Care Home: Grey Gables

What the care home does well The routines of the home are flexible and aim to allow residents their freedom and independence by enabling them to retain as much control over their lives as possible, thus promoting equality and diversity. Visiting arrangements are in place to suit the needs of individual residents. The health care needs of people living at the home are well met meaning that residents have confidence that the staff team would arrange for medical assistance quickly if they were unwell. The home is well managed, with good training provided for staff. Over 50% of the care staff team are now qualified. This means that people are supported by staff who have had their work practice assessed and are deemed to be competent workers. What has improved since the last inspection? There has been improvements to the range of activities made available. This has enabled people living at the home to take part in activities that suits their lifestyle and maintain their interests. This is now a real strength of the service. Further members of staff have achieved a National Vocational Qualification (NVQ) in care. The homeowner and one of the deputy managers has successfully completed the Registered Managers Award. The other deputy manager has been successful in obtaining the NVQ Level 4 in management. Other training that has taken place includes, medication courses, a leadership and management course, deprivation of liberty training, mental capacity act training, prevention of falls training and a train the trainer course. This helps to make sure that the staff team are well qualified to care for the people living at the home. As recommended at the last key inspection, a member of the management team now completes a separate assessment to highlight the strengths and needs of an individual prior to admission. This enables the management team to make a judgement whether assessed needs and requirements could be met at the home. However the detail recorded should be extended to make sure that all needs, wants and wishes are known. What the care home could do better: The staff team at Grey Gables try hard to provide a good quality service to the people that live there. There are however some areas that could be improved to strengthen the service further. For example, Grey Gables is only registered to accommodate people with a diagnoses of dementia on admission. However one person was admitted without this diagnoses. This is in breach of the conditions of registration. Following the pre admission assessment, the person who completed the assessment must write to the prospective new resident with the outcome of the assessment. This would confirm to the prospective new resident that their current needs, wants and wishes could be met at the home. Newly appointed staff should only take up their employment at the home when all the required clearances, references and disclosures have been obtained and deemed to be satisfactory. This would help to protect people living at Grey Gables. Key inspection report Care homes for older people Name: Address: Grey Gables 1 Lodges Grove Bare Morecambe Lancashire LA4 6HE     The quality rating for this care home is:   two star good 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: Denise Upton     Date: 0 8 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 35 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 35 Information about the care home Name of care home: Address: Grey Gables 1 Lodges Grove Bare Morecambe Lancashire LA4 6HE 01524425376 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Ewood Residential Homes Limited care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: The registered person may provide the following category of service only: Care home only: Code PC, to service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Dementia: Code DE The maximum number of service users who can be accommodated is: 16 Date of last inspection Brief description of the care home Grey Gables is registered to accommodate up to 16 people who have dementia. The home is situated in a quiet residential area of Bare in Morecambe and is close to local shops and amenities. The home is a large detached dwelling, situated on a corner site, with a small car parking area in the ground to the front. In addition, there is a small, secure garden area to the rear and side of the building. The home is comfortably decorated and has adequate communal space. There is also a small extension on the ground floor with bedrooms. There are bathroom and toilets on this floor. The first floor houses bedrooms and a bathroom. The home has 12 single bedrooms and 2 double bedrooms, one of these has an ensuite facility. The registered provider/manager is experienced and qualified in the care of people with dementia. Care Homes for Older People Page 4 of 35 Over 65 0 16 Brief description of the care home The current range of fees and what is included in those fees can be obtained from the registered manager at the home. 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: This unannounced key inspection site visit took place during the course of a mid week day and spanned a period of approximately eight and a half hours. At the time of this site visit 16 people were in residence. Twenty three of the thirty eight standards identified in the National Minimum Standards - Care Homes for Older People were assessed along with a reassessment of the requirements and recommendation made at the last key inspection. We spoke with the two deputy managers, and two members of the care staff team. In addition, two relatives and two residents who were at home were also individually spoken with and brief discussion took place with several other residents in a communal area of the home. Every year the registered manager is asked to provide us with written information about the quality of the service they provide. They are also asked to make an Care Homes for Older People Page 6 of 35 assessment of the quality of the service. This information, in part, has been used to focus our inspection activity and is included in this report. During the course of the site visit, a number of documents and records were examined and a tour of the building took place including communal areas of the home, toilets and bathrooms, some bedroom accommodation and the kitchen and laundry area. There is a stair lift in place to assist those residents who cannot manage the stairs. The last key inspection at Grey Gables Care Home took place on 7th September 2007 and an Annual Service Review was undertaken on 28th August 2008. The report relating to the service