs and wishes are properly assessed as part of the preadmission process to help make sure that the home can meet these. Soon after admission peoples progress is formally reviewed to make sure that all concerned are happy with the placement. Evidence: The home has a current statement of purpose that was seen to have been updated to reflect the change in management arrangements over the past few months and contained full information about the services the home could and could not offer. We spoke to a relative who visited the home during the inspection and whose person had recently been admitted to the home. The relative told us that she had received a helpful pack of information about the home when her person was admitted and that this had been useful. Care Homes for Older People Page 11 of 37 Evidence: We also saw evidence that peoples needs and preferences are properly assessed before they are admitted to the home. We inspected four residents files and these contained assessment information from the placing authority and from hospital discharge records as well as specialist health assessments, where appropriate. We also saw evidence that the home had undertaken its own assessment before the person was admitted, to help make sure that the home could properly meet those needs and preferences. Files also contained notes on peoples likes and dislikes and some evidence that staff are trying to compile a life history of the person to more fully understand what was important to them before they needed to move into residential care. At the last inspection a requirement had been made that initial reviews are planned and undertaken following the admission of a person to the home to confirm that the persons assessed needs were being properly addressed. Evidence was seen that this requirement was being met. The homes annual quality assurance assessment, AQAA, states; There is a review after the service user has lived at the home for six weeks to determine whether the placement is suitable or not. Service users are given the choice of making (Flaxen Road) their home or looking for an alternative placement. The relative spoken to told us that she had been invited to look round the home before admission and had attended a review meeting after six weeks. Other files inspected showed evidence of a six weekly review. We also received a survey form from a L.B. of Waltham Forest social worker who had recently admitted a resident to the home. The social worker stated; As a social worker I feel that the admissions process was very efficient and professionally conducted. My service user has been at Flaxen Road since (date) and a review took place today (approx. 4 weeks after).Mrs (X) looked amazingly well and content. Flaxen has given the family a free hand to personalise their mothers room, Mrs (X)s room looks excellent. The home does not provide intermediate care. Care Homes for Older People Page 12 of 37 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. The recording of peoples needs and wishes regarding the care and support they are offered needs to be kept up to date and regularly monitored so that staff can be confident that have current information and guidance on how to assist with these. Residents health is generally promoted by the home although more information about the outcome of medical appointments is needed for some residents, to ensure that staff are aware of any changes in the persons condition. Residents are protected by the homes medication policy and procedures. Evidence: The homes annual quality assurance assessment, AQAA, states; Care plans are drawn up on service users within 24 hours of their admission. All care plans are reviewed if the service users needs change. Risk assessments are also completed and included in the care plans. However, the new manager had also written in the AQAA; Due to the changes in the senior staff team in the last year, care plans were not reviewed as often as they should have been, this will now be addressed monthly. We looked at the files of four residents. On two of these we saw satisfactory care Care Homes for Older People Page 13 of 37 Evidence: plans that had been reviewed in the past month. These were generally satisfactory and included releavant information such as the persons needs and wishes regarding their medical and health needs, communication needs, skin care, and cultural and spiritual needs and preferences. It was also noted that these two care plans were informed by a range of current risk assessments. However these two care plans had not been signed, either by the person that completed them or by the resident or their representative. The third persons file contained a care plan that was dated 08/09/08 and showed evidence that it had been reviewed in 02/09. However, there was no evidence that this care plan had been reviewed since that date, so it was not possible to verify if the recorded needs and preferences were still current or the guidance for staff relating to these up to date. The fourth person whose file was inspected had been admitted to the home approximately six weeks before the date of this inspection. Although there was good quality multi-disciplinary assessment information on the file from the time of the admission there was no care plan available and a copy of one could not be located during the inspection. It was noted that a six week review had recently taken place on the person and feedback from the referring social worker and a relative spoken to during the inspection both indicated that the person had settled well into the home. However, as there was no care plan available it was not possible to see the guidance for staff on how the persons needs and preferences should be addressed, which may be particularly problematic for new or