Care Home: Harnham Croft Nursing Home

What the care home does well Harnham Croft is an attractive building, which is well maintained and clean throughout. High standards of equipment and furnishings are provided. All equipment is well maintained and regularly serviced. Staff are motivated and understand individual residents` needs. There are clear systems for regular quality audit of service provision by the provider, to ensure that services continue to meet residents` needs. A manager from the provider visits the home regularly and BUPA has been fully supporting the new manager throughout their induction process. People commented on the home. One person reported"I really like it" about the home, another "I`m happy with the care I receive" and another described the home as "very caring to residents". A relative commented "its thanks to the quality of care here that my [relative] is still here". A resident reported "staff are pretty good on the whole, oh yes, they are kind" and another described staff as "brilliant". A member of staff reported "I wouldn`t mind my mother being here". A person summed up their opinion of the home by stating "its fine as it is". What has improved since the last inspection? The home have reviewed their statement of purpose, to reflect their current practice. They have fully introduced BUPA`s systems for assessment of resident need and development of care plans. All care plans are now evaluated regularly, particularly when a residents` condition changes. There are systems for regular audit of assessments and care plans, to ensure that they are completed in accordance with resident`s individual needs and company policy. Registered nurses were now complying with company policy on administration of medicines. Care plans relating to the use of medicines which can affect a person`s daily living have been put in place, so that people can assess the effectiveness of such prescriptions, for the individual resident. The home has been refurbished throughout. More hoists have been provided to support people in manual handling. Accident records have improved and are now are fully audited, to identify any trends and enable management to take action if indicated. Proof of identify on staff files are now clearer. Agency staff have an induction and this is signed by the inductee and inductor. What the care home could do better: Some nursing and care documentation would benefit from improvement. Where a resident is assessed as being at risk of pressure ulcers, there must be evidence that such people have their positions changed in accordance with their assessed degree of risk. Clear, measurable wording should be used in care plans. Care plans relating to catheter care should be further developed. Records of the benefits or otherwise to residents of activities should be made to assist in care plan evaluation. Where a resident is prescribed a topical cream or a dietary supplement, there must be written evidence that this had been given to them. Where a resident has a medicine omitted, the reasons for the omission must be documented, in accordance with company policy. At mealtimes where a resident eats in their room, first and second courses should be served to them separately. Systems must be put in place to stop communal use of net underwear, as this can present a risk of infection and does not up-hold a person`s dignity. All hoist slings should be regularly laundered. There must be a full review of staffing levels and skill mix, to ensure that residents` needs can be met. A training plan must be developed to ensure that staff are trained in how to meet conditions associated with the ageing process. Key inspection report Care homes for older people Name: Address: Harnham Croft Nursing Home 76 Harnham Road Salisbury Wiltshire SP2 8JN     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: Susie Stratton     Date: 2 0 0 5 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 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 35 Information about the care home Name of care home: Address: Harnham Croft Nursing Home 76 Harnham Road Salisbury Wiltshire SP2 8JN 01722327623 01722334983 maguiren@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: care home 44 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability terminally ill Additional conditions: No more than 4 service users with a terminal illness may be accommodated at any one time No more than 4 service users between the ages of 18 - 65 years with a physical disability may be accommodated at any one time. The maximum number of service users who may be accommodated in the home at any one time is 44. The staffing levels set out in the Notice of Decision dated 31 March 2005 must be met at all times. Date of last inspection Care Homes for Older People Page 4 of 35 Over 65 44 0 4 0 4 4 Brief description of the care home Harnham Croft Nursing Home was first registered as a nursing home in 1947; it was renovated and extended in 1978, 1989, 1993 and a further extensive renovation was completed in 2003. The original building was built in 1898. Accommodation is provided over 3 floors and the grounds extend down to the River Nadder, with views looking towards Salisbury Cathedral. The home is owned by BUPA, a national provider of care homes. The managers post is currently vacant, although a person is acting into this role, they are supported by a team of registered nursing and care staff. An activities organiser and a team of ancillary and administrative staff are also employed. The home is situated on the main road in Harnham, which is on the outskirts of the city of Salisbury, about a mile from the city centre and three quarters of a mile from Salisbury District Hospital. There is a bus stop immediately outside the entrance and ample parking is available on site. The fee range is 650 pounds to 1,050 pounds per week. Items not included in the fees are hairdressing, chiropody, newspapers and telephones. Copies of the service users guide are available in the front entrance area and all residents are also given their own copy in their room. 