Care Home: Forest Care Village Elstree & Borehamwood

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What the care home does well Forest Healthcare senior managers provide support for the home`s manager and management team, and all together form a cohesive and strong management team for the service. The ethos of the home is that the whole staff, from senior managers to housekeeping and ancillary staff, work as a team together for the benefit of the people who live in the home. The home has very good procedures for monitoring the quality of the services it provides, and the people who live in the home are fully consulted and involved in decision making, both individually and through the elected residents` committee. There is a stable staff team who are enthusiastic about their work. During the inspection, all the staff we met were very keen to tell us about what they have been doing and the improvements that have been made in the home. The ethos of the home is that the welfare of the residents is everyone`s responsibility, and that all the staff, from the managers and registered nurses to the housekeeping and ancillary staff, work as a team. Everyone who we spoke to in the home was very pleased with the nursing care and personal care they receive. Several people said that the care is very good, and the staff do everything they can when they ask for help. One person said, "Oh, I really like the nurses." Another person said, "We are well looked after." The least positive comment was, "We are looked after okay but they have to get through so much." The home provides a very good standard of nursing care, with a high level of expert support. The dementia care unit now provides an excellent environment and quality of care for the people who live there. There was a very pleasant and relaxed atmosphere, and the staff appeared at ease, and engaged with people very well. The staff who we spoke to in the dementia care unit said that they had had good training and support and that they enjoyed their work and they were dedicated to providing a good quality of care. The home has a team of activities co-ordinators, the Lifestyle team. Different activities are held in different units each day, and people from everywhere in the home can join in. Several people said that they particularly enjoy the sessions with the music technician, and we observed some of these sessions, which were very much enjoyed with enthusiastic participation, during our visit to the home. What has improved since the last inspection? In the last inspection report we noted that the dementia care unit had improved in overall care and support. This has been consolidated and there have been further improvements, as noted above. The changes in the management team have affected the whole staff team throughout the home, and there was a very positive atmosphere throughout the home during our visit. The village atmosphere of the home has been enhanced by the large entrance hall, which contains a Village Shop that is run by residents, and a Village Cafe. The areacreates a feel of a village square, and provides a social meeting place for people from all areas of the home and their visitors. All the staff, including domestic staff and ancillary staff, have training in safeguarding vulnerable people, and in people`s rights under the Mental capacity Act. The home has responded appropriately to safeguarding concerns that have arisen during the last year, and there has been a reduction in the number of complaints to the home. What the care home could do better: The home provides a very good quality of nursing care, personal care and dementia care for the people who live there. We are confident that the manager and the organisation will continue to be proactive in ensuring that they meet the needs of the people who live in the home, and that the continued good practice will result in excellent outcomes. One area where the quality of care could be improved in order to make the care provided truly person centred and to meet the high aspirations of the service, is the Savannah Suite and Green Wing, for younger people with traumatic brain injury and other cognitive difficulties. The Annual Quality Assurance Assessment (AQAA) states that the philosophy of the Savannah Suite is to encourage independence of the people who use the service, despite their declining cognitive ability. However the ethos that we observed was more of a caring containment rather than positive cognitive rehabilitation and understanding. The guidelines and information on how cognitive impairment affects each person and the management of each person`s behaviour is not sufficiently detailed so that the staff know clearly what they should do, and we saw several instances where staff did not follow guidelines in the care plans. We were also concerned about the use of key pads for access to and from the dementia care units and the Savannah Suite and Green wing. The people who live in these units and their visitors do not have access to the numbers for the key pads, which means that they are not able to enter or leave as they wish, without staff assistance and supervision. This restricts the freedom of people in the home, and may be seen as a deprivation of liberty. We found that the temperature of the water in one bathroom was excessively hot, and that water temperatures are not monitored frequently enough to pick up any health and safety concerns. A new regulating valve was fitted to the faulty tap while we were in the home. One further improvement that will lift the experience of the people who live in the home is to ensure that people who are unable to or do not choose to leave their rooms to join in social activities in the home, do not feel isolated. Several people told us that they like to stay in their rooms, but no-one comes to their rooms to spend time socially with them. