Care Home: Green Heys

What the care home does well The general feedback from relatives was positive and they reported that care was now generally more consistent. One relative said: `This is much better than the last care home. Its clean and bright and staff are nice. The food is good and she [resident] is well looked after`. Another commented: `They are providing social events now. There could be more but the atmosphere is friendly and during the day there is something going on. Personal care is good. He`s [resident] always clean and tidy`. People responded positively to staff attention and interventions during the day. This shows that the people in the home respond positively to staff being present. We observed the lunchtime meal and this was a well organised and social event that was well paced and relaxed so that people were observed to be enjoying this time. We saw that dining tables on the units are well presented and that tables are laid appropriately so that people with dementia can be clearly orientated. We found that the management of health and safety in the home was good. This ensures that the environment for people is safe and maintained. What has improved since the last inspection? There were four requirements made on the last inspection of the home in June 2009 regarding peoples health and personal care needs. These addressed how the care is organised and communicated through the care plan for people, as well as the monitoring of basic health care needs. We were also concerned at the time with the way peoples personal care was being carried out, which did not respect their dignity. Overall we found improvements in all of these areas and the requirements have been met. Care notes clearly identified health care needs and the ongoing reviews where easy to follow. Basic monitoring forms for personal care needs as well as any routine monitoring of health care needs such as blood pressure recording, fluid intake and nutritional needs have been introduced. We spoke with a visiting professional who said that generally the medical care was well organised and that the nursing staff `knew what they were talking about` and were knowledgeable regarding the people they were supporting. We found people cared for were clean and appropriately dressed. Staff were observed to interact well and to provide ongoing support when needed. This ensures that peoples dignity is preserved. A requirement from the previous inspection was for people to be consulted about their social care needs and to enable them to partake in activities. Since then a person as been employed to organise and develop this. We spoke to the member of staff responsible who was able to show us the work that has been developed. There is now a daily programme of activity and these include group and one to one activities. We spoke to relatives who said this area of care had improved. The previous inspection report carried out in June 2009 listed three requirements around staffing that needed to be met. These were around competency of staff to meet peoples care needs, recruitment procedures to ensure all new staff have appropriate checks made prior to employment, and training of staff around privacy and dignity for residents. We felt that these requirements had been met although we have made further recommendations around specific training regarding dementia care. The manager and staff have worked to improve the home since the previous inspection visit which displays an ability to achieve improvement and the challenge now is to ensure this is continued. What the care home could do better: None of the assessments completed before or during the admission of people to the home covered mental capacity. This is particularly important given the advent of legislation in the Mental Capacity Act [MCA] which requires such assessments to be carried out so that a basis can be established for decision making around care needs on a daily basis as well as other life decisions. We looked at the homes information guide and found this to contain information about the company as a whole but was not particularly personalised to Greenhays. We spoke about the need to develop some information that was personalised to Greenhays as this would supply more immediate assistance for people moving into the home. The current care notes are very full and contain the relevant information about health and personal care needs but the care plans are also a communication tool and as they stand are very cumbersome and over inclusive in detail. Many of the care plans are duplicated. They are also written in differing formats, some of which do not allow for much personalisation and contain some negative language which can create a labelling effect and can act as a barrier to any enabling process the staff are trying to achieve. Also when we spoke to relatives about whether they had seen the care plans we found that this was not the case. One relative visited daily and had a lot of input by encouraging fluid intake for their relative but was not sure whether she had enough to drink. The care plan included some reference to this but it was generalised and crucially did not include any reference to the relative and the input provided by him. We would recommend further development so that relatives and service users are included in the care planning and evaluations. The registration for the home includes some people who have other mental health needs other than dementia. We spoke to some of these people at length and we were concerned that their social care needs were not as well addressed. During the evening staff were seen to be attentive and trying to reassure residents but there is a lack of organised activity input at this time and staff seemed at a loss to be able to distract or manage the diversity of care needs. The environment of the home was disturbed and residents were visibly distressed. One person commented: `I hate it here. Dont like to be among them [people with dementia]. Its very loud. People grab at me and its not right`. [A few minutes later we saw one confused resident try to sit on the persons lap]. We would strongly recommend