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: As part of this inspection, the homes file was reviewed and information obtained since the previous inspection considered. The home also submitted an Annual Quality Assessment Audit (AQAA). This is their assessment of the quality of their service provision. It also provided numerical information on services provided. Surveys were sent out to residents, their relatives, staff and external professionals who visit the home, and twelve were returned. Comments made by people in the surveys and to us during the inspection process have been included when drawing up the report. We looked at the AQAA, the surveys and reviewed all the other information that we have received about the home since the last inspection. This helped us to decide what areas we should focus on when doing the inspection. The site visit took place on Thursday 20th May 2010, between 8:50am and 4:40pm. A regulatory inspector performed the inspection. This person is referred to as we throughout the report, as the report is made on behalf of the Care Quality Commission Care Homes for Older People Page 6 of 35 (CQC). The visit was unannounced. The new manager was in charge of the home and they and a manager from a sister BUPA home were available for feed-back at the end of the inspection. During the site visits, we met with a range of residents across all parts of the home and also observed their care. We toured all of the home and observed care provided at different times of day. We reviewed care provision and documentation in detail for five residents, including two residents who had recently been admitted and looked at specific matters relating to a further three residents. As well as meeting with residents, we met with a registered nurse, five carers, the activities coordinator, a kitchen assistant, the maintenance man and two cleaners. We observed a lunchtime meal. We reviewed systems for storage of medicines and observed a medicines administration round. A range of records were reviewed, including staff training records, staff employment records, complaints records and maintenance records. 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: Some nursing and care documentation would benefit from improvement. Where a resident is assessed as being at risk of pressure ulcers, there must be evidence that such people have their positions changed in accordance with their assessed degree of risk. Clear, measurable wording should be used in care plans. Care plans relating to catheter care should be further developed. Records of the benefits or otherwise to residents of activities should be made to assist in care plan evaluation. Where a resident is prescribed a topical cream or a dietary supplement, there must be written evidence that this had been given to them. Where a resident has a medicine omitted, the reasons for the omission must be documented, in accordance with company policy. At mealtimes where a resident eats in their room, first and second Care Homes for Older People Page 8 of 35 courses should be served to them separately. Systems must be put in place to stop communal use of net underwear, as this can present a risk of infection and does not up-hold a persons dignity. All hoist slings should be regularly laundered. There must be a full review of staffing levels and skill mix, to ensure that residents needs can be met. A training plan must be developed to ensure that staff are trained in how to meet conditions associated with the ageing process. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will have their needs assessed prior to and after admission, to ensure that the home can meet their individual needs. Evidence: In their AQAA, the home reported that all new residents are admitted only after a full care management assessment has been made by the registered manager, or delegate, of their needs and it is clear the home can meet the needs. Assessments give opportunity for the prospective resident to meet staff, either in their own home of their current situation. A plan is then collated with the resident for daily living and longer term outcome, based on the care management assessment. They report that all mandatory assessments are completed within the first six hours and all documentation is completed within 72 hours of admission. They report that during the past twelve months, all staff have received in house training with regards to customer service care to ensure best service delivery when welcoming new and prospective residents and relatives. Care Homes for Older People Page 11 of 35 Evidence: We met with two people who had recently been admitted to the home. One person described Harnham Croft as a lovely place, they reported that they had been in hospital for a bit and were relieved not to be in hospital any more. Another resident reported that they found that some days were better than others and moving into a home was taking them time, for example they found it difficult getting used to being moved by a hoist, but they appreciated being able to lie in bed in the afternoons. We discussed with staff how they found out about new admissions. Care staff reported that they were informed about new residents needs at report and that if they had been off for a few days, they were always given a more detailed report. We observed that this dis take place when we visited. They also reported that they could read the residents records, which were in their rooms. A catering assistant reported that they were given a list about what a person liked to drink and how they drank, so that if the person could not tell them themselves, they knew the type of cup they needed, their drik preference and if they wanted milk and or sugar. We looked at residents pre-admission assessments and observed that they were completed in detail, reflecting a range of matters individual to the resident. For example one resident had a clear record of their past life and preferences, another resident had clear information about a wound they were admitted with. Where relevant discharge summaries from their previous provider were also included in their records. Residents needs were, as stated in the homes AQAA, re-assessed promptly after admission. We considered that the information in care plans would direct staff on how to ensure that they could meet newly admitted residents individual reeds. Care Homes for Older People Page 12 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. Residents