review is held at the CQC office and would be made available on request. Care Homes for Older People Page 7 of 35 What the care home does well: What has improved since the last inspection? What they could do better: The staff team at Grey Gables try hard to provide a good quality service to the people that live there. There are however some areas that could be improved to strengthen the service further. For example, Grey Gables is only registered to accommodate people with a diagnoses of dementia on admission. However one person was admitted without this diagnoses. This is in breach of the conditions of registration. Following the pre admission assessment, the person who completed the assessment must write to the prospective new resident with the outcome of the assessment. This would confirm to the prospective new resident that their current needs, wants and wishes could be met at the home. Newly appointed staff should only take up their employment at the home when all the required clearances, references and disclosures have been obtained and deemed to be Care Homes for Older People Page 8 of 35 satisfactory. This would help to protect people living at Grey Gables. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 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 10 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is admission and assessment procedures in place that helps to ensure the care needs of people are met. However the pre admission assessment information recorded is limited, so staff may not be certain that the individual needs of a prospective new resident could be fully addressed. Evidence: Prospective residents and/or their relatives are provided with the information they need in order to make an informed choice about whether to live at the home. The Annual Quality Assurance Assessment (AQAA) completed by the homes deputy manager prior to the site visit taking place, told us that the Statement of Purpose and Service User Guide had been updated and amended to make sure that the information provided was accurate and up to date. These two important booklets tell residents and prospective resident about the home and the services and facilities provided. However some of the information in the Service User Guide was inaccurate. For Care Homes for Older People Page 11 of 35 Evidence: example, the Service User Guide says that The Commission for Social Care Inspection inspects the Home at least twice a year. This is not necessarily so. The care home will have a formal assessment at least one a year but this may not include a site visit. Throughout the Service User Guide, the Commission is referred to as the Commission for Social Care Inspection, however this organisation ceased at the end of March 2009 and the inspection work of this former organisation is now undertaken by the Care Quality Commission. The Service User Guide also states that the homeowner has appointed a manager and an assistant manager to undertake responsibility for the care planning and service delivery on a day to day basis however there is no manager registered with the Commission except for the homeowner. It is important that the Statement of Purpose and Service User Guide provide current information that is pertinent at the time the booklets are given to an individual resident. The reader could then be confident that the information provided was accurate and truthful. It was also noted that the Statement of Purpose and Service User Guide were only made available in ordinary type print. In order to make sure that as many prospective residents, resident and relatives as possible have independent access to this information, consideration could be given to providing these booklets in an easy read style, suited to the resident group accommodated and in alternative formats such as large print or on audio tape if required. In order to ensure that residents are only admitted to Grey Gables care home if their assessed needs could be met, prior to admission one of the deputy managers undertakes an assessment of the prospective residents current strengths and needs in order to determine if the level of care and support required could be provided at the home. This information is recorded, which in some cases is supported by a Health and or Social Services assessment of current requirements. In the main this collated information, along with any further information provided by family or other advocates, provides the basis of the initial plan of care. All this helps to make sure that sufficient information is gained in order for the deputy manager to make an informed judgement as to whether the home could provide the care required. Records were viewed in relation to two residents that has been admitted to the home since the last key inspection. The pre admission assessment consisted in the main of a tick box style system but the information recorded was limited and did not cover the all the recommended areas for assessment prior to admission. For example, one of the pre admission assessments evidenced did not provide any information about this persons physical health, social interests, hobbies or religious needs and requirements Care Homes for Older People Page 12 of 35 Evidence: but did provide information about mental state and attitude. In order to undertake a comprehensive assessment of holistic strengths and needs, the pre admission assessment process should include recording sufficient detail about a wide range of possible care needs such as personal safety and risk, medication usage, history of falls, personal care and physical well being, mobility and dexterity, continence, oral health, foot care, diet weight and dietary preferences, sight, hearing and communication, social interests, hobbies, religious and cultural needs and mental state and cognition. Only by undertaking a comprehensive assessment of current strengths and needs could an informed decision by taken as to whether the holistic needs, wants and wishes of that individual prospective resident could be met at the home. Grey Gables care home is only registered to admit people with a diagnoses of dementia. However it was observed that one resident had been admitted to the home who at the time of admission, did not have a diagnoses of dementia but another mental health condition. This is in breach of the conditions of registration. It is essential that only people with a diagnoses of dementia be admitted to the home. The home is not registered to admit people with a different mental health condition unless there is a dual diagnoses and the primary need for admission was related to support needs associated with dementia. Whilst it appeared that the needs and requirements of people living at the home were being met, there is a requirement that any person that has been assessed for possible admission to a care home must receive written information following the pre admission assessment. This should confirm the outcome of the pre admission assessment and that the prospective residents current needs and requirements could be met at the home or alternatively that they could not be met. This should be provided prior to admission. There was no evidence that this had occurred. Intermediate care is not provided at Grey Gables care home. 