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Forest Care Village Elstree & Borehamwood 10-20 Cardinal Avenue Borehamwood Hertfordshire WD6 1EP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Claire Farrier     Date: 3 0 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 35 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 35 Information about the care home Name of care home: Address: Forest Care Village Elstree & Borehamwood 10-20 Cardinal Avenue Borehamwood Hertfordshire WD6 1EP 02082362000 02082073989 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Aspen Village Limited Name of registered manager (if applicable) George Catanescu Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 178. 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: Old age, not falling within any other category - Code OP. Dementia - Code DE. Physical disability Code PD. Date of last inspection Brief description of the care home Forest Care Village is owned and operated by Forest Healthcare, which is a private organisation. It is registered to provide nursing care and accommodation for 178 people with nursing care needs, who may have physical disbilities, or who may have dementia. Care Homes for Older People Page 4 of 35 care home 178 Over 65 0 178 0 178 0 178 Brief description of the care home Forest Care Village is a purpose built two storey building, with a small third storey. The home is divided into separate units. On the ground floor nursing care is provided for younger people with physical disabilities. On the first floor the Cardinal unit provides nursing care for older people. There is a fully equipped physiotherapy room. The Green Wing on the first floor and the Savannah Suite on the second floor provide the unit for younger people with traumatic brain injury and other cognitive difficulties. The dementia unit is on the ground floor and first floor. All the bedrooms are single and all have en-suite facilities. There is a lift to all the floors and the home is accessible for wheelchair use. The complex is situated a short level walk from the main shopping area of Borehamwood and accessible from the nearby main railway station. There is ample parking within the complex and people in the dementia care unit have access to a sensory garden to the rear of the property. Information regarding the service is included in the Statement of Purpose and the Service User Guide. For copies of these documents, the most recent CQC inspection report and up to date fees contact the home manager. Care Homes for Older People Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last inspection of this service was completed on 12th May 2008. On this occasion three inspectors spent one day at Forest Care Village, and the people who live there and work there did not know that we were coming. The focus of the inspection was to assess all the key standards. Some additional standards were also assessed. An Expert by Experience (EBE) took part in the inspection. The EBE is a person who has experience of the services that the home provides. The EBE met and talked to seven people who live in the home and two visiting relatives. We spent two hours sitting with people in the areas of the home where the most vulnerable people are looked after. This is called a SOFI - Short Observation For Inspectors. The aim of this is to get an impression of what life is like for the people who live there. We spoke Care Homes for Older People Page 6 of 35 to several people who were visiting the home. We also talked to some of the staff. When we were in the home we looked at the homes records, care plans and staff files, and we made a tour of the premises. We made a return visit two days later to complete the inspection and to talk to the manager about what we had seen during the inspection. The manager sent some information (the Annual Quality Assurance Assessment, or AQAA) about the home to CQC before the inspection, and his assessment of what the service does in each area. Evidence from the AQAA has been included in this report. What the care home does well: What has improved since the last inspection? In the last inspection report we noted that the dementia care unit had improved in overall care and support. This has been consolidated and there have been further improvements, as noted above. The changes in the management team have affected the whole staff team throughout the home, and there was a very positive atmosphere throughout the home during our visit. The village atmosphere of the home has been enhanced by the large entrance hall, which contains a Village Shop that is run by residents, and a Village Cafe. The area Care Homes for Older People Page 8 of 35 creates a feel of a village square, and provides a social meeting place for people from all areas of the home and their visitors. All the staff, including domestic staff and ancillary staff, have training in safeguarding vulnerable people, and in peoples rights under the Mental capacity Act. The home has responded appropriately to safeguarding concerns that have arisen during the last year, and there has been a reduction in the number of complaints to the home. 