agency staff. A requirement is made, with a negotiated timescale, that care plans must be up to date as well as being signed and dated to show who wrote them, who reviewed them and when and whether the resident or their representative had been involved in the process. The new manager confirmed that she had identified this as an issue when she first moved to the home and evidence was seen that she was addressing this as a priority. We were told that a permanent member of staff was allocated to each resident to act as a key worker. Staff spoken to confirmed this and were able to tell us what this role entailed, including one to one chats with the resident. However, there were no records seen of key worker sessions and a good practice recommendation is made that this should happen. This may well help make the task of regularly reviewing residents care plans easier. The four files inspected showed that people were registered with a GP and had access to a range of health care professionals including a dentist, optician, chiropodist as well as specialist health care professionals such as the local psycho-geriatrician service. We spoke to a visiting community district nurse during this inspection. The nurse told us that she had visited the home for a number of years for such tasks as administering Care Homes for Older People Page 14 of 37 Evidence: insulin for people with diabetes and changing dressings. She confirmed that none of the residents had pressure ulcers at that time and that she felt the staff were generally very professional, approachable and looked after residents well. However, for two of the four residents whose files we inspected the records did not show a clear audit trail for how the results of identified health care appointments are followed up and dealt with. One residents file showed they had attended Whipps Cross hospital in September 2008 for some exploratory medical tests. The record at that time showed that the tests could not be completed and they would need to be undertaken again using an anaesthetic. The file did not show the result of this. However, on an archived file that was later found it was established that the tests had been successfully completed in October 2008 but that record showed also that the results of a biopsy were now awaited. No further record was available to show the outcome of the biopsy nor were staff able to inform us of the result. The staffs assumption seemed to be that this must have been satisfactory as the person had seen their GP since that time and no further medical intervention had been suggested by the GP. We neither saw nor heard any evidence that the home had queried the results of the biopsy with the GP. On a second persons file we saw a record that the person had seen their GP on 22/06/09 for a physical condition and also because they were exhibiting behaviour that challenged staff. The record showed that the GP had referred the person to a psycho-geriatrician for further assessment regarding the challenging behaviour. Another note stated the person had seen a psycho-geriatrician the following day, 23/06/09, and that the home should receive feedback from the GP following that appointment. No other outcome was recorded or known by staff although on the day of the inspection a new prescription arrived at the home for that person for medication to be administered at night time, which staff were apparently unaware of. Senior staff contacted the GP at that time to seek further clarification. A requirement is made that the home must obtain and record a proper audit trail for all medical appointments attended by residents, or to record why this is not possible and any further action they are taking regarding this, to enable them to properly understand and to implement any medical recommendations and/ or treatment as appropriate. We saw the homes medication policy which was satisfactory. We also inspected the medication administration record (MAR) chart and medication stored for three residents. These indicated that people were being assisted with their medication safely and without mistakes. Satisfactory records were seen of medication being recorded Care Homes for Older People Page 15 of 37 Evidence: when it entered the building and when it is disposed of. None of the current residents are prescribed controlled medication but the home has proper storage facilities and a register to record this if controlled medication is prescribed in the future. Care Homes for Older People Page 16 of 37 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. The home provides a range of activities that the majority of residents enjoy. Relatives and friends are made welcome, which they and residents appreciate. People are encouraged to make as many decisions for themselves to help them maintain their independence. The range of meals is currently being updated to further meet residents needs and wishes. Evidence: The homes annual quality assurance assessment, AQAA, states: Activities are organised on a daily basis for service users according to their wishes, and these are recorded. The AQAA goes on to say in the section titled What we could do better the following: we could improve our way of monitoring what activities service users take part in; improve the range of activities offered to the service users to enhance their lifestyle and to try to involve service users in activities taking place in the community. On both of the units we saw a recurring list of daily activities for residents although were told by staff that these were a guide and other activities could take place if residents wanted this. The list of activities seen included art and craft, exercise to music reminiscence/ memory games, a coffee morning and a sherry morning on a Care Homes for Older People