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. Personal and health care needs appear to be met and people are treated with dignity and respect, promoting a feeling of well being and confidence that any health issue would be dealt with. Evidence: Each person living at the home has a written plan of care and three of these were viewed. Again care plans were predominately of a tick box system with some room for expanding the information. However the quality of the recording varied. Some person centred care planning was evident for example, for one person the care plan stated that she liked two pillows on her bed and liked her tea without sugar. This is good detail that helps staff to ensure a consistent approach when supporting this resident. Other information on the care plans seen were however less well developed and in some cases the pre admission assessment information had not been carried through to the actual care plan. It was also evident that relevant risk assessments had also been undertaken however the outcome of the formal risk assessment had not always been incorporated into the actual care plan. There should also be a specific care plan in place regarding medication that is based on the pre admission information and Care Homes for Older People Page 14 of 35 Evidence: amended and reviewed accordingly. For one person, the moving and handling risk assessment had indicated that the resident used a walking stick. Through discussion with the deputy managers, it became evident that not only did the resident use a walking stick but she also used a walking frame and that staff always had to make sure that the resident always had these. This detail was not identified on the formal risk assessment or the care plan. For the same resident it was recorded that she was diabetic that was controlled by daily injections. We were informed that the District Nurse visited each day to give the diabetic injection but this information was not recorded in the care plan. Again in the hobbies section it was written, Likes spending time with her daughter and going to the day centre. However we were also verbally told that this resident also enjoyed bingo, ball activity and chatting but these interests were not identified at all in the care plan. Consequently staff did not have written information on how to assist this resident to enjoy these activities. It was also recorded that this resident was interested and cared about her appearance. This information could have been expanded upon to provide staff with detail of what they should be doing to ensure this lady was assisted to maintain her appearance in the way she preferred. With regard to another resident, from the quite detailed daily record, it was evident that this particular resident could become verbally aggressive. However there was no risk assessment evidenced or care plan in place to instruct staff how to support this resident when she was being verbally aggressive. This information is important to make sure that the resident is protected and that all staff are clear about the way they should respond to the situation in a calm and consistent way. However on another care plan evidenced, it was stated that this particular resident could be resistive to care and may hit out at carers. In this instance the information provided was quite detailed and directed care staff in what they should do in order to defuse the situation, protect the resident and themselves. In order to provide consistent care planning, all care plans should be of the same high quality and give detailed and up to date guidance for staff to follow. This would help to ensure that individually assessed needs are addressed in the same way by all the staff team. Residents and/or their relatives had been given opportunity to be involved in the care planning process, so that they could have some say about the care provided. One relative spoken with said that she had been asked about her mothers care and had seen and had explained to her the content of her mothers care plan before signing the document. It was evident from records seen that a formal review of the individual care plan takes place on a monthly basis. If no changes are required this is clearly Care Homes for Older People Page 15 of 35 Evidence: recorded. However when amendments are required the person undertaking the review and subsequent amendment(s) should sign and date the amendment in order to take ownership of the task completed and to confirm accuracy of the recording. Whilst it was evident that some improvement could be made to the actual detail recorded on the individual care plan, residents and relatives spoken with were very clear that they felt the assessed needs of people were being well met by the staff team. One relative told us that the home was, Meeting mums needs and she is settled in, very homely. The same person went on to say, There is a nice homely atmosphere, mum was sat between two staff having a drink when they were writing their reports, they (the staff) are good with her, let her do what she wants such as sitting up with the night staff and doing her nails. It was evident through discussion and records seen that residents health care needs are being fully met. This was also confirmed through comments from residents and staff spoken with. All stated that people living at the home always received the medical attention that they needed when they needed it. There is a good relationship with health and social care professionals in order to maintain residents health and social well-being. Each resident has a key worker that takes a special interest them, staff get to know people well and can soon identify any changes in health and well being. At present, medical input visits are recorded on the individual daily diary sheet. This makes it more difficult to track medical visits and outcomes from the daily diary sheet as a lot of other information is also recorded on these sheets on a daily basis. In order to address this, it is recommended