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 set out on page 4. Care Homes for Older People Page 9 of 35 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 35 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 35 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 who are considering moving into the home have sufficient information, and a detailed assessment, to be confident that their needs will be met. Evidence: The home has an up to date Service User Guide and Statement of Purpose available to prospective residents and their families to provide them with the information they require to make an informed choice. The website for Forest Healthcare (www.foresthc.com) is easily accessible and provides information on the services provided by the home. The Annual Quality Assurance Assessment (AQAA) states that in the next 12 months the web site will give far more information regarding the services available at Forest Care Village. Forest Healthcare are planning to produce a DVD with information for professionals and another one aimed at people who are considering moving to the home. The Statement of Purpose states, Our primary objective is to improve the quality of life of our clients and their families and we seek Care Homes for Older People Page 12 of 35 Evidence: to promote independence, choice and dignity of the individual. We believe that clients must be safe and secure at all times, whilst providing a relaxing and stimulating environment that motivates them to live a full and happy life. From this inspection we have assessed that the home has gone a long way towards meeting these aspirations, and that the Statement of Purpose provides an accurate account of the services that the home provides. One amendment should be considered. The Statement of Purpose states that the home provides neuro and spinal injury care for the younger person (1865 years). However we met one person in the unit for people with cognitive impairment who was aged 77, and had been over 65 when admitted to the home. The Statement of Purpose should specify very clearly who the services can be provided for. The home carries out comprehensive assessments before people move to the home. The information from the assessment is used to write the care plans, and these provide the staff with the information that they need in order to provide a good quality of care for each person. The assessments include risk assessments for moving and handling and the risk of falls, for pressure area care and for nutritional needs. We looked at the contracts for people who are privately funded. They contain details of the homes terms and conditions, and the fees for each person, and signed agreements are kept in the home. Letters are sent out to notify people of any changes to the fees. Care Homes for Older People Page 13 of 35 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live in the home are confident that they will receive a good quality of personal care and healthcare. However the care plans for people with cognitive impairment do provide sufficiently detailed information on how cognitive impairment affects each person and the management of each persons behaviour. The ethos for these people is more of a caring containment rather than positive cognitive rehabilitation and understanding. Evidence: Everyone who we spoke to in the home was very pleased with the nursing care and personal care they receive. Several people said that the care is very good, and the staff do everything they can when they ask for help. One person, who had had a stroke and was unhappy with their situation, spoke to the Expert by Experience (EBE), and grudgingly agreed that their care in the home was okay. This person said, Oh, I really like the nurses. Another person, who the EBE described as severely disabled, said, We are well looked after. The least positive comment was, We are looked after okay but they have to get through so much. One person who was staying in the home Care Homes for Older People Page 14 of 35 Evidence: for a short respite break said that the staff had been very gentle when using the hoist. The home provides a very good standard of nursing care, with a high level of expert support. GPs from the local medical centre attend three sessions a week at the home. A neuro rehabilitation consultant and consultant physiotherapist from Northwick Park Hospital visit the home on a fortnightly basis. The home employs their own physiotherapists, and there is access to a speech and language therapist when needed. The home also has good support form the local tissue viability nurse and the support services for diabetes and for enteral feeding. Several of the nurses employed in the home have specific skills. We looked at a sample of care plans in different areas of the home. The care plans are generally well written, with good details of each persons personal care needs and healthcare needs. They include assessments for pressure area care and nutritional assessments for each person, and there are good systems for monitoring the risks of pressure sores, falls, and poor nutrition. There are good risk assessments that ensure that people can live safely in the home. The care plans for people who need end of life care showed that the staff have the expertise and understanding to provide a caring and comfortable environment. There is multi-disciplinary professional involvement, and good procedures for management of symptoms and pain control. On the dementia care unit the care plans contain good information on each persons health and personality, with risk assessments and guidelines for their behaviours. Our observations showed that the staff were aware of these guidelines, for example for close supervision for one person, and for aggressive language and how to assist with eating a meal for another. We spent some time sitting with people in the area of the