Page 17 of 37 Evidence: Saturday. However, there was no record on the units of whether the planned activities took place each day or whether alternative activities were provided. We were informed that a new activities coordinator was being transferred to the home from another of the Boroughs homes, for 1 1/2 days a week. We also saw evidence of one off activities including a recent trip to Southend and a BBQ. During this inspection we saw some residents being encouraged to join in a game with a soft ball and also a music session in the morning; a bingo session was held in the afternoon. Although some residents were seen to enjoy these activities others did not want to join in. Staff were seen to interact on a one to one basis with residents, which the residents observed seemed to enjoy. On files seen there was a record sheet for staff to record which activities residents had taken part in but those seen had not been filled in for some months. Daily notes seen were variable in detail and quality and those seen did not give a clear picture of what activities the person had participated in or been offered. This was discussed with the manager who confirmed that this was work in progress. A good practice recommendation is made that a record is kept of which activities each resident takes part in each day, to help staff decide how the programme can be developed to contain more activities that resident enjoy and are likely to participate in. The majority of the current residents are white British in ethnic origin although there are a few from different ethnic minority communities. It was noted that the home had a multi-faith calendar displayed and we were told that the home intended to celebrate a range of different festivals in the coming year. Each persons file seen included a section on their cultural and spiritual needs and preferences. This included what religion they are, if any, and whether and how they like to practise their religion. The homes AQAA includes; (Residents) may be married, single, gay or lesbian. they have different personalities and political views. We adhere to the equal opportunity policy and treat all service users as individuals..... Evidence was seen that the home operates an open door policy for residents family and friends. Two visiting relatives were spoken to during the inspection and gave us positive feedback about the home. One informed us that they were happy with the care provided, that the home kept them informed of hospital visits and sent them copies of minutes of meetings as they lived outside of London and could not always attend these. Another relative informed us in a survey; Excellent care. Very good atmosphere; Very caring and attentive staff. Visitors are always made very welcome. All the residents have a diagnosis of dementia although some are more independent that others in various areas of their lives. One resident was seen to have a key to their Care Homes for Older People Page 18 of 37 Evidence: bedroom door and was observed using this independently of staff. Evidence was also seen of staff spending time on a one to one basis with residents to ascertain their views and wishes regarding areas of their day to day life and prompting them to be as independent as they could, for example, with personal care tasks. The home has a four week menu that was seen that showed a range of healthy options. However, the new manager told us that the home was in the process of writing a new menu, which the home would then consult a dietitian about. On the current menu the main meal is served of an evening with a lighter meal at mid-day. We talked to the agency cook who informed us that none of the current residents wished for food from different cultures although peoples preferences were known, e.g. one person did not eat pork and others were vegetarian. We were also informed that if a resident was admitted who was Jewish or Muslim then the home could meet their needs. The home was also seen to provide gluten-free meals where needed. On the day of the inspection the lunch was bacon, egg and beans, which most people seemed to enjoy. It was noted that people who were vegetarian were only offered egg and beans. On further discussion it was noted that the vegetarian option for the main meal could also be limited with an example being vegetarians being offered frozen cheese crispy bake on one day. The manager stated that this was one of the reasons that she was working to create a new menu, where more options would be available, including fresh vegetarian dishes and for the main meal to be at mid-day and the lighter meal of an evening. The cook spoken to during this inspection was employed through an agency although had worked at the home for a number of years. At the last inspection a good practice recommendation was made that the home should consider employing a permanent cook to assist in maintaining good personal and professional relationships with staff. We were told at this inspection that this was now going to be acted upon as a permanent cook was available from another of the Boroughs homes, that was due to be closed. At he last inspection a requirement was also made that a faulty fridge was replaced and this had been complied with. It was noted that the kitchen staff kept a range of satisfactory and up to date health and safety records. Care Homes for Older People Page 19 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home benefit from satisfactory procedures being in place to deal with any complaints or concerns that may be raised. However, system for recording of complaints needs to be reviewed to help evidence that the procedures are being robustly followed. People are protected by the homes safeguarding procedures that are properly implemented and which staff