that a separate individual record is maintained of all health care professional visits for each resident. This could be held in the care file along with other relevant information. This should record the date of the visit, reason for the visit and outcome. As part of the visit, we checked how medicines were being handled. The medication administration records of a number of people living at the home were viewed along with records relating to medication brought into the home, administered to residents and sent back to the pharmacist for disposal. There is a photograph of each person attached to the drug administration record and a record of the initials and signature of each member of staff that has responsibility for the administration of medication. This is good practice and helps prevent mistakes being made. Very recently the management team approached an alternative pharmacist who offered a better service, to supply prescribed medication to the home. The day prior to Care Homes for Older People Page 16 of 35 Evidence: the site visit taking place was the date arranged for the change over. Medication is now supplied in blister packs and staff are being provided with training with regard to the new system. However staff had already noted that there were some teething problems. For example medication to be taken when required had not been identified as such by the pharmacist on the medication administration record. The management team were taking the necessary steps to address this issue. Weekly medication audits are also planned for the next few weeks so that any errors in the management of medication is quickly spotted and action is taken to prevent staff making the same mistakes again. Individual protocols are in place in respect of when required medication. This makes sure that staff have clear written information as to when it would be appropriate to give this medication so as to provide a consistent approach that meets the individual needs of that particular resident. Whilst it is acknowledged that staff were getting use to the new medication system, it was noted that there were some hand written entries in the new drug administration records that had not been signed, dated and countersigned by a second person to confirm accuracy of the recording. Some short life medication such as eye drops has also not been dated on opening. This is strongly recommended to make sure that short life medication is not used by its use by date. The management team commented that all staff are aware of these recommendations and that they were usually adhered to. Medication is securely stored and there is provision for a resident to elect to self administer their own prescribed medication following the successful outcome of a formal risk assessment. However we were told that it was some time ago since a resident had wanted to do this or had had the capacity to safely store and administer their own prescribed medication. It was observed that the privacy and dignity of residents was well respected and that staff were sensitive and mindful of residents feelings. One resident spoken with said that she thought her privacy and dignity was well respected and told us, Nice people (the staff team) and listen to you. Everything goes along very nicely. I am happy to listen to them and they are happy to listen to me. Two relatives spoken with who visit the home regularly, both felt that residents privacy and dignity was well respected and that the staff team were, very good, all very friendly. Staff receive training in respect of maintaining privacy and dignity during their induction training and National Vocational Qualification (NVQ) training, a qualification that the majority of staff working at the home has achieved. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive the support they needed to live their chosen lifestyles. Evidence: Residents are supported to enjoy a lifestyle of their choice and encouraged to keep up with their hobbies and interests. Daily routines are kept flexible to take into account individual preferences. Staff obtain as much information as possible about the social, cultural, and leisure needs and interests of people living at the home. This means that staff have the information they need to make sure that the care and support provided is right for that person. This is a real strength of the service that is devised for the benefit of residents. People living at Grey Gables are provided with an activities programme covering a seven day period. Each morning and afternoon an in-house activity is arranged that covers a range of experiences. This includes drama and movement, reminiscence, a games morning, memory boxes, a sewing class and an exercise class, an art group, dance and music, a film morning, a musical instrument afternoon that includes, bells and tambourines and a well supervised and risk assessed baking afternoon. Sunday is reserved as a pamper day. There is a person who visits on a monthly basis to Care Homes for Older People Page 18 of 35 Evidence: undertake a massage for people that enjoy this activity and an outside singer visits occasionally to entertain residents. Religious festivals are celebrated as are birthdays and at Christmas a church choir visits the home along with entertainment provided by another church. There is a excursion and social event planner and future arranged outings include, a theatre visit in Lancaster to see a show, a war time party afternoon at an outside venue and a coach trip and tea out. One resident was enabled to visit Blackpool for a two day break with her key worker and the key worker has since made a photo album of the event and given it to the resident. Because of the success of this mini break, other two day breaks are being explored for other residents. It is anticipated that a mini bus will be made available in the near future so residents can enjoy regular trips out to the local area and further afield and we were also told that some residents go out nearly every day with their family. A number of residents also enjoy undertaking domestic tasks such as setting the tables, cleaning model cars and dusting. It is understood that these tasks are incorporated in the individual care plan so as to enable the resident to continue with activities that they are familiar with and which they enjoy. One relative told us that her husband is not really motivated to take part in activities but that Staff try hard to coax him. He is assisted and supported to join in as much as he wished to. Another relative said that for her mother, the best bit of living at the home was the Activities they do and