home where the most vulnerable people are looked after. The aim of this was to get an impression of what life is like for the people who live there. There was a very pleasant and relaxed atmosphere. The staff appeared at ease, and engaged with people very well. They talked to people while they were assisting them so that the person understood what was happening. They used respectful but friendly language when talking to people, and spent time with each person, talking to them or using hand massage. Everyone was alert and interested in their surroundings. The staff who we spoke to said that they have good training and support and that they enjoy their work and they are dedicated to providing a good quality of care. The dementia care unit now provides an excellent environment and quality of care for the people who live there. In the Savannah Suite and Green wing, the units for younger people with cognitive impairment, the care plans were hand written, and some were not easy to read. The guidelines and information on how cognitive impairment affects each person and the Care Homes for Older People Page 15 of 35 Evidence: management of each persons behaviour is not sufficiently detailed so that the staff know clearly what they should do. We saw several instances where staff did not follow guidelines in the care plans. One person has a care plan that states that they are inclined to talk about their previous employment as though it was the present. The care plan states that staff should orient this person, and remind them always of the time, place etc. But we saw one staff member asking this person about their work, where they were going that evening, and what they would be doing, which exacerbated the disorientation. This persons room was very bare, with no curtains, no personal possessions, and damaged furnishings. The staff who we spoke to said that this person preferred it that way, and a risk assessment for aggression stated that unnecessary stimulus should be removed, as this can cause injury to the person or to others. But there is no consideration that the bare room may trigger some disorientation. Proper consideration should be given, and recorded, to how this persons environment may be improved. Another person moved to the Green Wing from the younger persons unit on the ground floor in order to address some of their behaviour. However their care plan does not provide any clear guidelines so that staff can understand and support this person to manage their behaviour. There are some risk assessments, but they are poorly written and unclear, and do not show how the person can be supported to carry out their chosen activities in a safe way. One of these risk assessments is for absconding, which is a derogative and punitive term for the person wishing to walk out of the home. ABC charts for monitoring peoples behaviour are available in the unit, but they are not used, and the staff who we spoke to did not have a clear understanding of the reasons for using them. The Annual Quality Assurance Assessment (AQAA) states that the philosophy of the Savannah Suite is to encourage independence of the people who use the service, despite their declining cognitive ability. We have observed disruptive and challenging behaviour diminish almost to the point of non existence, and it only tends to be present when there is a change of some sort. However the ethos that we observed was more of a caring containment rather than positive cognitive rehabilitation and understanding. Improvements in the other parts of the home mean that most of the nursing care is very good, and dementia care is excellent. The Savannah Suite and Green Wing are areas where further improvement is needed, in order to make the care provided truly person centred and to meet the high aspirations of the service. The records made when medication is received into the home and when it is given to residents are reasonably good and demonstrate that generally people receive the medication as prescribed. We carried out a spot check of a sample of medication records in the Savannah Suite and the Cardinal unit. In three cases the MAR (medication administration record) chart did not tally with the number of tablets that were available, and in one case the medication had been administered but the MAR Care Homes for Older People Page 16 of 35 Evidence: chart was not signed. There is no evidence that medication has been administered incorrectly, but the recording needs to be more accurate. A robust system of auditing would ensure that any errors are noticed and rectified without delay. The BNF (a reference book that provides up-to-date guidance on prescribing, dispensing and administering medicines) that we saw in the home was dated 2006, and should be replaced with up to date copies. The home maintains some homely remedies. These are medicines that can be bought over the counter and do not require a prescription such as Paracetamol. The protocol for administering these has been signed by the GP, and the records show the reasons for giving the remedy. Appropriate risk assessments are in place for people who take Warfarin, and for people who look after their own medication. Care Homes for Older People Page 17 of 35 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has facilities and staffing to provide a stimulating environment for the people who live there. However people who choose not to join in the programmed social activities may feel isolated. Evidence: The home employs a team of activities staff, the Lifestyle team. Different activities are held in different units each day, and people from everywhere in the