that the social care is organised appropriately with the above observations in mind and the needs of all residents are met. We looked at staff members understanding of abuse and how this is reported and investigated. It is important that staff have an understanding of the `wider picture` of the reporting and investigation process as they may well be part of such an investigation as a possible alerter. We would recommend that some inhouse training is conducted so that all staff are aware of the local policies and know where to access them and also have a basic knowledge of which external agencies such as social services, police and the Care Quality Commission [CQC] may be involved. As potential whistleblowers staff need also to be aware of the direct contact of the safeguarding team at social services. We looked at staff training and their competencies around managing interventions for people with dementia. We have made some recommendations that staff have more indepth training to meet peoples needs who may have more challenging behaviours. This will further develop staff competencies so that they may deliver good care. The manager at the time of the inspection has been in post for six months following the last inspection. We were advised that the manager is to be replaced and this has been confirmed since the visit. The home has a history of continual management change over a long period. We are concerned that this inconsistency may reflect the inconsistency in care standards over the same period. There are further developments needed before any degree of continuity and consistency in care standards will be achieved in the longer term. Key inspection report Care homes for older people Name: Address: Green Heys Park Road Waterloo Liverpool Merseyside L22 3XG     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: Michael Perry     Date: 1 4 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 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Green Heys Park Road Waterloo Liverpool Merseyside L22 3XG 01519490828 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.c-i-c.co.uk Community Integrated Care care home 47 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: Service Users to include up to a maximum of 47 DE(E), of which up to a maximum 10 DE, and up to a maximum 10 MD. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection Brief description of the care home Green Heys is a purpose built Care Home, which provides nursing care to people who have dementia. The Home provides care for 47 service users over retirement age and care to ten people from the age of fifty upwards. Green Heys is situated close to Crosby village. There is a local library within walking distance and a number of shops. Public transport is approximately 5 minutes walk away. Green Heys is a privately owned establishment; the owners are a charitable organisation with a number of establishments in the North West. There are 34 single rooms, and 4 double rooms. All Care Homes for Older People Page 4 of 32 Over 65 47 0 10 10 Brief description of the care home have en-suite facilities. There are gardens to the side and rear of the Home. There is 1 main dining room and 3-day rooms one of which is for residents who smoke. The home is built around a central courtyard, which is accessible to all. Current fees for the service are 531 - 643 pounds per week Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last inspection of the service was in June 2009 and at that time it was rated as Poor and we made ten statutory requirements and a good practice recommendation so that the home could improve. We also met with representatives of the provider [owners] to ensure that an action plan was formulated to address our concerns. We issued a warning letter as we were particularly concerned about the lack of attention to peoples health and personal care needs. This inspection was carried out over three days totalling 12 hours. We visited during the evening to observe care standards at this time as well as more regular day time hours. We met with and spoke to a number of nursing and care staff as well as the manager and other senior managers in the organisation. Care Homes for Older People Page 6 of 32 We observed care and spoke with relatives and visitors including professionals visiting the home. A separate pharmacy inspection was carried out by a pharmacy inspector and the findings are also included in this report [see health and Personal Care]. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? There were four requirements made on the last inspection of the home in June 2009 regarding peoples health and personal care needs. These addressed how the care is organised and communicated through the care plan for people, as well as the monitoring of basic health care needs. We were also concerned at the time with the way peoples personal care was being carried out, which did not respect their dignity. Overall we found improvements in all of these areas and the requirements have been met. Care notes clearly identified health care needs and the ongoing reviews where easy to follow. Basic monitoring forms for personal care needs as well as any routine monitoring of health care needs such as blood pressure recording, fluid intake and nutritional needs have been introduced. We spoke with a visiting professional who said that generally the medical care was well organised and that the nursing staff knew what they were talking about and were knowledgeable regarding the people they were supporting. We found people cared for were clean and appropriately dressed. Staff were observed to interact well and to provide ongoing support when needed. This ensures that peoples dignity is preserved. A requirement from the previous inspection was for people to be consulted about their social care needs and to enable them to partake in activities. Since then a person as been employed to organise and develop this. We spoke to the member of staff responsible who was able to show us the work that has been developed. There is now a Care Homes for Older People Page 8 of 32 daily programme of activity and these include group