walks out, I know she is safe and happy. A resident spoken with individually told us, Smashing do today, enjoyed the activities here and I have been out for a walk, I have had a nice time actually. Although a wide range of activities is offered on a weekly basis it was not always possible to make sure that peoples known individual hobbies and interests were being met. As previously stated in this report, specific care plans were not always in place regarding social care needs or updated to reflect the current interests of the individual resident. The religious needs of people living at the home are considered important. Church representatives used to visit the home regularly but because of a change of circumstances, these visits have temporarily ceased. The management team are in the process of obtaining the necessary information to make sure that similar visits can take place in the future. We were told that a number of residents are regularly escorted to a church of their choice by members of their family and that staff would assist a resident to attend a church service if this was requested. Care Homes for Older People Page 19 of 35 Evidence: People are encouraged to maintain contact with their family and friends, so that they can continue to be part of family life and retain existing friendships. As seen, visitors are made welcome at any time of the residents choice and guests can be entertained in any communal area of the home or in individual bedroom accommodation. There appeared to be a good relationship between residents, staff and relatives with one relative describing the staff as Interested, kind and caring and All the residents here seem happy and settled enough. Another relative stated that she had a good relationship with the staff team and was confident that she would always be immediately informed if there was any concerns or change in circumstances. People are encouraged to exercise choice and maintain control of their lives. Advocacy information is available. People are also supported to manage their own financial affairs for as long as they wish to and are able to, although in reality most people are assisted in this task by a relative or other advocate. People spoken with said they were happy with the meals provided. One resident described the meals as, Food good, very good food. A relative told us that her mother, Seems to enjoy her meals, she never complains. Breakfast is served at a time of choice for the resident and can be served in the dining room or residents could enjoy breakfast in bed if they so wished. Generally breakfast consisted of a choice of cereals, grapefruit, eggs, toast etc but a cooked breakfast can be served on request. The main lunchtime meal is generally a set meal with a good range of foods served and an alternative meal of the residents choice can be provided if required. There is flexibility regarding the timing of this main meal. We were told that one resident prefers to eat later and this is accommodated and supported. The teatime meal is generally of the residents choice. Supper is served in the evening and hot and cold drinks are provided at regular intervals throughout the day or on request. A relative told us that her husband required help with cutting his food up before eating. Staff do this discretely to maintain the dignity of this person. Another resident is diabetic and their menu is determined by this. Specialist diets in respect of medical, religious or cultural requirements can be provided if required. Menus are periodically changed to reflect the seasons and residents are encouraged to have their say about meals and mealtimes through informal chats with staff. 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. Complaints are handled well and taken seriously ensuring people feel listened to. Evidence: Grey Gables care home has in place a complaint policy and procedures which includes details that any complaint would be responded to within a maximum of 28 days. From information in the Annual Quality Assurance Assessment (AQAA) completed by the deputy manager prior to the site visit taking place, a record of complaints is kept that includes details of any action or investigation undertaken. Written details of the complaint procedure is incorporated in the Service User Guide, a copy of which is provided to each resident. The complaint procedure is also displayed in communal areas of the home and there is also a complaint and suggestion book by the front door with loose sheets for people to take away and complete. It was noted however that the copy of the complaint procedure provided to residents is in normal size print and the wording may be difficult for some residents to easily understand. It is suggested that in order to ensure that as many residents as possible have access to the information, consideration should be given to providing this information in a more suitable easy read format that could include large print and in an audio format. Since the last key inspection, one complaint had been received at the home. This was a serious complaint that resulted in an adult, multi disciplinary safeguarding referral Care Homes for Older People Page 21 of 35 Evidence: being made. The local protocols for reporting and investigating any allegation of abuse were followed. The management team at the home fully cooperated in the matter and the allegation was thoroughly investigated with good records kept. Appropriate action was taken in order to ensure the protection of residents. The matter is now concluded. However the action taken shows that complaints are taken seriously and acted upon to improve the service and to protect the interests of residents living at the home. No further complaints have been received by the home or by the Commission. Staff spoken with were clear about what they would do if a complaint or an allegation of abuse was made to them. Residents and relatives spoken with also knew who they should speak with if they were unhappy or concerned about anything. At the time of the site visit no concerns were expressed by the people spoken with, but there were many complements. In order to ensure that all staff working at the home have regular, up to date adult protection training, the two deputy managers have recently undertaken a train the trainers adult protection course and are about to cascade this training to each member of the staff team. It is also important that staff are provided with regular, refresher adult protection training in order to clearly clarify what adult abuse is, the triggers that may result in adult protection issues and to remind staff of their responsibility in this matter. