Care Home: Flowerdown Nursing Home

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What the care home does well The service provides a comfortable and welcoming home where there is a range of activities to interest and stimulate the residents. The service ensures all perspective residents who have expressed an interest to move into the home have a comprehensive assessment undertaken on them. This is to ensure the service can meet their needs. This includes ensuring there are enough staff with the relevant experience and skills to meet those needs. The residents and relatives had positive things to say about the home and staff. The majority said they liked the environment and their bedrooms, the food, entertainment and said good things about the staff. What residents and relatives said about staff and the registered manager: "It is a great nursing home with a lovely atmosphere and the staff are respectful and gentle". "All staff are very friendly, helpful and kind". "The manager and staff are all very approachable". The home provides residents and their relatives with information on how to raise concerns and make a complaint. The manager has an open door access policy for management contact and will visit all residents on a daily basis to check if they are ok. Staff are encouraged to improve their knowledge and skills in the aspect of caring for the residents. Staff complete a thorough induction into care when starting in the home and they are provided with training that is appropriate and relevant to the needs of the residents. This includes completing a national vocational qualification (NVQ). The home carries out a thorough recruitment process to ensure residents are not placed at risk of harm. The manager and the company regularly monitors the standard of care provided in the home and meetings take place with residents, relatives and staff to seek their views and ensure staff are aware of their responsibilities. What has improved since the last inspection? Following the last visit to the home the home was issued with a requirement to register the manager with the Care Quality Commission. The manager applied to, and successfully registered with the Commission. The home is continuing to develop its person centred approach and routines have changed to suit residents individual needs. Improvements to the homes decoration, cleanliness and environment have been made, and new ideas in respect of activities are encouraging more residents to participate and develop relationships with other residents living in the home. The home has re-established the NVQ programme and more staff now have, or have enrolled on a NVQ. What the care home could do better: The home tells us in their Annual Quality Assurance Assessment that they have made improvements in effectively identifying residents at risk of malnutrition. They told us this has been achieved by using the Malnutrition Universal Screening Tool (MUST). Each resident has a nutritional assessment undertaken on them on admission, which requires regular monitoring and reviewing to ensure residents are receiving the correct level of nutrients and fluids. There is evidence that assessments are not regularly reviewed and residents are not receiving the required assessed level of fluids, placing them at risk of malnutrition and dehydration. The home could do better to ensure staff are fully aware of the importance of maintaining a healthy nutritional diet and the importance of accurate monitoring and recording. The home is required to improve this area of care. Key inspection report Care homes for older people Name: Address: Flowerdown Nursing Home Harestock Road Winchester Hampshire SO22 6NT     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: Christine Walsh     Date: 2 1 0 1 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 33 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 33 Information about the care home Name of care home: Address: Flowerdown Nursing Home Harestock Road Winchester Hampshire SO22 6NT 01962881060 01962881935 flowerdown@fshc.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Tamhealth Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Name of registered manager (if applicable) Mrs Violet Gwaze Type of registration: Number of places registered: care home 53 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 53. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP). Date of last inspection Brief description of the care home Flowerdown Nursing Home is registered to provide care and accommodation for fifty three older persons who require nursing care. The home has been extended over the years and accommodation is provided in forty eight single rooms and one shared room, situated on two floors of the old house and Care Homes for Older People Page 4 of 33 0 Over 65 0 Brief description of the care home the new extension. The home has completed an extensive programme of redecoration and refurbishment. The home has large well-maintained gardens and ample parking space. Flowerdown is owned and operated by Four Seasons Health Care, a large independent care provider in the UK. The home is situated in a semi rural area on the outskirts of Winchester, Hampshire. The home accepts residents funded by Social Services with top-up fees. Service users pay extra for hairdressing, chiropody and personal toiletries. Care Homes for Older People Page 5 of 33 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 Annual Quality Assurance Assessment (AQAA) document was completed by the registered manager and sent to the Care Quality Commission on time. The AQAA informed us that the service ensures the race, gender identity, disability, sexual orientation, age, religion and beliefs of the residents are promoted at the point of pre-admission assessment, which is comprehensive. The AQAA told us residents preferences around activities and religion are respected and catered for and staff receive person centred care and equality and diversity training has been introduced and proving effective. The information obtained to inform this report was based on viewing the records of the people who use and work for the service. For this purpose the records of four residents were looked at in depth. The day-to-day management of the home was observed, and discussions