will generally have their nursing and care needs met. The commitment of staff in the home is shown by the fact that there were only a few issues identified under health and personal care, despite the home experiencing a high usage of temporary staff. Evidence: In their AQAA, the home reported that all residents have comprehensive personal plans produced with the help of the providers assessment tool, which are reviewed monthly and updated as necessary. They report that the care plans are live and change according to the residents needs. They reported that they record and report on the treatment of pressure ulcers, as well as assess and document actions taken to alleviate the risk. All residents nutritional needs are assessed using a recognised nutritional assessment tool. There is a monthly medication audit to ensure staff adhering to policy procedures for all medicines in the home. They also report that all residents are registered with their choice of GP. People commented to us about nursing and care provision in surveys. One person Care Homes for Older People Page 13 of 35 Evidence: reported I am well cared for, another that they were happy with the care I receive. While most people felt that they received the care and support that they needed, many felt that staff were not always available to do this and that while most staff listened to them and acted on what they said, others did not. We discussed these responses with staff at all levels in the home and they reported that the home were currently using high levels of agency staff, across all nursing and care groups. This had meant the potential for a lack of consistency in approach to residents. The new manager was progressing a recruitment campaign but in the meantime had managed to secure agency staff who worked regularly in the home, so the situation was improving. The registered nurse in charge reported that they ensured that they gave a full and detailed report at the beginning of every shift, to ensure that staff, including agency staff, knew individual residents needs. We observed that this was the case when we visited the home. The registered nurse also reported that they tried to ensure that if two agency staff had to work together, that one of the staff had worked in the home for a period of time and knew the residents they were caring for. Three of the agency staff we spoke with were able to inform us about the needs of the resident they were looking after in some detail. One agency carer reported on how much they enjoyed working in the home. Where staff may not know a residents needs, records including assessments and care plans, are very important in supporting staff on how to meet individual residents needs. All assessments and care plans were kept in residents rooms, to allow for ready access by all relevant persons. We observed that records were completed in accordance with the providers policies and procedures, as was stated in the homes AQAA. We reviewed a range of residents assessments and care plans and found that most were completed in detail and reflected what residents and staff told us about. All residents had assessments for risk such as pressure ulceration, dietary risk, falls and manual handling needs. If a risk was identified, a care plan was put in place to direct staff on how risk was to be reduced. For example one residents condition had changed, so their dietary risk assessment had been re-assessed and their care plan revised, to show their current needs for support. Another person has sustained a fall, which made them less mobile and their care plan had been revised to reflect this. Where a resident had a need for a urinary catheter, the clinical reason for the catheter was documented and there was a full record of changes of the catheter. Where a person had a wound, there was clear evidence that the tissue viability nurse had been contacted for advice and that the home were following this nurses care plan. Records relating to wound care showed an ongoing assessment of the wounds response to Care Homes for Older People Page 14 of 35 Evidence: treatment programmes. Care plans did not only relate to peoples complex needs. One person who needed to wear glasses had clear information about this need and their varying needs for support. Generally care plans gave a rounded impression of the resident, reflecting the person as an individual. As would be anticipated, some areas would benefit from improvement. Some care plans did not include measurable language, with terminology such as as soon as possible or for a short time only. Care plans would benefit if words such a soon or short were defined in measurable language. While most care plans had been evaluated monthly and when a persons condition changed, one persons care plan had not been reviewed for three months. There was no indication that their condition had changed. Care plans relating to urinary and supra-pubic catheters would benefit by stating precisely how often and when, the persons urine bag needed changing and precise care requirements for the catheter insertion site. Where people were at risk of pressure ulceration, the home uses turn charts to ensure that a persons condition is altered regularly. Some turn charts indicated that the person was not having their position changed at the frequency directed in their care plan and one person did not have a turn chart in their room for the whole morning of the inspection, so no records of changes of position were made. If people do not have their positions changed as directed by their condition, they may be at risk of pressure ulceration. Pressure ulcers once sustained are painful, take an extended period to heal and may present risk of infection, therefore emphasis must always be on their prevention. A relative we spoke to felt that an agreed change to their relatives care plan was not consistently being followed by all staff. This was investigated during the inspection and the matter clarified by the manager. There was evidence of close liaison with residents GPs, with full records maintained. A residents records showed the contacts made with their dentist by the home, to support their eating needs. The registered nurse reported on the good liaison with external healthcare professionals. An