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment in this home is good and provides residents with an attractive, homely and well-maintained place to live. Evidence: Grey Gables care home is situated in a residential area of the town and close to community resources. Communal areas of the home are bright and welcoming consisting of a lounge located at the front of the building, a dining room, a second lounge at the rear of the building and a recently built conservatory. This leads out to an attractive decking area that is provided with seating and tables and a lower patio area that is accessible to residents. The conservatory is home to a budgie that is owned by a resident and enjoyed by other residents and one of the lounges accommodates the piano of a further resident. At present staff are trying to arrange for a piano teacher to visit the home and give some tuition to the resident. Individual bedroom accommodation is in the main for single occupancy and residents are encouraged to take into the home, personal items to make this private space homely and comfortable. There is an ongoing programme of maintenance and renewal to make sure that the high standards are maintained. To ensure safety, radiators are guarded and there is a centrally controlled thermostatic device to control the temperature of water delivered from hot water outlets in resident accommodation. This helps to prevent the risk of accidental Care Homes for Older People Page 23 of 35 Evidence: scalding. A lockable facility is provided in each bedroom for the safe storage of personal items and aids to independent living such as grab rails are provided to meet the needs of residents accommodated. The home is also provided with a stair lift for ease of access throughout the building. There is however an expectation that all doors in all individual bedroom accommodation be fitted with a lock with the resident retaining the key. However it is recognised that some residents may not have the capacity to safely hold a door key or to use a door lock appropriately. We were told that no bedroom door at Grey Gables is provided with a door lock. If there is concern that a resident may not be safe to hold a key, this should be determined through the formal risk assessment process with the outcome clearly recorded and regularly reviewed. Residents should not be deprived of their right to privacy without good reason. Residents spoken with all said that they were happy with their bedroom accommodation and the communal accommodation provided and that the home was always fresh and clean. There are a variety of policies and procedures in place for the control of infection and safe handling of waste products. Laundry facilities are located in a small designated area within the home and does not intrude on residents. All laundry is washed at an appropriate temperature. We were told that although there had been problems with the laundry system, improvements have now been made. It is now the key workers responsibility to make sure that at each shift period, each resident received their correct personal clothing. The key worker is then required to sign to this effect. The majority of staff have already received infection control training meaning that they know how to prevent the risk of cross infection. It has already been arranged that the more recently appointed members of staff will receive this important training by the end of September 2009. 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. Staffing arrangements, recruitment and training ensure that people are well cared for and supported. Evidence: At present the home is enjoying full occupancy. At the time of this unannounced visit there were four management and care staff on duty including the two deputy managers. Domestic and catering staff were also on duty. These staffing levels remained constant in the busy morning period. During the afternoon period, management and care staffing levels are reduced by one, to a deputy manager and two members of the care staff team. However on the day of the site visit, the second deputy manager remained on duty for the afternoon period but this was the direct result of the inspection and was supernumerary to the staff rota. Staffing levels at night consist of a waking watch member of staff, one person sleeping in and a further member of staff on call. It is understood that this is the normal management and care staffing complement throughout the seven day period. There appeared to be sufficient staff on duty to address the needs of residents accommodated and allow for some individual time to be spent with those living at the home and for regular activity to take place as well as ensuring that the physical needs of people are met. Residents spoken with had no concerns about the number of staff and told us that staff were always around and that their wants and needs were being well met. This was also reported by relatives and members of staff spoken with. Without exception very Care Homes for Older People Page 25 of 35 Evidence: positive comments were made about the staff team. One relative told us that the staff were, Kind and caring and that staff were, Meeting mums needs well. A resident said she, Enjoyed the people, staff and the people living here. National Vocational Qualification (NVQ) training is promoted, with 13 of the 17 members of the management and care staff team having achieved at minimum a Level 2 of this award. A number of staff have also achieved the more advanced Level 3 qualification of this award. For the remaining four members of the care staff team without an NVQ qualification, arrangements have already been made for them to commence this course of study. NVQ training is a nationally recognised qualification for care staff. When as anticipated, all care staff will have been trained, this will well exceed the minimum standard expected. This will mean that all the management and care staff team at the home will have their skills, knowledge and understanding externally assessed to make sure they have the ability to provide a good standard of care. As part of the inspection process, we look at a number of random staff files to make sure that all the required information, references and clearances had been obtained for the management team to make an informed decision whether or not to appoint that person. There is a structured recruitment policy and procedure in place for the employment of new staff. This helps to protect residents and to ensure that only suitable people are employed at the home. The staff files of three members of staff working at Grey