are aware of. Evidence: The homes annual assurance assessment,(AQAA),states; A copy of the complaints procedure is displayed on the notice board and includes the Care Quality Commissions contact number. We listen to complaints and take immediate action. The home continues to use the L.B. of Waltham Forests complaints procedure, which was seen displayed in the home at this inspection. This procedure is up to date and clearly informs the reader of how any complaints will be dealt with by the home and by the Borough. At the last inspection the homes complaints record did not show any complaints logged since the inspection before that but contained a number of compliments. At this inspection the complaints log was inspected and showed no entries at all since 2004, indicating that his may have been a previous complaints record. The new manager was clear that no complaints had been received at the home since she has worked there, which was May 2009. However, it is our opinion that it is unlikely that no concerns or complaints at all have been raised with the home since 2004. A requirement is made that the system for recording all complaints or concerns, Care Homes for Older People Page 20 of 37 Evidence: including more minor and verbal ones, is reviewed to make sure that all are recorded and the action taken to deal with them is also recorded. This is in order for the home to monitor any concerns to ensure that they have been dealt with properly and to show evidence that this information is used as part of the homes quality assurance mechanisms. Nevertheless, feedback from residents, relatives and others such as the Community Nurse spoken to was positive about the home and the care it provides. When asked people told us they were confident that if they had any concerns the home would deal with them appropriately. One relative wrote in the survey form they sent us, I feel very fortunate and have great peace of mind knowing how well (my relative) is looked after. The home had an up to date copy of the L.B. of Waltham Forests safeguarding adults policy and procedure, a copy of this was also displayed in the entrance hall of the home. Records seen and staff spoken to evidenced that staff receive regular training in keeping people safe from abuse. Two safeguarding allegations had been made to the home since the last inspection and both had been properly reported to L.B. of Waltham Forests safeguarding team. One investigation has been completed and and recommendations from that investigation had been acted upon by the home and the other allegation is still being investigated. Both allegations had also been reported to the Commission as required and we are satisfied with the actions taken by the home to date regarding these allegations. Care Homes for Older People Page 21 of 37 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 design and layout of the building meets residents needs although a range of identified refurbishment and redecoration work is needed to make the physical environment safer, more homely and a more comfortable home for the residents to enjoy. Evidence: The home was purpose built in 1989 and is a single storey bungalow style building. It comprises two twelve-bed units each with twelve single bedrooms including its own sink unit, and two with en-suite facilities. Each unit also contains a communal lounge, dining area, adapted toilets and bathrooms and also has a conservatory. One of the conservatorys is designated as a smoking area. A large bright entrance foyer connects the two units. A social worker commented in the survey form she had returned to us; I like the building design, it is a good setting for residents with dementia. At the last inspection a requirement was made that the home complied with an environmental health requirement for the homes smoking area to have a self-closing door, to comply with current legislation. We were pleased to see that this had been completed. Care Homes for Older People Page 22 of 37 Evidence: We were told by the manager that when she took up post she had identified a number of areas in the home that needed urgent redecoration or refurbishment and that the money to complete these had been agreed by senior managers. She went on to say that because of the amount of work the Borough was obliged to put this work out to tender, and this was confirmed by the responsible individual. On a tour of the building we noted and confirmed the areas that needed work undertaken. These included: refurbishment of the shared shower and bathrooms; redecoration of residents bedrooms, toilets, laundry area, hairdressing room and new bedroom furniture and and curtains. Given this identified work is necessary to provide a comfortable environment for residents and also has a potential implication for their health and safety as well as others that use the building, a requirement is made regarding this. The home must ensure that the identified work that is currently out to tender, including that listed in the Environment section of this report, must be completed by November 2009. This a negotiated timescale agreed with the responsible individual as reasonable, given the amount of work to be undertaken. We gathered information from both a tour of the premises and from the AQAA that some new furniture had been bought in the past year including several new beds, including electric profiling beds, new seating for the garden and that the garden pond had been refurbished. We also saw some of the residents bedrooms that had been personalised and which residents and there representatives told us they were happy with. The laundry and laundry equipment was satisfactory and the home had the necessary infection control procedures in place. Care Homes for Older People Page 23 