external health care professional was meeting with this registered nurse during the inspection and they reported on the clear information given to them by the home and their detailed records, which they reported staff followed. A relative informed us that the home had sought the support of a physiotherapist for their relative. We observed a medicines round during the inspection. The registered nurse performed the medicines round correctly and safely in accordance with national and the providers guidelines. We observed that the registered nurse discussed residents needs for pain relief with them, giving the resident time to respond. Medicines, Care Homes for Older People Page 15 of 35 Evidence: including Controlled Drugs, were safely stored. Where changes were needed in medication records, these were signed, dated and counter-signed. There were clear systems to ensure that residents received medicines prescribed on an intermittent basis. The home has a homely medicines policy, which was reviewed regularly and dated and signed by the residents GPs. Where residents were prescribed drugs on an as required basis, there were clear individualised care plans for the use of such drugs. Where residents were prescribed drugs such as aperients, mood altering drugs or pain-killers, which could affect their daily lives, these were referred to in their care plans. This will support staff in assessing the effectiveness of the medicines treatment, to enable them to advise GPs where relevant. We observed that several residents were prescribed topical creams and other applications, or dietary supplements, but there were no clear systems to show that the resident had received these prescribed medications as directed by their GP. As care staff may often apply such creams or support the resident in taking in dietary supplements, systems need to be developed to provide evidence that the resident has been given such medicines as prescribed. The home uses a standard medicines administration record, which has a key which registered nurses need to complete if a resident has not taken their medication. If O is put on the medicines administration record, there is a directive that the reason for the omission needs to be documented on the back of the record. We observed several occasions where O was put on the record but the reason for the omission was not documented. This needs to take place to enable assessmet of why a person has not been given their prescribed medication. We observed that all personal care was performed behind closed doors. Where a resident had restless behaviours, such as throwing off their bed clothes, this was quickly noted by staff and their dignity preserved. Staff consistently called residents by their preferred name, as directed in the persons records. One residents relative commented particularly to us on how they appreciated the care the staff took to ensure that their relative was well turned out. Care Homes for Older People Page 16 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. Residents will generally have their social care needs met, in the way that they choose. Evidence: In their AQAA, the home reported that they have a structured activities programme, with a dedicated activities organiser. Activities are available as groups or as individual sessions for residents as they wish, with one to one sessions taking place in the mornings or afternoons as requested. There is a timetable for activities displayed in lounge. They also report that assistance from relatives who wish to be involved with activities in the home has been a great success. They ensure that all personal plans are individual and based on the choices and preferences of the residents. They employ an open visiting policy, taking into account residents wishes. They report that they have developed their menus to allow for resident choice and preferences. They encourage the involvement of residents and staff in the development of the menus. Residents may eat in the dining room or their own rooms as requested. Dining is not rushed but an important time during the day. The chef will meet or speak to the residents or family if a concern, complaint or suggestion is raised and they visit the dining room weekly to chat with residents and receive feedback. People commented to us about this area in surveys. One person reported that they Care Homes for Older People Page 17 of 35 Evidence: enjoy to chat with the activities lady and another that they always have an ear to listen to me. People commented on the meals. One person reported I receive good meals, another that they do enjoy the meals and another that the food is wonderful. People talked to us about how their social care needs were met. One resident reported on the good chatty rapport with staff and that they had a choice about what they could do. Another person reported that they went downstairs quite a bit and enjoyed this because they could sit and talk to people. A resident described a carer who was always cheery and how they enjoyed giving [the person] a bit of lip. Another resident reported that it was up to them if they went downstairs. We met with several visitors who all confirmed that they could come into the home when they wanted to. Most visitors reported on the good communication with staff and that they felt involved with their relatives care. For example one visitor reported that they appreciated being able to come into the home at lunch-time to support their relative with eating their meal. We observed that the activities programme was clearly displayed by the main sitting room, as stated in the homes AQAA. We met with the activities person who was very enthusiastic in their role. They reported that they had found that many residents really enjoyed having their nails done and that BUPA had funded them in going on a course, so that they could develop this area. They also reported that many residents enjoyed the cross-word group and that the gardening club was developing. Where residents did not come out of their room, they always went to see them regularly, sometimes reading to them, sometime just for a char. They reported that many of the people who did not leave their rooms particularly enjoyed visits from the PAT dog. The activities person said