took place with residents, relatives and staff. In addition Have Your Say Care Homes for Older People Page 6 of 33 comment cards were completed and assisted in informing this report. The people who use this service are referred to as residents. The service was last inspected in February 2009 and received a 1 Star (Adequate rating) following that visit. Care Homes for Older People Page 7 of 33 What the care home does well: What has improved since the last inspection? Following the last visit to the home the home was issued with a requirement to register the manager with the Care Quality Commission. The manager applied to, and successfully registered with the Commission. The home is continuing to develop its person centred approach and routines have changed to suit residents individual needs. Improvements to the homes decoration, cleanliness and environment have been made, and new ideas in respect of activities are encouraging more residents to participate and develop relationships with other residents living in the home. The home has re-established the NVQ programme and more staff now have, or have enrolled on a NVQ. Care Homes for Older People Page 8 of 33 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. 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 33 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 33 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. The home ensures the people who wish to move into the home have their needs assessed prior to admission, this is to make sure the home can meet their needs. However the home must ensure all areas of the assessment are completed, such as areas that address equality and diversity. These areas must be completed to ensure vital information about the prospective residents is not missed. The home does not provide intermediate care. Evidence: The AQAA (Annual Quality Assurance Assessment) told us. Prospective residents and their families are treated as individuals and with dignity and respect for the life changing decisions they need to make. The AQAA also told us prospective residents are supported and encouraged to be involved in the assessment process, which is carried out by skilled staff. Before agreeing admission we carefully consider the needs Care Homes for Older People Page 11 of 33 Evidence: assessment for each individual prospective person and the capacity of the home to meet their needs. The home uses the CHAP (Care and Health Assessment Profile) assessment. The document is comprehensive and covers all aspects of the residents physical, mental and social wellbeing. The assessment tells the reader the residents strengths and the areas of support and how they need to have their specific needs met. The assessment identifies areas of potential risk which then links to further assessment and identifies what action is required to lessen the risk. An example of this was seen in respect of residents risk of developing pressure ulcers, of which four were viewed. The assessment links to a weight management plan, which includes required daily dietary and fluid intake and monitoring of vulnerable pressure areas. The assessment also includes an area where the social, sexual, religious, ethnic origin and their wishes at the time of their death are recorded. It was noted that for the residents whose assessments were viewed these areas had not been completed. This was previously raised with the manager during the last visit to the service. The AQAA told us the assessment is comprehensive and is carried out by skilled staff who are sensitive to the needs of the prospective resident, however this is not evidenced by the areas that are not completed in the assessment document. The AQAA also told us that staff have received equality and diversity training. Vital information about the prospective resident could be missed and have an impact on their future care if these areas in the assessment are not completed. It was noted that residents are asked what gender of staff they would like to have to assist them with their personal care and what they name they would like to be known and called by. Care Homes for Older People Page 12 of 33 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 home ensures each person who uses the service has a personal plan in place that describes how they wish to be supported, this demonstrates an understanding of person centred planning, however care plans must be followed to ensure peoples needs are being met. Some areas of care require improvement and better monitoring by management and senior nursing staff to ensure the people who use the service are having their health care needs met, such as their nutritional health and weight management. The people who use the service receive their medications by safe administration practices. The people who use the service are supported by staff who are aware of the values of dignity and privacy and treating people with respect but who dont always put these principles of care into practice. Care Homes for Older People Page 13 of 33 Evidence: The AQAA told us The pre admission is completed fully which enables staff to develop a comprehensive person centred care profile. The care plans are highly individualised and they include evidence that we value improving outcomes for people who use the service. The AQAA also told us that the service has a comprehensive internal audit and monitoring system resulting in robust action plans to identify and address shortfalls. It also told us home could do better to Improve documentation by keyworkers so that they do daily entries instead of at least once a month. Four residents personal plans were viewed. The care plans are developed from the information obtained from the pre-assessment document and covers areas of health and personal care and residents emotional and social welfare. The pre-assessment document provides detail on the residents individual likes and dislikes and how they wish to be supported. Areas of residents health and personal care identified as needing support and/or are at risk are documented in the care plan for staff to follow. Care plans appear person centred and reflect how the resident wishes to be supported from getting up to going to bed. The majority of Have Your Say comment cards received from residents, relatives