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are generally supported by a sufficient number of staff to meet their needs and who have a range of skills, qualifications and competencies. However, timely recruitment to vacant posts, including senior posts, on a permanent basis may help provide more consistency of care for residents and assist in improving the recording practice in the home generally. People accommodated are protected by the homes recruitment policy and procedures. Evidence: An up to date staffing rota was seen, which correctly recorded the staff on duty during the inspection. The rota indicated that four care staff were on duty, two on each unit, and an additional senior member of staff was on duty throughout the day. At night there are two staff on duty and we were told that a designated on call manager is also available for advice and support. The homes annual quality assurance assessment, AQAA, states; During the night hours we have two care assistants on duty. We operate an on-call system to support staff out of hours. The care agency also provide an on-call service in case extra staff are required to escort a service user to hospital. The managers hours are in addition to the rota and the home also employs administrative staff, a laundry assistant, a cook and contract cleaners. Our judgement is that the staffing ratios are adequate to meet the needs of the current residents. We noted that since the previous registered manager retired from the home at the Care Homes for Older People Page 24 of 37 Evidence: end of August 2008 there have been temporary management arrangements in place. The deputy manager acted up as manager from that time although she has been on long term sick leave for the majority of that time. One of the two senior care staff is currently acting up as deputy manager; the other senior care post is vacant and is being covered by a care assistant. The new manager is also the registered manager of another of L.B. of Waltham Forests directly managed registered care homes for older people that is now in the process of being closed. This is part of an ongoing review of the in-house services that the Borough provides. The new manager is currently working four days a week at Flaxen Road and one day a week at the home that is in the process of closing. The result of this has been a lack of continuity in the management arrangements at the home since September 2008 and significant use of agency staff. It is our judgement from talking to a number of staff during this inspection that this has had a negative effect on morale for some staff, which needs to be addressed. In addition timely recruitment to vacant posts on a permanent basis has been significantly delayed because of the ongoing review and restructuring of the Boroughs residential provision for older people, including its in-house provision. This has led to the need to maximise redeployment opportunities for staff affected by the closure of other homes. This has resulted in the use of agency staff in a variety of posts on a long term basis. The ongoing use of agency staff has in turn contributed to the lack of recording in key areas, such as reviewing care plans. This is acknowledged by the new manager in the homes annual quality assurance assessment (see the Personal and Health Care section of this report). A good practice recommendation is that all vacant posts should be recruited to on a permanent basis and in a timely manner in order to provide consistency of care for residents and to assist in developing staff morale. As a result of the the overall review of the Boroughs in-house provision as described above, we were told that no new permanent staff have been recruited to the home since the last inspection. However, we noted that the home, and L.B. of Waltham Forest has clear and appropriate recruitment policies and procedures for when new staff are appointed. Staff files sampled at this inspection showed evidence that these had been properly used in the past. Of the the sixteen permanent care staff currently employed at the home fifteen of these have achieved the national vocational qualification (NVQ) level two in care or above. We also saw evidence of a staff training matrix that the new manager is in the process of updating. This showed evidence that staff are receiving regular core training and refresher training and staff spoken to stated that this was helpful in performing their duties. Evidence was seen of recent staff training including Care Homes for Older People Page 25 of 37 Evidence: safeguarding adults and the Mental Capacity Act, including the Deprivation of Liberty Safeguards, DOLS, that came into force in April 2009. Care Homes for Older People Page 26 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home now benefit from the service being managed by a competent, qualified and experienced manager. However, she needs further support from the provider organisation to assist progress areas outside of her management control. People accommodated and other stakeholders are consulted to promote and monitor the quality of the service they receive. Peoples financial interests are safeguarded while living in the home. The formal staff supervision arrangements in the home need improving to support staff meet the needs of people living there and to assist in their own development. A range of health and safety procedures generally protect people living in the home although further work is needed to evidence this protection. Evidence: The previous registered manager of the home retired at the end of August 2008 and interim management arrangements have been in place since that time, see the Staffing section of this report for more details. Care Homes for Older People Page 27 of 37 Evidence: The new manager has been