that staff informed them promptly of changes in residents conditions, if a residents condition had changed. If they noticed a change in a resident, they reported that staff listened to them. The activities person showed a good verbal knowledge of individual residents needs and was aware of all residents for whom practice of religion was important. They agreed that they did not always document resident participation in activities and we recommended that they should do this, to support assessments of the benefit to the resident of the different activities offered to them. We received a range of different comments from residents about ther meals. Commentes varied from the foods very good, wonderful food, I never leave a thing, the foods not bad actually, through theres not a lot of choice, to meals not very good and the foods horrible. A relative who was visiting the home at lunch-time reported the food is exceptional here, without the wonderful meals my [relative] would not be as good as is. Care Homes for Older People Page 18 of 35 Evidence: We observed a lunch-meal. Residents could have a starter before their main meal if they wished. There was a choice of first course and dessert, with a clear system for ensuring the resident was given what they had ordered. The dining room was nicely laid out with cloth table-cloths and proper crockery, similar to a good standard hotel. Residents who sat in the dining room sat at small tables to assist the social atmosphere. There was also a larger table to the rear of the room, where residents who needed assistance to eat their males chould be supported. We observed carers giving residents a choice if they would like to eat in their room or the dining room. They also gave residents a choice about if they wished to wear a clothes protector and respected how the resident replied. We observed a carer informing a confused relative of what the meal was. Another carer very gently awoke a resident who had fallen asleep, to remind them about the food before it became cold, also offering them more gravy. Another carer was observed sitting next to a resident, trying the encourage them to eat in a kindly manner, respecting the residents response. The atmosphere during the meal-time was unhurried, supporting the social occasion. Residents who ate their meals in their rooms had meals taken to them on a tray. Where residents needed support to eat, staff sat down with them, assisting them to eat in an unhurried manner. We observed that both the first course and dessert were taken to the resident at the same time. This means that a residents dessert may become hot or cold and become less palatable while they were eating their main course. It may also mean that residents who are reluctant to eat, will eat only their dessert, avoiding their first course, which may be more nutritious. Care Homes for Older People Page 19 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. Residents will largely be supported by the homes procedures for complaints and safeguarding, however issues raised relating to staffing levels and responce times to call bells needs further action by the provider, to fully reduce risk. Evidence: In their AQAA, the home report on their complaints policy, which has agreed timescales for managing complaints. The information that accompanies the policy is prominently displayed in the home. The policy includes a three tier framework including the home, the regional management team and the operational quality department. They report that BUPA has has robust allegation of abuse and neglect policies, allowing staff to raise concerns within the home or to senior staff outside the home. They also report that training is available regarding to all aspects of protection. Concerns, suggestions and complaints are raised and shared at meetings with registered nurses, carers and heads of department, and used as a learning tool. The new home manager has received training in handling investigations. There is an open door policy for all visitors, staff and residents in the home to discuss any areas with the Home Manager. Generally residents reported in surveys that they knew who to raise issues of concern to them. One person commented that they could always talk to someone. We asked people about how they raised issues of concern to them during the inspection. One person reported I keep getting the manager up to me when they wanted to raise an Care Homes for Older People Page 20 of 35 Evidence: issue and another if Im not happy, I talk to a registered nurse and they usually sort it out. A visitor raised an issue of concern with us during the inspection, and with their permission, we reported it to the home manager, who promptly came to see the visitor and had begun to take action to address the matter during the inspection. A member of staff reported if Im unhappy about something, I confide in and tell [the manager] We looked at the homes complaints procedure and observed that all issues were logged, including apparently small concerns to an individual. Records showed evidence of full and impartial investigation of matters raised. Following investigation the manager sends a clear response to the complainant. BUPA has a monitoring system to enable quality review of complaints, to ensure that their own policies are followed and any trends identified. Many people raised issues with us in surveys and during the inspection about response times to the call bells and low staffing levels. We observed that such matters had been documented and we are requiring elsewhere in this report that the home takes action to address such matters, to ensure resident safety and that their concerns are addressed. A member of staff was very aware of BUPAs whistleblowing procedure and able to give us examples of when they might need to whistleblow. We looked at training records and observed that staff had all recently been trained in their responsibilities for reporting suspicions of abuse. We discussed staff awareness of actions to take in the event of an allegation of abuse and staff at all levels were aware of actions to take, including people like the laundry person and kitchen assistant. The home manager has experience of working within local safeguarding procedures, including making a