Gables were viewed, two of which were of staff that had been recently appointed. This included an application form, two references including one from the previous employer, a criminal records bureau disclosure and a check against the nationally held list of people have been deemed unsuitable to work with vulnerable people. However for one recent employee, although one of the references was from a former employer, the second reference was from a personal friend. Where ever possible two professional references should always be requested. A personal reference may not be objective and it may be difficult to make sure that the personal reference was actually written by the person nominated. It is also recommended that the actual start date of a new employee is clearly recorded on their personal staff file so there is no confusion. There was clear evidence that a POVA First and a full Criminal Records Bureau (CRB) disclosure had been obtained but the actual CRB disclosure had been destroyed prior to the site visit taking place. From discussion with the deputy managers, it would appear that they has been misinformed. There is a requirement that the complete CRB disclosure is retained until the next Care Quality Commission (CQC) site visit takes place. Once the CRB disclosures have been viewed as part of the site visit inspection, Care Homes for Older People Page 26 of 35 Evidence: they can then be destroyed. A record was however kept of the date the CRB disclosure had been received and any relevant information from the CRB. This information was held in a collective book. In order to ensure confidently with regard to this sensitive issue, it is recommended that if a record is required of the CRB disclosure, the individual information should be incorporated in that staff members personal staff file. It was however noted from the individual staff files seen, that one new employee had actually started working at the home several days before the POVA First clearance had been received. In order to protect residents, it is imperative that nobody is allowed to take up employment at the home until all the required references and clearances, including the POVA First disclosure are received and deemed to be satisfactory. On receipt of the POVA First clearance, providing all other references are deemed to be satisfactory, the person can commence employment so long as they are adequately supervised at all times and receive formal supervision on a least a weekly basis until the full CRB clearance has been received. Good additional training is also provided that is valued by staff. Further training in specialised areas is provided specific to the individual needs of the people living at the home and to develop the skills and knowledge of the individual member of staff team. Recent training for some staff has included, medication courses, a leadership and management course, deprivation of liberty training, mental capacity act training, prevention of falls training and a train the trainer course. In addition a number of staff have completed an extended four month dementia care training course. However another eight members of staff require this important training but the funding has been withdrawn. Another agency is trying to find a solution to the problem so that staff at Grey Gables and staff at other care homes in the area can access this training. This helps to ensure that a good, individualised service is promoted by a well trained staff team. 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. Grey Gables is well managed so that it is run in the best interests of the people who live there. Evidence: The homeowner is also the registered manager at Grey Gables and has responsibility for the day to day management of the home. However there are now also two deputy managers that form part of the senior management team. From discussion with the deputy managers during the course of the site visit, it is understood that there is a proposal that one of the deputy managers is to submit an application to the Care Quality Commission for consideration to become the registered manager at Grey Gables. If the application is successful, this will mean that this person will have day to day management control of the home rather than the homeowner. One of the deputy managers has successfully completed the Registered Managers Award and the second deputy manager has completed an NVQ Level 4 in management. The Registered Managers Award is a professional qualification that all managers of care home are expected to achieve to make sure that the home is run in the best interests of the Care Homes for Older People Page 28 of 35 Evidence: people that live there. Staff spoken with told us that they felt very well supported by the management team and felt that their views and opinions were valued. One member of staff said, I definitely get a lot of support and we are asked questions about individual residents when the care plan is being reviewed. Another member of staff said, Feel well supported, always have support with professional and personal things. We were also told that there was, Good relationships within the staff team and another person said, Good staff group, not like coming to work, have a good chat and then get down to business, I never come on shift and not know what is going on. Because Grey Gables is a fairly small home with a good relationship between residents, staff and relatives, feedback about the home is often informal and ongoing during general discussion or one to one chats. However there are also more formal ways in place to find out what people think about the home and whether staff are meeting the needs of the people living there. Quality monitoring is considered important. Different questionnaires are periodically made available to residents, their families and professional staff that visit the home. We were told that the latest questionnaires completed in July 2009 provided many good and excellent comments but also some constructive criticism. Responses are collated and action is taken as required. For example, some residents said that the stair lift should be able to be folded when not in use so that people could walk up the stairs more easily. As a result of this, a belt has now been provided to enable the stair lift to be kept folded until required. Resident meetings did not prove successful but where ever possible, residents are verbally informed of the outcome of the questionnaires. There is an open door policy for relatives to find out what people felt about the home. This method of quality monitoring clearly suits the people living at the home and their