working in the post since May 2009. She is also currently the registered manager of another of the L.B. of Waltham Forests in-house registered care homes for older people, which is in the process of being closed. The manager is working four days a week at Flaxen Road and one day a week at the other home. When the process of closing that home is completed she will work at Flaxen Road on a full time basis. The new manager is competent and knowledgeable about the needs of older people and management of care homes and has a proven management track record as registered manager of the home that is closing. A range of improvements are currently needed to the home and these are described throughout this report. However, the new manager had already identified the majority of these and reflected this when she sent us the homes latest AQAA. We also noted the efforts she is making to address these including work to update residents care plans, updating other documentation kept in the home, staff supervision and work to progress the upgrading of the physical environment. A social worker told us in their survey form; (The new manager) is a great manager - the best really. Flaxen Road will I think go from strength to strength. However, the home has not had a consistent senior management team since August 2008, see the Staffing section of this report for more details, and this has still not been fully resolved. In addition, other vacant posts are still not being recruited to on a permanent basis in a timely way either. We also noted that staff morale is variable, especially among the senior staff team. It is our judgement that the above poses a real difficulty in continuing to maximise the welfare and wellbeing of the residents and is outside of the control of the new manager. This is therefore a significant factor to the quality rating in this section of this report being judged as Adequate. A good practice recommendation is made that the Borough appoints and consolidates a permanent senior staff team at the home and that the manager applies to the Commission to be the registered manager of the home; this is to help strengthen and formalise the lines of accountability for the benefit of the residents. The homes AQAA states, An independent survey was carried out last year with service users to gain their views on the service that we are providing. However, neither the results of this, nor the action that was taken as a result, were readily available at this inspection. The responsible individual, the senior manager nominated by the Borough to take overall responsibility for the day to day management of the home, told us that the independent survey was going to be repeated later this year and a good practice recommendation is made to reinforce this. The home should formally seeks the views of residents, relatives, and other stakeholders, including Care Homes for Older People Page 28 of 37 Evidence: health and social professionals, about the quality of care the home provides and act on this information to continue to improve that quality of care. We did see evidence that the home holds monthly residents meetings, three monthly relatives meetings and has introduced a monthly newsletter for residents and relatives. We were told that information from these are used as part of the homes quality monitoring mechanisms. Other managers from the Borough, including the responsible individual, undertake monthly monitoring visits to the home and we sampled reports of these. We were pleased to see in the last report that the visiting officer had identified a range of necessary improvements needed at the home although these did not seem to have been identified on previous visits or, if they had, did not appear to have been acted on by the L.B. of Waltham Forest. The homes responsible individual attended the home for the feedback on this inspection. She acknowledged that the home needed further work and input from the Borough and assured us that she was doing all in her power to have this actioned. We emphasised to the responsible individual that in addition to herself it is imperative for the current manager to be fully supported by all the relevant senior managers/ budget holders within L.B. of Waltham Forest, in her efforts to improve the quality of service the home offers. The homes AQAA states; Service users money is held in the safe and receipts are are obtained for all expenditure. Receipts are also given by the home for monies being handed in for safe keeping. We sampled the money held for one resident and the corresponding records, which were found to be up to date and accurate. The homes AQAA also stated under what the home could do better; Supervision with both permanent and agency staff needs to be more regular, and needs to be closely monitored by the manager as well as by the service manager during Regulation 26 (monthly monitoring) visits. The manager told us that she is now undertaking unannounced night visits to the home and would be taking forward regular supervision of the night staff as well as the day staff. Again, it is our view that the manager will need the support of a consistent senior staff team to share this task and to progress it effectively. Records seen confirmed that staff were not receiving regular supervision and a requirement is made regarding this, particularly as staff morale was judged to be variable. At the last inspection a good practice recommendation was made that the homes policies and procedures should be regularly reviewed in the light of changing legislation and good practice advice from bodies such as the Department of Health. At this inspection this requirement was seen to have been acted upon with the manager showing us evidence of the work she had undertaken to ensure that copies of the