safeguarding alert to protect a resident. One issue was handed back to the home for action and a review of records and discussions with the manager showed that the issue was fully investigated and relevant action taken in accordance with the providers procedures. One issue relating to a recommendation for review of staffing levels in the home at night by the multi-disciplinary team did not appear to have taken place. Care Homes for Older People Page 21 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. Residents will have their needs met by an environment which is well maintained, clean and safe. Evidence: In their AQAA, the home reported that the home is supported in maintaining the environment by a central team of experts. That they have have a specialist property and estates department, as well as a hotel services department. The regional manager visits focus on the standard of housekeeping. They report that there are in house monthly auditing of areas the environment, laundry, infection control, undertaken by housekeeping team and by monthly walk rounds with the housekeeper and maintenance manager to audit home cleanliness and maintenance. They report that rooms are safe and comfortable, personalised as the residents wish and all rooms have en suite facilities. The kitchen has a five star rating from the local Environmental Health Department. During the past year, the exterior of the home has been decorated and a complete renovation of the home internally. They have employed a gardener to take care of outside areas. Some people commented to us about the refurbishment. One person reported that their room looks lovely after all the paint and clean up, another that they liked their carpets and their new room and another that they liked the new TV. A person described the home as a lovely place to us when we visited them. Another person Care Homes for Older People Page 22 of 35 Evidence: reported on the wonderful new mattress theyve given me. We looked at the equipment provided and observed that all wheelchairs were named and in a good condition. A resident told us that they had recently been assessed for a new wheelchair and that they anticipated its delivery would take place shortly. All of the hoists were regularly serviced and their chassis were clean. We looked at bathwater temperature recording and observed that a record was taken by carers of the bath water temperature before every bath, as is advised by the Health and Safety Executive. There are full systems in place to prevent risk of cross infection. Staff reported on the ready availability of disposable gloves and aprons. There were safe systems for the disposal of waste, including clinical waste. People who need to be transferred using a full body hoist sling have their own slings, which are named for them. Disposable slings are also available. Several residents are assisted to transfer using Standaid type hoist. The slings for this hoist appeared to be well-used and the home should set up a system to ensure that these slings are regularly cleaned, to improve their overall appearance. We met with a housekeeper, who was using the standard BUPA cleaning system. They were aware of their role and of the importance of securing all hazardous cleaning chemicals. We spoke with a second housekeeper who was also enthusiastic in their role, describing their new carpet shampooer and how difficult it was to remove used chewing gum from surfaces. All of the toilets, showers bathrooms and en-suites we inspected were kept at high standards of cleanliness, this included difficult to reach areas such as the undersides of raised toilet seats and high shelving. We talked to residents about the laundry and they did not raise any concerns with us. One resident reported the laundry - thats ok. The laundry person reported that all staff complied with the company policy on infected and potentially infected laundry. They reported that staff also separated used items at source and they did not have to re-sort them in the laundry. They reported that mop heads were washed every day. The laundress reported that the home did not have a problem with un-named clothes and that they or the carers could nearly always identify who any un-named clothing belonged to and would mark them up and return them to their owners. There were no bins or racks of un-named clothes and all clothes containers had clothes which were marked for the same person in them. This shows good practice, as in many homes where there is a high level of temporary staff, standards on practice in relation to the laundry has been shown to be complex to maintain. The only exception was net underwear, where there were receptacles for such underwear, which the laundress Care Homes for Older People Page 23 of 35 Evidence: reported staff came and helped themselves to. Communal use of net underwear has the potential to present a risk of cross infection, particularly fungal infections and does not up-hold residents privacy or dignity. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs will be met by staff who have been safely recruited and have largely been trained in their role. There is evidence that their needs will not be met by the numbers of staff on duty or their skill mix. Evidence: In their AQAA, the home reports that they endeavour to maintain agreed staffing levels at all times. They report on the good level of staff retention. They also report on the improved skill-mix. They state that rotas reflect residents needs at specific times of the day. They report that Bupa has comprehensive human resource policies and procedures to aid staff management and recruitment. They describe the training matrix specific to the home that identifies the training requirements of staff and that all mandatory training is up-to-date.They report on the robust induction programme and buddy system for new starters. We received a wide range of comments in surveys about staffing levels. No-one reported satisfaction with the numbers of staff on duty. One person reported that the home needed to have more staff, another that the home needed to add a few extra staff in order to relieve residents waiting a long time before being assisted. Many people responded specifically about long waits for their bell to be answered. One