and one to one activities. We spoke to relatives who said this area of care had improved. The previous inspection report carried out in June 2009 listed three requirements around staffing that needed to be met. These were around competency of staff to meet peoples care needs, recruitment procedures to ensure all new staff have appropriate checks made prior to employment, and training of staff around privacy and dignity for residents. We felt that these requirements had been met although we have made further recommendations around specific training regarding dementia care. The manager and staff have worked to improve the home since the previous inspection visit which displays an ability to achieve improvement and the challenge now is to ensure this is continued. What they could do better: None of the assessments completed before or during the admission of people to the home covered mental capacity. This is particularly important given the advent of legislation in the Mental Capacity Act [MCA] which requires such assessments to be carried out so that a basis can be established for decision making around care needs on a daily basis as well as other life decisions. We looked at the homes information guide and found this to contain information about the company as a whole but was not particularly personalised to Greenhays. We spoke about the need to develop some information that was personalised to Greenhays as this would supply more immediate assistance for people moving into the home. The current care notes are very full and contain the relevant information about health and personal care needs but the care plans are also a communication tool and as they stand are very cumbersome and over inclusive in detail. Many of the care plans are duplicated. They are also written in differing formats, some of which do not allow for much personalisation and contain some negative language which can create a labelling effect and can act as a barrier to any enabling process the staff are trying to achieve. Also when we spoke to relatives about whether they had seen the care plans we found that this was not the case. One relative visited daily and had a lot of input by encouraging fluid intake for their relative but was not sure whether she had enough to drink. The care plan included some reference to this but it was generalised and crucially did not include any reference to the relative and the input provided by him. We would recommend further development so that relatives and service users are included in the care planning and evaluations. The registration for the home includes some people who have other mental health needs other than dementia. We spoke to some of these people at length and we were concerned that their social care needs were not as well addressed. During the evening staff were seen to be attentive and trying to reassure residents but there is a lack of organised activity input at this time and staff seemed at a loss to be able to distract or manage the diversity of care needs. The environment of the home was disturbed and residents were visibly distressed. One person commented: I hate it here. Dont like to be among them [people with dementia]. Its very loud. Care Homes for Older People Page 9 of 32 People grab at me and its not right. [A few minutes later we saw one confused resident try to sit on the persons lap]. We would strongly recommend that the social care is organised appropriately with the above observations in mind and the needs of all residents are met. We looked at staff members understanding of abuse and how this is reported and investigated. It is important that staff have an understanding of the wider picture of the reporting and investigation process as they may well be part of such an investigation as a possible alerter. We would recommend that some inhouse training is conducted so that all staff are aware of the local policies and know where to access them and also have a basic knowledge of which external agencies such as social services, police and the Care Quality Commission [CQC] may be involved. As potential whistleblowers staff need also to be aware of the direct contact of the safeguarding team at social services. We looked at staff training and their competencies around managing interventions for people with dementia. We have made some recommendations that staff have more indepth training to meet peoples needs who may have more challenging behaviours. This will further develop staff competencies so that they may deliver good care. The manager at the time of the inspection has been in post for six months following the last inspection. We were advised that the manager is to be replaced and this has been confirmed since the visit. The home has a history of continual management change over a long period. We are concerned that this inconsistency may reflect the inconsistency in care standards over the same period. There are further developments needed before any degree of continuity and consistency in care standards will be achieved in the longer term. 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 10 of 32 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 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are admitted following an assessment of their needs so that the home can have an understanding of how they need to care for them. Evidence: We looked at the assessments carried out prior to people being admitted to the home. We looked at two care files. Both people had been assessed by senior staff who had visited them in previous care settings. The assessments highlighted care needs around various activities of daily living including social care needs. These were backed up by further information and assessments from social workers and also health care professionals such as community nurses. This sort of assessment ensures that peoples care needs are known to the home and staff are able to meet them. None of the assessments covered peoples mental capacity. This is particularly important given the advent of legislation in the Mental Capacity Act [MCA] which requires such assessments to be carried out so that a basis can be established