Care Homes for Older People Page 29 of 37 Evidence: boroughs current policies and procedures were now being kept at the home. A range of satisfactory health and safety documentation was seen including: an Environmental Health report; evidence that hoists were being serviced regularly; that portable appliances were being checked regularly and that the water supply was being checked to minimise the danger of legionella. However, neither a current electrical installation certificate nor a current gas safety certificate could be located at this inspection and a requirement is made regarding these. The fire log was inspected and showed that fire alarms, fire call points and fire doors were all checked regularly to make sure they were working properly and that fire fighting equipment was being regularly serviced. However, a current fire risk assessment could not be located during the inspection and a requirement is made regarding this. Care Homes for Older People Page 30 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 31 of 37 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 The registered provider must ensure that care plans are written and show how each service users needs in respect of their health and welfare are to be met; and also that these plans are kept under review. This must include keeping care plans up to date, reviewing them at least monthly and ensuring that they are signed and dated to show who wrote them, who reviewed them and when and whether the resident or their representative had been involved in the process. This requirement is made to assist staff in safely meeting residents current needs and wishes in ways that they prefer. 30/09/2009 2 8 12 The registered provider must ensure that that the 28/08/2009 Care Homes for Older People Page 32 of 37 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 home promotes and makes proper provision for the health and welfare of service users. This must include obtaining up to date information and recording a proper audit trail for all medical appointments attended by residents, or to record why this is not possible, including recording any further action the home are taking regarding this. This requirement is made to assist staff to properly understand and to implement any medical recommendations and/ or treatment as appropriate. 3 16 22 The registered provider 31/08/2009 must ensure that the system for recording all complaints or concerns, including more minor and verbal ones, is reviewed to make sure that all are recorded and that the action taken to deal with them is also recorded. This is requirement is made in order for the home to be able to monitor any concerns to ensure that they have been dealt with properly and to show evidence that this Care Homes for Older People Page 33 of 37 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 information is used as part of the homes quality assurance mechanisms. 4 19 23 The registered provider must ensure that the premises is kept in a good state of repair externally and internally. This must include completing the identified work that is currently out to tender and that is listed in the Environment section of this report, by the end of November 2009. This requirement is made to promote the health and safety of residents and to provide a comfortable environment for them to live in. 5 36 18 The registered provider must ensure that all staff employed at the home are appropriately supervised. This must include care staff receiving formal supervision at least six times a year. This is to support staff to meet the needs of people accommodated and to assist in their own development. 6 38 23 The registered provider must take adequate precautions against the risk 31/08/2009 31/08/2009 30/11/2009 Care Homes for Older People Page 34 of 37 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 of fire. This includes having an up to date fire risk assessment in relation to the home. This requirement is made to maximise fire safety for all that use the building. 7 38 13 The registered provider 31/08/2009 must ensure that all parts of the home that residents have access to are free from hazards to their safety. This must include ensuring that home has a current gas safety certificate and electrical installation certificate. This requirement is made to maximise safety to all that use the building. 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 7 Allocated key workers should write a monthly summary of the work they undertake in this role, which will assist in the monthly review of residents care plans. The home should keep a record of which activities each resident takes part in each day, to help staff decide how the programme can be developed to contain more activities that resident enjoy and are likely to participate in. All vacant posts should be recruited to on a permanent basis and in a timely manner in order to provide 2 12 3 27 Care Homes for Older People Page 35 of 37 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 consistency of care for residents and to assist in developing staff morale. 4 31 The L.B. of Waltham Forest should appoint and consolidate a permanent senior staff team at the home and support the manager to apply to the Commission to be the registered manager of the home; this is to help strengthen and formalise the lines of accountability for the benefit of the residents. The home should further structure and show evidence of the ways it seeks the views of residents, relatives, and other stakeholders, including health and social professionals, about the quality of care the home provides and act on this information to continue to improve that quality of care. 5 33 Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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