and visiting professionals told us they are happy with the standard of care provided in the home. Despite the home identifying risks it was evidenced that actions required to minimise risks were not carried out as stated in the care plans and risk assessments. All personal plans seen for four residents told us they were at risk of malnutrition, weight loss and risk of pressure ulcers developing. Their body mass index (BMI) were assessed as very low making them a high risk of developing pressure ulcers and malnutrition. Despite evidence that the home is taking steps to minimise the risk of residents getting pressure ulcers, there was limited evidence that action was being taken to minimise the risk of weight loss, dehydration and malnutrition. A recent quality audit (Regulation 26 visit) identified concerns regarding weight loss, the regulation 26 report identified and recorded an action to refer to a dietician this had not taken place. An investigation into a recent complaint also identified staff failed to record all fluids given and taken by the resident concerned. The service is placing residents at risk of dehydration and malnutrition and must address this concern. Training records told us both carers and trained staff will be receiving training in using Care Homes for Older People Page 14 of 33 Evidence: the Malnutrition Universal Screening Tool (MUST). The manager told us the home has developed good relationships with healthcare professionals and all residents are supported to access a general practitioner when required. This was observed on the day of the visit when it was identified during the managers visit to each resident that some residents required a doctors visit. A trained member of staff told us she was aware of her role and responsibilities in ensuring residents receive the right care and support to maintain a healthy lifestyle and are made comfortable during their end of life. The member of staff told us they had received training in safe administration of medication and setting up syringe drivers. Residents are supported with their medication. Medication administration records (MAR) provided evidence that residents receive their medication as required, using safe practices as per the Royal Pharmaceutical Guidelines. There is evidence that the manager regularly audits medication, including administration, recording and storage. The registered manager demonstrated that she has an awareness of the importance of respecting the dignity and privacy of residents at all times and in all aspects of their care. The manager told us this starts for the resident at the assessment stage when you are asking them how they would like to have their needs met. A health professional told us. The registered manager has a wonderful way with the residents, she is respectful and encourages as much independence as possible. Through observation it was evidenced residents were being addressed respectfully and time was being made to listen, respond and act on requests. Through observation of the residents it was clear that attention had been taken in respect of their appearance and dress. Staff spoken with at the time of the visit told us they had received training in the Principles of Care, which included the core values of respecting residents privacy and dignity and respecting individual rights, wishes and needs. The registered manager must however ensure conversations held between relatives, visitors and staff of a personal nature, are not held in a public place, as this breaches the confidentiality of the resident. A conversation of a private and which included intimate details about a resident was overheard in the foyer of the home. Care Homes for Older People Page 15 of 33 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 social, cultural, religious and recreational interests and needs of the people who use the service meet their expectations and preferences. The service provides a welcoming and comfortable home where residents can meet and are supported to maintain contact with family and friends. Improvements have been made in respect of supporting people who use the service to exercise choice and control over their lives. People who use the service are provided with three meals a day of their choice in pleasing and comfortable surroundings. Evidence: The AQAA told us We employ an enthusiastic Personal Activities Leader who has spent time with residents identifying their interests as individuals, including developing life histories. It went onto tell us Some residents have access to groups e.g. Community lunch clubs and meal times are calm and unrushed. Care Homes for Older People Page 16 of 33 Evidence: The home has a comprehensive activity programme of which residents are encouraged to participate in. The registered manager told us activities are driven by the homes enthusiastic activities coordinator, who recently has introduced a gentlemans club. There was evidence of activities taking place at the time of the visit and photographs of residents engaged in stimulating activities such as Arts and Crafts, celebrating birthdays, outside entertainers and religious activities including Holy Communion. Good feedback during this and previous visits told us residents are pleased with the variety of entertainment and activities provided for them. The registered manager told us the gentlemans club is proving to be a success and encouraging residents who would normally stay in their rooms to participate. An adapted dart board and football table is available and the gentlemen have access to old war movies, Wii games and other table top games such as chess and droughts. An occasional beer is also enjoyed. The activities coordinator is in the process of developing a ladies club, which will include knitting and crocheting amongst other activities enjoyed by ladies. The home has a pleasant and tastefully decorated quiet room where residents can meet with their relatives if they wish. The quiet room has a pleasant outlook into the garden. It is warm and comfortably furnished. The manager informed us the room can be used for family gatherings to celebrate birthdays and anniversaries. Visitors were observed being welcomed warmly and the registered manager made herself available to speak with visitors if they wished