for Care Homes for Older People Page 12 of 32 Evidence: decision making around care needs on a daily basis as well as other life decisions. This was discussed with the manager who said that training for staff in this area is planned. We spoke to relatives and some residents about the sort of information supplied on admission to the home. Most said that staff had been helpful and informative during the early stages of admission but could not remember any written information such as the homes service user guide. The manager said this was displayed in the foyer along with other information about the home. We looked at the homes information guide and found this the contain information about the company as a whole but was not particularly personalised to Greenhays. For example there was no reference to who was the manager or about staffing levels in the home and how they were qualified. Also we could find no reference to the kinds of daily life and activities. The complaint procedure also needed some updating. We spoke about the need to develop some information that was personalised to Greenhays as this would supply more immediate assistance for people moving into the home. Care Homes for Older People Page 13 of 32 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. Peoples health and personal care needs are met so that they are treated with dignity and respect. Evidence: There were four requirements made on the last inspection of the home in June 2009. These addressed how the care is organised and communicated through the care plan for people, as well as the monitoring of basic health care needs and referral to appropriate provision of health care from external professionals. We were also concerned at the time with the way peoples personal care was being carried out, which did not respect their dignity. Overall we found improvements in all of these areas and the requirements have been met. For example one person we reviewed had pressure sores to their heels. These were well monitored in the care notes and the care plan was extensive in terms of actions to be carried out and also reviews and evaluations. It was easy to follow the care and see what progress had been made. Care Homes for Older People Page 14 of 32 Evidence: The managers have also organised input from a nurse working for the company who has introduced basic monitoring forms for personal care needs as well as any routine monitoring of health care needs such as blood pressure recording, fluid intake and nutritional needs. These back up the information in the main care file and are more readily available to care staff teams. We spoke with a visiting professional who said that generally the medical care was well organised and that the nursing staff knew what they were talking about and were knowledgeable regarding the people they were supporting. Since the last inspection the manager has created a senior carer role whose job is to lead a team of carers and act as a link between nursing and care staff. We spoke to one of these team leaders and she said that she felt this had improved care and communication was better. Likewise nursing staff welcomed this development. We made some observations of the daily care. We found people cared for were clean and appropriately dressed so that their dignity was preserved. Staff were observed to interact well and to provide ongoing support when needed. For example, when assisting people to feed or to mobilise. The manager reported that following the previous inspection all staff had undergone training and updates around the importance of maintaining privacy and dignity for people with dementia. This was confirmed by staff spoken with. We did still have some issues that managers and senior staff need to address by further developing the care. For example the current care notes are very full and contain the relevant information about health and personal care needs but the care plans are also a communication tool and as they stand are very cumbersome and over inclusive in detail. For example many of the care needs are duplicated on different care plans. This was the case for all three people reviewed who had care plans duplicated for mobility needs and other personal care needs. The care plans are also written in differing formats, some of which do not allow for much personalisation and contain some negative language such as problem [as opposed to need] and incontinence [ as opposed to continence needs]. This is relevant because language in care plans can create a labelling effect which can act as a barrier to any enabling process the staff are trying to achieve. Some results of this are that staff reported that it can take anything up to three hours to review a care plan. Also when we spoke to relatives about whether they had seen the care plans and we found that this was not the case. Relatives said that staff Care Homes for Older People Page 15 of 32 Evidence: informed them of any urgent medical needs or changes but the overall care plan was not discussed. One relative visited daily and had a lot of input by encouraging fluid intake for their relative but was not sure whether she had enough to drink. The care plan included some reference to this but it was generalised and crucially did not include any reference to the relative and the input provided by him. Medication A pharmacy inspector visited the service as part of the key inspection on 26th January 2010. We checked how medicines were stored and looked at a sample of medication stocks and records. We also talked to the newly appointed manager and two nurses about handling medicines. Medicines were stored safely and dealt with only by qualified nurses. This helps to make sure that they are not misused or mishandled. Most records were clear and accurately showed how medicines had been received, administered and disposed of. Good record keeping helps to ensure that medication is handled and administered correctly. There were clear instructions for staff to follow showing how medicines prescribed to be taken when required were to be given. This helps to ensure that these medicines are given correctly and