home can join in. The home has several shared areas and smaller spaces where people can socialise and enjoy activities. In the entrance hall there is a cafe environment, and activities such as bingo and music also take place there. The entrance hall also contains a Village Shop, which is run by some of the residents. It stocks and sells small snacks, stationery and personal items such as toothpaste and shampoo. There is a music room equipped with a variety of keyboards and percussion equipment that people can use, in addition to the sessions that the music technician holds on each unit (see below). There is also an internet room that is equipped with wireless computers that residents can access. There is an active residents committee, with representatives from all areas of the Care Homes for Older People Page 18 of 35 Evidence: home. The Annual Quality Assurance Assessment (AQAA) stated, This has proved to be a very robust committee, with its members taking very seriously their role as representatives of clients at Forest Care Village. The committee members often discuss issues with clients before bring them to the meetings and clients find this a very sensitive way to raise a concern which means a lot to them, but which they may not want to take directly to management in the form of a complaint. We have a simple philosophy, we ask the clients what they think, we involve them in decision making, we listen to our clients, and we implement appropriate ideas and suggestions. The Expert by Experience (EBE) spent lunchtime on Cardinal unit, and spoke to seven people during this time. She said that she saw no evidence of activities taking place while she was in the home. Most of the people who she spoke to said that they chose not to join in organised social activities in the home, and they had their own belongings, including music equipment, electronic games and radio, which they enjoyed. Several people who we spoke to said that they like to stay in their rooms, but no-one comes to their rooms to spend time socially with them. One care plan stated, Does not like to participate in activities. But there was no guidance or information for staff to take activities to the person, or to spend time with them. Other people who we spoke to said that there are activities that they enjoy taking part in in the home, and also outings in the homes transport, and entertainers who visit the home. During the inspection we saw a bingo session taking place, and the homes music technician holding sessions in several of the units, which were much enjoyed. The Annual Quality Assurance Assessment (AQAA) stated that these sessions have progressed from a one man show to most of the clients being able to participate and sing, and that people on the dementia care units recognise him and relate to why he has arrived on the unit. While we were there we noted that people were engaged with singing and music. In the dementia unit there is a sensory area (Snoezelem) which provides a calm atmosphere, a sensory garden, and small areas and rooms arranged with items of interest and memory for the people there. In addition to the music activity, there was a baking session while we were there, and those who took part made shortbread. In the Savannah Suite a coffee morning took place in the morning, But this seemed to be no different from a mealtime, with the staff serving drinks and snacks, and no special social activity or interaction. The AQAA stated, Clients (in the Savannah Suite) are supported in making teas and coffees and to offer to make these for others and many clients have regained skills which were lost in previous placements and or institutional settings. We saw no evidence of this during our visit, or from individual care plans. There was a music session in the afternoon, and we saw staff playing board games with one person. However during lunch the television was on, with the Care Homes for Older People Page 19 of 35 Evidence: sound muted, and a CD was playing. There was no indication that anyone wanted this, or did or did not want to watch television. There is a daily activity record for each person on this unit, including music time, coffee morning, reading newspapers and exercise class. Very little is recorded to take place in the evenings. The AQAA stated that one member of the Lifestyle team works at evenings and weekends. But we saw little evidence of their involvement on the Savannah Suite and Green Wing. Everyone who spoke to the EBE said that the meals in the home are good, or very good. The residents committee has had a lot of input into improving the meals in the home, and a new contract with an external caterer is in progress, which should ensure that meals are provided more efficiently and effectively. Care Homes for Older People Page 20 of 35 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 live in the home are confident that their concerns are listened to, and that they are safeguarded from the risks of abuse. Evidence: The management team has worked hard during the last year to improve the way that complaints and concerns are dealt with in the home. The Annual Quality Assurance Assessment (AQAA) states, We view complaints as a positive tool to provide an appropriate platform for clients, families, advocates and others to be able to raise concerns in partnership with ourselves and to know that these concerns will be addressed in a timely and thoughtful way, supporting the person who has complained, throughout the investigation process and outcome. The home has a satisfactory complaints procedure in place, which is given to everyone in the Service Users Guide. The