to do so. A resident told us they were very pleased to see their relative who had visited the home earlier in the day. The same resident told us they had made friends with another person living in the home and looked forward to their daily meetings, where they share a cup of afternoon tea and often go for a walk around the garden together. The registered manager told us friendships between residents is important and encouraged in the home. A resident told us at the time of the visit. I dont want for anything, Im happy with the staff and care provided, I enjoy the food but prefer not to join in activities. The development of person centred planning and providing staff with training in the Principles of Care and Equality and Diversity tells us the home is taking into account Care Homes for Older People Page 17 of 33 Evidence: the needs, wishes, choices and decisions made by residents. This was observed on the day of the visit, staff were observed to be offering choices of beverages, meals and activity. It was also noted residents were supported to spend their day as described in their personal plans. The registered manager told us the home will be providing all staff with training in respect of deprivation of liberty, (DOLs), this is to ensure the best interest of residents is not denied because their capacity to make decisions has been affected by their illness, this includes having photographs taken and use of bed rails. The registered manager told us the home is in the process of developing staffs understanding of DOLs as it recognises that this is an area where the home needs to improve. Each persons personal plan tells the reader the specific likes, dislikes and food allergies resident may have. As referred to in Health and Personal Care standard eight, a MUST assessment takes place. However as previously stated evidence told us action is not taken to minimise identified risks. The service provides residents with support to eat and drink when required and physical aids, such as guards on plates and lids on cups to prevent spillages. This assists in preserving the residents independence and dignity. Meals were observed to be appealing and wholesome. Residents told us at the time of the visit that they enjoyed most meals they receive. Four Have Your Say comment cards received from residents told us two always like the meals they receive and two told us sometimes they like the meals. Care Homes for Older People Page 18 of 33 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 people who use the service are confident that the home is listening to their concerns/complaints and acting on what they are saying. The home must ensure all areas of the persons health and wellbeing are protected to minimise the risk of harm. Evidence: The AQAA told us all complaints are handled as per the company policy and all complaints are taken seriously. The AQAA went on to tell us that the home reports all safeguarding issues without delay to ensure the safety of those involved. All staff have a PoVA check before working in the home and receive training in the protection of vulnerable adults. The numerical data in the AQAA told us the home has received six complaints in the last twelve months of which 83 percent were resolved within a twenty-eight period. This is a considerable reduction from the fourty-five complaints received the previous year. The registered manager told us she feels this is because she and her staff make themselves available to meet with and listen to residents and their relatives, dealing with concerns as quickly as possible. Care Homes for Older People Page 19 of 33 Evidence: Staff spoken with at the time of the visit told us how they would respond to concerns, which included always trying to deal with the concern as soon as possible, writing the concerns down and informing a senior member of staff or the manager. The registered manager told us she has an open door policy, meets with each resident everyday during her rounds and holds regular meetings with residents and relatives to keep them up to date with changes and to listen to their views and ideas. A relative told us. There are regular meetings with the manager for residents and relatives. The manager is always available to deal with any problems and listen to suggestions. She has a very hands on style. A resident told us. I find staff pleasant and helpful and always ready to listen. Residents who were spoken with said they know who to speak to if they are unhappy. They told us they regularly see the manager who asks them if everything is ok. The AQAA told us that where complaints raise concerns that a resident has been abused they will make an immediate referral to social services under the Local Authorities Safeguarding Protocol. The home notifies the Care Quality Commission when a referral has been made. The Care Quality Commission is aware the home has taken appropriate action to safeguard residents and has made referrals to Social Services and the Protection of Vulnerable Adults register (PoVA), when required. Staff are referred to PoVA (referrals will now be made to the Independent Safeguarding Authority (ISA)) when they have been dismissed for abuses against vulnerable adults. The register enables providers of care services to check all new staff prior to offering them a job and ensure they do not pose risk to residents in their care. The registered manager provided evidence that all staff undergo a PoVA and a criminal record bureau (CRB) check before starting in the home. The registered manager also provided evidence that all staff have received training in abuse awareness, which is repeated annually. Care Homes for Older People Page 20 of 33 Evidence: Staff spoken with at the time of the inspection and in Have Your Say comment cards confirmed they had received training and are aware of what to do if they suspect or witness an abusive act. Care Homes for Older People Page 21 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service live in a spacious, clean and welcoming home, which is free from unpleasant odours. Evidence: The AQAA told us the home employs a full time maintenance person who is supported by the Regional Estates Team. The AQAA told us the home holds three monthly health and safety meetings and the home is kept clean