consistently. Some records about covert administration (placing medicines in food or drink with consent from the prescriber) were less clear and it was not always easy to see exactly how these medicines should be given. Some audits (checks) had recently been done. Having a robust system of audit helps to address any areas of weakness and improve the service that is offered. Care Homes for Older People Page 16 of 32 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 life of people living in the home continues to be developed so that they feel relaxed and engaged in the daily life. Evidence: A requirement from the previous inspection was for people to be consulted about their social care needs and to enable them to partake in activities. Since then a person as been employed to organise and develop this. We spoke to the member of staff responsible who was able to show us the work that has been developed. There is now a daily programme of activity and these include group and one to one activities. We spoke to relatives who said this area of care had improved. We saw some activities organised while we were inspecting the home such as a group sing a long in the day room as well as trip out on the last day. The care notes contain reference to assessments of peoples social preferences and histories. A new project is the completion of social profiles which detail each persons life history and these can be used to engage staff, residents and relatives. We observed that the managers and staff are developing the environment in line with many good practice principals such as orientation aids and bright decor and this is Care Homes for Older People Page 17 of 32 Evidence: being further developed. Staff reported that there have been outings organised as the home has access to a mini bus. Relatives reported that they can visit at any time and that staff are always welcoming and friendly. There has been some relative meetings organised but lately these seem to have fallen off. Events like this can help relatives and visitors feel involved in the life of the home. The general feedback from relatives was positive and they reported that care was now generally more consistent. One relative said: This is much better than the last care home. Its clean and bright and staff are nice. The food is good and she [resident] is well looked after. Another commented: They are providing social events now. There could be more but the atmosphere is friendly and during the day there is something going on. Personal care is good. My relative is always clean and tidy. People responded positively to staff attention and interventions during the day. This shows that the people in the home feel safe with staff being present. We observed the lunchtime meal and this was a well organised and social event that was well paced and relaxed so that people were observed to be enjoying this time. The food was well presented and appetizing. We saw that dining tables on the units are well presented and that tables are laid appropriately so that people with dementia can be clearly orientated. The registration for the home includes some people who have other mental health needs other than dementia. We spoke to some of these people at length and we were concerned that their social care needs were not as well addressed. One person said she went out occasionally (at least weekly outings are prescribed on the care plan) but did not like to have communal trips as they did not want to be associated with people with dementia. Another person was spoken to during the evening visit. The unit was very disturbed as one resident with dementia was shouting and causing other residents to be agitated. Staff were seen to be attentive and trying to reassure residents but there is a lack of organised activity input at this time and staff seemed at a loss to be able to distract or manage the diversity of care needs. One staff said: We keep an eye on [resident] and he eventually calms down. Care Homes for Older People Page 18 of 32 Evidence: Meanwhile other residents were visibly distressed and one person spoken with said: I hate it here. Dont like to be among them [people with dementia]. Its very loud. People grab at me, its not right. [A few minutes later we saw one confused resident try to sit on the persons lap]. This shows that the home has a diverse range of care needs to meet from people with dementia and challenging behaviour through to those with more functional mental health needs. We would strongly recommend that the social care is organised appropriately with the above observations in mind and the needs of all residents are met. Care Homes for Older People Page 19 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are policies and procedures and staff are trained so that peoples concerns are listened to and reported and they are protected Evidence: We found the complaints procedure to be available in the home and displayed in both the information supplied by the home [service user guide] and also displayed in the entrance to the home. Relatives spoken with said that they felt able to speak with staff and raise concerns. The manager advertises a surgery so that any issues can be raised and dealt with although he reported that uptake on this had been variable. We looked at the complaints log for the home and found one complaint listed from April 2009 which had been dealt with appropriately by the senior manager for the organisation. This concerned lack of stimulation and activities generally for people and also failure by staff to facilitate a GP appointment and include the relative. The investigation had addressed the issues appropriately. There have been no complaints since the last inspection in June 2009. We spoke with staff and the manager who have an understanding of the principals involved in both recognizing and reporting any alleged abuse. Staff reported some training in this area although training records were unclear as to the extent of this and whether all staff were up to date. Staff reported e - learning updates which covered Care Homes for Older People Page 20 of 32 Evidence: aspects of safeguarding and abuse awareness. Staff