record of complaints shows that peoples concerns are listened to and investigated properly. Also that the number of complaints has reduced, and that people who have made complaints have been satisfied with the outcomes. There have been six safeguarding investigations during the last year. These have all been referred appropriately by the home, and the results of the investigations have shown that the home has acted well in the interests of the people who live there. All the staff who we spoke to during this inspection were very aware of their responsibilities for safeguarding the people in the home and for whistle blowing if they Care Homes for Older People Page 21 of 35 Evidence: have any concerns. All the staff, including domestic staff and ancillary staff, have training in safeguarding vulnerable people, and in peoples rights under the Mental capacity Act. A staff awareness week was in progress during the week when we visited the home. This involved activities and training to improve the awareness of staff of diversity in the home, with a focus on what abuse is when its not obvious, such as failing to people with dignity and respect. Care Homes for Older People Page 22 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home and gardens provide a comfortable, attractive and safe environment for the people who live there. However the use of key pads in some areas restricts the freedom of people in the home, and may be seen as a deprivation of liberty. Evidence: Forest Care Village is a purpose built two storey building, with a small third storey. The Annual Quality Assurance Assessment (AQAA) states, Unlike many care buildings the Forest Care Village is large enough to provide several distinct areas which have been developed to create different environments with different features and themes. The village atmosphere is enhanced by the large entrance hall. This contains a Village Shop that is run by residents, and a Village Cafe. The area creates a feel of a village square, and provides a social meeting place for people from all areas of the home and their visitors. This area was well used as a relaxing and social space during our visit. The home is divided into separate units. On the ground floor nursing care is provided for younger people with physical disabilities. In addition to the Village Square, there is also a small sensory room on the ground floor, and a well equipped music room (see Daily Life and Social Activity). On the first floor The Cardinal unit provides nursing care for older people. There is a fully equipped physiotherapy room. The Green Wing on the first floor and the Savannah Suite on the second floor provide the unit for younger Care Homes for Older People Page 23 of 35 Evidence: people with traumatic brain injury and other cognitive difficulties. The dementia unit is on the ground floor and first floor. The home has acted on advice from the Alzheimers society regarding the use of tactile trails, primary colours, pictures at eye level and signage. There is a sensory garden for people in the dementia unit. Throughout the home there are a variety of assisted baths and showers for people to use, and appropriate equipment, such as hoists, for people with disabilities. There are appropriate procedures for the control of hygiene and for effective management of laundry. There is a team of over 20 housekeeping staff. The home appeared to be generally clean and well maintained. During our visit we noticed that the carpets in the corridors appeared to be scuffed in some areas, and detracted from the atmosphere of corridors as village streets. The management team are aware of this, and have plans to replace the carpets with a suitable solid surface. One of the lifts is also in need of refurbishment. We made a spot check of water temperatures in a sample of bathrooms, to make sure that the temperatures are maintained at a safe level. In one bathroom on the first floor the temperature of the water measured 59 degrees Centigrade, which may cause a risk of scalding for people who use the bathrooms. This was addressed immediately, and a new regulator valve was fitted before we left the home, which maintains the water temperature at a safe level. The records show that water temperatures are checked on a rolling programme every three months. This is not frequently enough to pick up any health and safety concerns. Access to and from the dementia units and the Savannah Suite and Green wing is by key pads. People who live in these units and their visitors do not have access to the numbers for the key pads, which means that they are not able to enter or leave as they wish, without staff assistance and supervision. This restricts the freedom of people in the home, and may be seen as a deprivation of liberty. The Expert by Experience (EBE) was also concerned about the locked gates to the home, although the number needed to open them is clearly available for visitors. She said, It could be said that this is not really that necessary and somewhat smacks of an oppressive regime which is not what the management means to convey. Some visitors who have contacted the Commission have concerns about the security of the home, particularly in the evenings. This has been addressed by new doors to the home, and increased hours for reception staff. Care Homes for Older People Page 24 of 35 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 people who live in the home are supported by a stable staff team. The staff in most units in the home have the experience and training to understand and meet the needs of the people who live there. The staff on one unit would benefit