and tidy by a housekeeper who directs her team to ensure all areas of the home are maintained. Flowerdown Nursing Home is a large home accommodating up to fifty-three residents. The home is built over two levels and over a number of years has been extended to accommodate the needs of residents and the current number of places. A tour of the building provided evidence that care has been taken to provide a homely and welcoming environment which has been tastefully decorated and furnished to a high standard. Communal areas are bright, airy and spacious. Residents spoken with at the time of the visit said they liked the homes environment and that their bedrooms were comfortable. Bedrooms were observed to be homely, clean, well maintained and personalised reflecting the residents personality and individuality. Care Homes for Older People Page 22 of 33 Evidence: The garden has been landscaped and includes raised flowerbeds, a water feature and patio area. There is access to the garden from some of the ground floor bedrooms. Bird tables and surrounding woodland encourages wildlife into the garden. A number of residents commented on how they enjoy watching the birds and squirrels from their rooms and how delighted they had been to see a young deer in the garden a couple of days previously. The AQAA told us in the last twelve months they have redecorated bedrooms as they have become vacated and before admitting a new resident, all worn carpets have been replaced and communal rooms are now being used effectively. Changes to the environment were seen at the time of the inspection and noted to have been completed tastefully and in keeping with the style of the home. The registered manager told us she continues to work with the housekeeper to ensure the environment is cleaned to a high standard, and to ensure the home remains free from unpleasant odours and the risk of infection is minimised. The housekeeper told us she takes pride in her work and is proud of her team who work very hard to maintain good hygienic standards. This was evident during a tour of the home. The home has separate laundry and sluicing facilities. In these areas of high infection risk staff are provided with appropriate training and protective clothing. Discrete notices around the service advises staff of the importance of good hygiene practices and notices in clinical areas inform the staff how they must wash their hands. Training records tell us that all staff including ancillary staff have received training in infection control. A member of staff confirmed that she has received infection control training and that staff are made aware if a resident has or is a carrier of an infectious condition. Throughout the service including the entrance, antibacterial hand gels are in place and visitors are encouraged to use them. Staff were observed wearing protective clothing to coincide with the activity they were carrying out. Different colour disposable aprons and gloves are used when supporting residents with personal care and assisting them with meals. Care Homes for Older People Page 23 of 33 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. The home continues to ensure there are sufficient numbers and skilled staff to meet the needs of the people who use the service. The service carries out appropriate recruitment checks on staff, which minimises the risk of harm to the people who use the service. The service ensures all staff are provided with the appropriate training and skills to meet the needs of the people who use the service. However all staff would benefit from training in effectively meeting peoples nutritional/fluid intake needs and accurate record keeping. Evidence: The AQAA told us We have not used agency staff for the last ten months and that has helped with the consistency of care the residents receive. The AQAA goes onto tell us the home does well to provide training for carers and trained staff and to enrol carers on a national vocational qualification (NVQ). The numerical data in the AQAA told us the service currently has fourty-five staff, including trained and ancillary staff. The registered manager told us there are a small number of vacancies which she is currently in the process of recruiting to. Care Homes for Older People Page 24 of 33 Evidence: Staff were observed carrying out their day-to-day duties using a calm and relaxed manner, spending time with residents in light hearted discussion and answering call bells promptly. A relative told us. There is now a consistency of staff, there appears to be a low staff turnover and the use of agency staff has been eliminated. The quality of carers is high. Another said. My mother is well looked after. Following the last visit to the home the registered manager was informed improvements were needed in the area of staff achieving a NVQ. At the time there were less than fifty percent with a NVQ. The manager provided evidence that more staff are currently undertaking a NVQ and others are in the process of being nominated to enrol. A member of staff told us she had been nominated to do a NVQ and had received a wide range of training since she had started working in the home. Recruitment records seen at the time of the inspection told us the home carries out a thorough recruitment process. It requests an application to be completed, obtains appropriate checks, for example, a CRB and PoVA check, two references and asks the applicant to attend an interview. Comment cards received from staff told us their employer carried out checks before they started working in the home. The registered manager told us all new staff complete an induction into the home, and are supervised by a trained member of staff. A completed induction booklet was seen and told us staff receive training in the principles of care, understanding the organisation, safety at work, which includes training in moving and handling, food hygiene and infection control and communicating effectively, which includes record keeping. A training matrix provided evidence of the varied training staff have received and training planned for in the next six months. A trained member of staff told they also receive training to maintain and improve their clinical skills, such as the use of syringe drivers (a devise used to administer