spoken with were good at identifying potential areas of abuse but were unclear about how any allegations would be investigated and what external bodies [social services etc] may be involved, once reported. They were also unclear about how to access the local safeguarding policies and procedures. Indeed the manager found these difficult to locate. It is important that staff have an understanding of the wider picture of the reporting and investigation process as they may well be part of such an investigation as a possible alerter. We would recommend that some inhouse training is conducted so that all staff are aware of the local policies and know where to access them and also have a basic knowledge of which external agencies such as social services, police and the Care Quality Commission [CQC] may be involved. As potential whistleblowers staff need also to be aware of the direct contact of the safeguarding team at social services. The home has had one safeguarding issue since the last inspection. This concerned a member of staff who took photos of residents on a trip and the concern was around possible data protection issues. The matter was appropriately referred and then managed by the service. This shows that the homes management are acting appropriately in ensuring people are protected. Care Homes for Older People Page 21 of 32 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 home is maintained and clean so that people living there enjoy comfortable surroundings. Evidence: We found that the home continues to be upgraded and maintained with respect to the quality of the decor and furnishings and facilities. We found all areas accessible and safe and general improvements to the environment with respect to some orientation aids so that people can find it easier to get around the home. There is a good range of aids and adaptations around the home including specialised chairs, beds and bathrooms and toilets. The day areas are bright and there is visual stimulus with art projects and pictures and photos displayed. The activity organiser is developing personalised social history profiles which can become part of memory boxes posted outside bedrooms which may act as further orientation aids. The bedrooms seen were personalized and displayed evidence of peoples individual lifestyles. This shows good practice. The home was found to clean and there are policies and procedures in place for the control of infection. There are regular audits of the environment and the manager was able to show that there is continual upgrading which reflects good practice principals Care Homes for Older People Page 22 of 32 Evidence: in dementia care. We did received two issues of concern. One related to the garden room and the fact that it appears rather bare and under developed at the moment. This was fed back to the manager for action. Also we received a complaint following the inspection about the adequacy of the heating in the home. This was also mentioned by one relative at the time of the inspection as being inconsistent at times especially in relation to bedrooms. We have written to the manager separately about this and also included some recommendations at the end of this report. Care Homes for Older People Page 23 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are recruited and trained so that the basic care needs of residents can be met but there needs to be further progress so that staff have competencies to meet some of the more challenging needs of people. Evidence: The previous inspection report carried out in June 2009 listed three requirements that needed to be met. These were around competency of staff to meet peoples care needs, recruitment procedures to ensure all new staff have appropriate checks made prior to employment, and training of staff around privacy and dignity for residents. At the time of the inspection visit the home had two trained nurses and these were supported by appropriate care staff numbers. Care staff are supported by housekeeping staff, kitchen staff and an activities organiser [a new acquisition since the last inspection]. The manager works supernumerary to these figures and also has the assistance of an administrator. A maintenance person is also employed. This is sufficient staff for the number of residents in the home. We looked at the duty rotas and spoke to staff and both confirmed that the numbers were more consistent and that there has been a reduction in the use of agency staff cover since the last inspection. Staff spoken with felt that they were supported by the management and that there Care Homes for Older People Page 24 of 32 Evidence: was enough staff to carry out the care needs of the residents. Staff spoken with generally understood the care needs of the people in the home and could explain their role in providing support. We observed the staff to be warm and supportive in their interactions with the residents and this was confirmed as consistent by speaking to residents who could express an opinion and also relatives. During our observations we also observed that staff interactions with residents were positive and recognized residents individuality. We were concerned that at times the home can become very noisy and disturbed and that staff, at these times may not have the underlying skills to manage and carry out effective interventions. This was particularly evidenced on the evening inspection [see daily life and social activities section]. We spoke with staff and one commented: Generally things are better but still not consistent. There are to many management changes. Not long enough for staff to experience any degree of consistency and ownership. There are too many different care needs. Challenging behaviours take up a lot of time and there is not enough expertise to manage them. Staff can feel overwhelmed. Most staff are involved with some training. Over 50 percent of care staff have achieved a National Vocational Qualification [NVQ], and most other staff are on these courses. We did not find any evidence from interviews or training records of staff having awareness sessions or training around dementia care