from specific professional support and training, so that they can understand and meet the needs of the people who live there. Evidence: The home employs sufficient staff to meet the needs of the people who live in different parts of the home. There are qualified nurses in each unit on each shift, and the the ratio of care workers to residents varies according to need from 1:2 for complex needs to 1:4 for dementia care and general nursing care. Two people have 1:1 care and support, and a few people who are assessed as needing residential rather than nursing care receive care on a ratio of 1:8 staff to residents. The staff team is stable, with low turnover, and the Annual Quality Assurance Assessment (AQAA) recorded that there has been no need to use agency nurses or care workers in the last three months. The staff come from a wide variety of ethnic and national backgrounds, which match the people who live in the home. In the last inspection report we found that there was an issue for some residents who have difficulty understanding some members of staff whose first language is not English. In the AQAA that was completed for this inspection, the manager said, We expect all overseas and European staff to have Care Homes for Older People Page 25 of 35 Evidence: good spoken English and appropriate written English skills and this is determined at interview. The home works in partnership with the Hertfordshire Care Providers association to provide language skills for staff who need this, or who wish to further improve their English. No one who we spoke to on this occasion mentioned that they have problems with language with the staff who provide their care. We looked at the files of three members of staff who have recently started to work in the home. They contained all the required information, including good references, evidence of work permits where needed and a satisfactory CRB (Criminal Record Bureau) disclosure. Everyone who we spoke to in the home said that the staff are very good and caring, and they treat the residents with care and respect. We observed good practice and a caring relationship between the staff and residents in Cardinal Unit and on the dementia care unit. In the dementia unit we observed the staff talking to people and encouraging them to communicate and take part in the musical activity. They distracted and gently persuaded some people who showed distress to move and do something different. We saw people who were otherwise not responsive following staff with their eyes and smiling at them. In the Savannah Suite and Green Wing the staff were caring and communicative, but they did not have sufficient information or training to be able to support some of the people there appropriately (see Health and Personal Care, Daily Life and Social Activities). All the staff who we spoke to during this inspection were enthusiastic and positive about their work in the home. They feel well supported by the management of the home, and we felt that there has been a general improvement in morale among the staff. They told us that a lot of training is available to them, and the training has helped them to provide a better quality of care for the people who live in the home. The home accesses a lot of training from Hertfordshire Social Services. They also train their staff in-house, and three members of staff are qualified moving and handling trainers. Some training sessions are arranged during the night, starting at midnight, specifically for the night staff. Specific training and support has been provided by the Alzheimers Association on dementia care, and Northwick Park Regional Rehabilitation Unit and the Spinal Injury Association on physical and neurological rehabilitation. The staff on the Savannah Suite and Green Wing would benefit from similar professional support and training for cognitive impairment and traumatic brain injury. Almost 50 of the care staff have qualifications at NVQ level 2 or above. Staff are expected to register for NVQ training at level 2 when they complete their induction, and then to progress to NVQ level 3. Care Homes for Older People Page 26 of 35 Care Homes for Older People Page 27 of 35 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 manager of the home leads a team of staff who all place the welfare of the residents as their highest priority. The views of the residents and other involved people are actively sought in order to ensure that a good quality of care is provided. Evidence: During the last year a new management structure has been put in place for the home and for Forest Healthcare. The previous manager is now Group Operations Manager for the company, and the new manager has worked in senior positions for several years, and at Forest Care Village since 2006. He was appointed as manager in December 2008. His registration with CQC was completed following this inspection. He is supported in the home by a Clinical Services Manager and a Non Clinical General Manager. Each unit is managed by an experienced registered nurse. The Forest Healthcare senior management team of Regional Operations Manager, Group Operations Manager, Group Clinical Services Development Manager and Chief Operations Officer provide support for the manager, and all together form a cohesive Care Homes for Older People Page 28 of 35 Evidence: and strong management team. The homes brochure states, Forest Healthcare believes its success and strength lie in empowering its managers to promote the independence of their care centres to service the local communitys needs and to provide clients and their families with security, quality, dignity, and