medications at a regular measured dose), care plan training and administering medication. This demonstrates the registered manager is equipping staff with the skills to meet the diverse needs of residents, however the manager must consider the importance of ensuring all staff are aware of the importance of accurate record Care Homes for Older People Page 25 of 33 Evidence: keeping. Evidence at the time orf the visit told us records in respect of monitoring fluid and food intake were not being completed accurately. Care Homes for Older People Page 26 of 33 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service benefit from a manager who has been registered as fit to run the home and discharge her responsibilities fully. The home has quality systems in place to seek the views of people who use the service and improve quality. However the identified concerns raised in Health and Personal Care must be addressed to ensure quality of care is maintained and continually monitored. The service has policies and procedures in place to ensure the people who use and work in the home are kept safe. Evidence: The AQAA told us, We maintain all statutory records and documentation required by current legislation. It went on to tell us the manager has an open door policy and involve staff in the day-to-day running of the home including inviting them to health and safety and quality and clinical governance meetings. Care Homes for Older People Page 27 of 33 Evidence: Since the last visit to the home in February 2009 the manager has been registered as Fit by the Care Quality Commission to manage the service. The registered manager knew at the time of the last visit that improvements were required to bring the home up to standard. On this occasion she told us she is aware there is always room for improvement which she continues to look at with the involvement of residents, relatives and with the support of staff as to how this can be done. The manager demonstrates clear leadership skills and values, this is supported by comments received from residents, relatives, staff and other professionals. They tell us the manager is approachable, always available, listens to them and works hands on side-by-side staff, offering guidance and support. This was observed on the day of the inspection. A member of staff told us. Violet is always very interested in the residents and she is very approachable. A visiting professional told us. The manager of the home is always willing to help. Another staff member said. There have been a lot of changes in the last eighteen months. I think our attitude towards improving our home is good. We are always looking to improve the quality of life for our residents. Despite the home having an enthusiastic and person centred registered manager, there still remains concerns regarding the individual health and personal care of residents, especially those who require assistance to maintain a healthy nutritional diet and fluid intake, which the registered manager must address and regularly monitor. The home has a number of systems in place to monitor the quality and performance of the service. The manager told us she holds regular meetings with residents, relatives and staff and has taken on their comments in ways that they can improve standards in the home. In addition regulation 26 visits are undertaken on a monthly basis. (A service manager who does not work day-to-day in the home will visit the service and assess quality and standards by talking to residents, staff and visitors. Records relating to the residents, Care Homes for Older People Page 28 of 33 Evidence: staff and the environment are also viewed. A report is completed identifying areas where improvements have been made and areas for further improvement). A copy of this report is kept in the service. We saw evidence of these reports, which detailed actions and time scales. There was evidence on this occasion however that not all actions have been addressed. The home supports residents to keep their personal finances safe. The homes administrator has the responsibility to deposit, withdraw and maintain accurate records of expenditure. This is done using a specific computerised system, which the administrator told us she updates regularly and which provides a clear audit trail. The administrator went on to tell us regular audits are carried out by internal and external auditors. During the course of the inspection the homes head of maintenance carried out checks on the homes fire alarms and fire fighting equipment. Fire records provided evidence that fire systems and equipment is serviced by external contractors and by the head of maintenance, however it was noted in records that there had been three consecutive weeks where fire alarms had not been checked. The registered manager told us she will address this shortfall. Training records provided evidence that all staff had received a least two training sessions in fire fighting and had received other training in respect of health and safety. Care Homes for Older People Page 29 of 33 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 30 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 12 The service must ensure all 31/03/2010 people who use the service who are identified as at risk of malnutrition receive required daily food and fluid intake and records accurately reflect changes to their nutritional needs. This is to ensure the people who use the service have their health care needs met and maintained. 2 38 24 The service must consult 16/04/2010 with the fire safety service in respect of what fire checks must take place and how often. The service must ensure the health, safety and welfare of the people who use the service is promoted and protected. Care Homes for Older People Page 31 of 33 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 30 It is recommended that all staff recieve training in record keeping, to ensure accurate records are kept at all times on the people who use the service. Care Homes for Older People Page 32 of 33 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. © 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. Care Homes for Older People Page 33 of 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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