generally or for some of the more challenging behaviours people with dementia may present with. We would recommend this is considered and actioned. It was difficult to evidence staff training over all and the manager found it difficult to get current training statistics due to the way this information is stored. Never the less staff files seen and staff spoken with evidenced ongoing support around training. In particular the home have organised all staff to complete updates around dignity in care as required previously. This shows that the staff have the basic skills to care for people in the home but need more intense training around specific care needs particularly challenging dementia care. The managers reported that the company have developed a training package around this. From speaking with the manager and staff and looking at training records we also felt that the service currently has little knowledge of the Mental Capacity Act and also the new Deprivation of Liberty [DOLs] safeguards. This is important to understand as they form much of the legalities around care and management of people with dementia in particular. Care Homes for Older People Page 25 of 32 Evidence: We looked at some staff files and found that the checks required for each staff prior to employment had been made and that staff were recruited thoroughly. This ensures that staff who work in the home are fit to do so. This is an improvement since the last inspection and meets the requirement made. Care Homes for Older People Page 26 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The managers have achieved improvement over a six month period and this now needs to be made consistent so that the home is consistently run in the best interests of people living there. Evidence: The manager at the time of the inspection has been in post for six months following the last inspection. We were advised that the manager is to be replaced and this has been conformed since the visit. Following the last inspection there was a requirement for the service to have a registered manager and this therefore remains [manager at the time of the inspection has not applied for registration over the 6 month period]. The home has a history of continual management change over a long period. Staff commented that we have had ten managers in the last ten years. Its very unsettling. We are concerned that this inconsistency may reflect the inconsistency in care standards over the same period. Since the last inspection the manager has been supported by senior managers of the company and there has been some progress in meeting requirements made. There are further developments needed though before Care Homes for Older People Page 27 of 32 Evidence: ay degree of continuity and consistency in care standard will be achieved in the longer term. We looked at many different records on the inspection and those concerning the monitoring of care needs have improved so people are safe. These records are important to back up the running of the home. Some records such as training records for staff need to be better organised and more readily accessible and available for the manager. This was noted on the homes own audits. The manager discussed the various internal audits that are carried out including regular environmental checks and also visits by senior managers in the company who also complete a regular inspection and report [Regulation 26 report] which provides further feedback for the manager. We found that the management of health and safety in the home was good. We spot checked some safety certificates and they were up to date. This ensures that the environment for people is safe and maintained. The Health and Safety policy is available. The manager and staff have worked well to improve the home since the previous inspection visit which displays an ability to achieve improvement and the challenge now is to ensure this is continued. Care Homes for Older People Page 28 of 32 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 29 of 32 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 31 8 An application to register a manager of the home to be responsible for the day to day running of the home is to be submitted to CQC. [previous requirement 30/09/09 not met] To ensure that the home has a consistent managment base. 30/03/2010 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 1 We would recommend that the information given to people about the home [service user guide] is developed and updated with reference to comments in the report. The assessments completed prior and during admission need to include an assessment of mental capacity. We would recommend that the care plans and notes are further developed to include more concise entries about care needs so that they can be used more practically as a 2 3 3 7 Care Homes for Older People Page 30 of 32 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 communication tool. This includes the use of a single care planning format and evidence of input from relatives and people living in the home. 4 5 9 12 There should be clear guidance for staff to follow where covert administration of medicines has been authorised. The registration for the home includes some people who have other mental health needs other than dementia. We would strongly recommend that the social care is organised appropriately with the observations listed in the report in mind, and the needs of all residents are met. We would recommend that some in-house training is conducted around safeguarding so that all staff are aware of the local policies and know where to access them and also have a basic knowledge of which external agencies may be involved. We would recommend that some thought be given to developing the garden room to make this a more therapeutic area. We would recommend that the management review the heating in bedrooms to ensure consistent temperatures. 8 30 We recommend further training is developed for staff around: Dementia care Mental Capacity Act Deprivation of Liberty Safeguards. 6 18 7 19 Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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