choice and the very best care that is available in the UK. Forest Care Village is working towards, and in several areas has achieved, this high aspiration. The ethos of village life is enhanced by the changes to the environment, and in particular the village square appearance of the entrance area. In the Annual Quality Assurance Assessment (AQAA) the manager wrote, We have a simple philosophy, we ask the clients what they think, we involve them in decision making, we listen to our clients, and we implement appropriate ideas and suggestions. There is a very positive attitude to meeting challenges. The response to the query in the AQAA on issues that have made it hard to improve as much as the service would like was, We have not come across any issue that we could not overcome. As a team we share ideas and look for opportunities in any situation and always turn a negative into a positive. The ethos of the home is that the whole staff, from senior managers to housekeeping and ancillary staff, work as a team together for the benefit of the people who live there. The staff who we spoke to during the inspection said that they are well supported and clear about their responsibilities, and the manager is approachable and available if they need to speak to him. Everyone has regular supervision and appraisals of their work. The home has very good procedures for monitoring the quality of the services it provides. The Group Operations Manager carries out regular monitoring visits that include talking to the people who live in the home and the staff. The residents committee continues to hold regular meetings which enables residents to have a say in how the home is run. They invite members of the management team to these meetings where they wish to put ideas to them or have any issues to raise on behalf of the residents who do not attend. (See Daily Life and Social Activities.) Every day five people are chosen randomly, and an audit is carried out of their care and care plans, with a questionnaire for each person about their care, activities, and the quality of the food. We saw the report of the quality audit for March 2009, which had involved 42 people on a one to one basis, in pairs and also in groups, supported by the activity coordinators. For all the questions the majority, and in most cases a large majority, agreed strongly or somewhat with the statements about the care and service in the home. There were very good responses to the questions on participation in decision making and the competence of the staff. 87 agreed that the staff care about them, and 72 that they are comfortable bringing concerns to a staff member. It was also Care Homes for Older People Page 29 of 35 Evidence: notable that no-one strongly agreed that they were bored, and the same number somewhat agreed and somewhat disagreed with this statement. Policies and procedures are in place to safeguard residents financial interests. Money is stored safely and adequate records are maintained in order to protect the people in the home from financial abuse. Appropriate records are maintained for the health and safety of the residents and staff in the home, and the staff follow the homes policies and procedures.The home has a comprehensive risk assessment for the premises that includes a fire risk assessment, and all the staff take part in regular fire drills so that they know what to do to ensure the safety of the people in the home. We found that the temperature of the water in one bathroom was excessively hot, and that water temperatures are not monitored frequently enough to pick up any health and safety concerns(See Environment). Care Homes for Older People Page 30 of 35 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 35 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 manager must ensure that all care plans provide adequate and appropriate details of each persons needs. Care plans should provide staff with the information that they need to be able to meet the individual needs of each person in the home. 30/07/2009 2 9 13 Measures must be put in place to ensure that medication is audited effectively, and that any errors in medication are noted and rectified without delay. This will make sure that everyone has the care and medication that they need in a safe and effective way. 30/07/2009 3 12 16 Arrangements must be put 30/07/2009 in place to make sure that staff involve everyone in the home in their choice of Care Homes for Older People Page 32 of 35 activities and social interactions. The good practice and involvement of staff in some areas of the home is not evident in all areas. In particular, staff should ensure that people who stay in their rooms do not feel isolated. 4 19 13 The registered person must ensure that the use of key pads does not subject people in the home to any form of physical restraint or deprivation of liberty. People who live in the home should be free to enter and leave the areas where they live as they wish, unless there is an assessed risk to their safety. 5 25 13 Measures must be put in place to ensure that water temperatures are monitored on a regular basis. Hot water temperatures for all outlets to which the people who live in the home have access must be regulated to close to 43 degrees Centigrade, in order to ensure that people in the home are not at risk of scalding. 30/06/2009 30/07/2009 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 Care Homes for Older People Page 33 of 35 improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 34 of 35 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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