families. It is understood that staff meetings take place on a regular basis, with senior staff meetings taking place more frequently. There is also a handover of information during the daily shift hand overs. This means that staff have opportunity to have their say about the running of the home and influence change. Policies, procedures and practices are regularly reviewed so that best practice principles are maintained. People living at the home are encouraged to remain financially independent or are assisted in this task by a relative or other advocate. However where the home does retain monies for some people, a robust system is in place to protect the interests of residents. This includes a clear and accurate record of any financial transactions undertaken and secure facilities to store monies held. Receipts are kept. However it is recommended that staff who authorise or assist in a financial transaction should sign Care Homes for Older People Page 29 of 35 Evidence: to this effect. There was evidence that formal one to one staff supervision is taking place on a regular basis along with annual staff appraisals. This was confirmed by the supervision notes seen and through discussion with the members of staff individually spoken with. This means that staff have opportunity to meet privately with their supervisor in order to discuss work practices and training needs as well as any other issues relating to working at the home. Records relating to health and safety were seen. Records showed that equipment such as manual handling equipment and fire equipment are regularly serviced and that electrical installation and electrical equipment are also checked. Staff also receive mandatory health and safety training including, fire safety training, manual handling training, first aid training, food hygiene training and infection control training. The majority of staff have all undertaken this important health and safety training and it is understood that this mandatory health and safety training is about to commence for all recently appointed staff. We were also informed that at present there are no environmental risk assessments in place. This should be kept under review. If there is any suggestion that the physical environment of the home could present some potential risk, a formal risk assessment should be undertaken in order to minimise that risk and so protect residents. 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 2 14 Following the pre admission 31/10/2009 assessment, the prospective resident must be informed in writing the outcome of the assessment. This would confirm to the prospective resident that their current needs and requirements could be met at the home. 2 3 43 Grey Gables is only registered to accommodate people with a diagnoses of dementia. If a resident is admitted to the home without this diagnoses, the conditions of registration have been breached. 31/10/2009 3 29 19 Newly appointed staff must not take up employment at the home until at minimum, at POVA First has been 31/10/2009 Care Homes for Older People Page 32 of 35 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 received and deemed to be satisfactory. This would help to protect people living at the home 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 The Service User Guide and Statement of Purpose should contain accurate information that is pertinent at the time a copy is provided to an individual. Where ever possible residents should be made aware of any changes to the Service User Guide or Statement of Purpose. The Service User Guide should be provided in a format that is most easily understood by the resident group accommodated. Consideration could be given to making this information available in large print or in audio format. A full pre admission assessment should be undertaken to ensure that individual strengths, needs, wants and wishes are known in order that an informed decision can be made as to whether the specific needs of that individual could be met at the home. A formal risk assessment should always be undertaken when a risk is identified with significant outcomes incorporated in the care plan. The person undertaking the monthly review and completing any subsequent amendment to the care plan should sign and date the amendment to take ownership of the recording. Significant outcomes of any formal risk assessments undertaken should be included in the care plan. All care plan and risk assessment outcome information should be detailed and provide up to date information that is reviewed and amended as required. 2 1 3 3 4 7 5 7 6 7 7 7 Care Homes for Older People Page 33 of 35 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 8 7 All relevant pre admission assessment information should be carried through to the care plan so that the holistic needs and wants are met in a consistent way. It is recommended that a seperate individual sheet be developed to record health professional visits rather than the current practice of writing this information on the daily diary sheet where it may be difficult to find over a period of time. Any hand written entries on the drug administration record should be signed, dated and countersigned by a second person to confirm accuracy of the recording. Short life medication should be dated on opening. It is recommended that the homes complaint procedure be provided in an easy read format that is suitable to meet the capabilities and understanding of people living at the home. All staff should receive the planned adult protection training as soon as possible and regular refresher adult protection training should be provided at regular intervals. All bedroom doors should be provided with a lock to ensure privacy for the occupant, unless a formal risk assessment outcome indicated that this would not be appropriate for that particular resident. The full CRB disclosure in respect of newly appointed staff should be retained until the next CQC site visit inspection. In order to maintain confidently, any information in respect of CRB disclosures should be recorded separately rather than in a collective book as at present. Where ever possible two professional references should always be requested rather than a charactor reference. The actual start of a new employee should always be clearly recorded. When staff assist or are involved in a residents financial transaction, the financial record should be signed to this effect. 9 8 10 9 11 16 12 18 13 19 14 15 29 29 16 17 18 29 29 35 Care Homes for Older People Page 34 of 35 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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