person reported that staff needed to be a bit more quicker, another that staff needed to be quicker when bell is rung, another bells need to be answered quickly Care Homes for Older People Page 25 of 35 Evidence: and another ring the bell - come quicker. Several people also commented to us on this during the inspection. One person reported if I press my buzzer - they dont come, another theyre short staffed quite a bit, another I ring my bell, they come, not straight away particularly aweful waiting for the toilet and another I feel that theyre very, very busy with other people. We tested a bell with a resident who wanted assistance. After three minutes, a member of staff had still not appeared. A member of staff came four and a half minutes later. The member of staff was very apologetic but reported that they had been looking after another resident. Our observations showed that staff were busy, caring for residents and seeking to support them by meeting their needs. We reviewed the homes print-out for responses to call bells and observed that while staff often did get to a person in under three minutes, there were many occasions on which they did not. In a care home with nursing, staff need to be able to attend promptly as there is the potential for a resident to have a medical emergency. It is also very uncomfortable for a person who has continence care needs to wait for long periods for the toilet and slow attendance can be a factor in a person who needs assistance developing incontinence. The minutes of a multi-agency safeguarding meeting indicated that professionals considered that there were not always enough staff on duty in the home, particularly at night. At this inspection, we found that residents were not always having their positions changed at the frequency directed in their care plans. This may relate to staff not correctly completing records, but it may also relate to staff availability to perform this role. Minutes of meeting also bring up issues relating to staffing levels (see Management below). The home needs to uperfomr a review of its staffing levels, to ensure that residents needs can me met and call bells be responded to in a prompt manner. We looked at the skill mix. During the inspection, there was one registered nurse on duty. This person was very busy, initially performing the medicines round, which took some time to do, as would be anticipated in a care home with nursing where many residents need to be given a range of medication and adequate supports to take the medication. The registered nurse was also busy with other clinical issues, including performing dressings and contacting external health care professionals. This left the registered nurse with very little time to actively supervise the carers on duty, to ensure that they were meeting residents needs. As the home uses agency staff who will be less familiar with residents needs, supervision is a key area to ensure that quality of nursing and care is maintained. A medical emergency occurred during the inspection. The registered nurse dealt with this appropriately and took all relevant Care Homes for Older People Page 26 of 35 Evidence: actions. The medical emergency did not occur when the registered nurse was performing medicines administration (as it could have done). If it had occurred at such a time, residents would have received their prescribed medication late. This is not a satisfactory situation and needs urgent review by the provider to ensure the safety of residents. The manager reported that the home were using high levels of agency staff and were currently recruiting more permanent staff. They reported that their efforts in this respect had been successful and that to ensure continuity of staffing that they always tried to book the same agency staff. recruitment of registered nurses remained a problem and BUPA were considering a range of avenues to address this. When we inspected, there were more agency carers on duty than permanent careers. All agency staff we met with had worked in the home for a period of time and said they liked working there. They knew the needs of the residents we asked them about. In homes where a similar situation has arisen, there is often evidence of a reduction is standards of care, it is much to the credit of the manager and her staff that this has not happened in this home in any significant way, though clearly the current situation is not ideal. We looked at the files of three recently recruited staff. All showed full compliance with the providers polices and procedures. All included full proof of identify, a full employment history, police checks, two relevant satisfactory references and a health status questionnaire. All staff were interviewed using an interview assessment record to assess their strengths and areas for development. All people had been issued with a job description, which both parties had signed. In one case, a document was not held on the individuals file; the manager was fully aware of the issues. We advise that copies of all matters relevant to employment of a staff member is held on the persons file in the home, to comply with the providers policies and to assist in audit. All staff have a standard induction programme, which complies with national guidelines, when they commence their employment. There was evidence that agency staff were also given a brief induction. After their induction period, care staff are supported in undertaking National Vocational Qualifications by the provider. We looked at training records. The manager has performed an audit of training for staff working in the home and has ensured that all mandatory training is up-to-date. The manager has up-dated the training matrix. The matrix now enables the manager to see at a glance who is due for training and when. The manager next needs to develop a training programme to meet the needs of residents who have conditions common for elderly people, such as stroke care, dementia care, diabetes care, Care Homes for Older People Page 27 of 35 Evidence: arthritis care and people who have visual or auditory loss. This will support staff in caring for the residents who are living in the home. Care Homes for Older People Page 28 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. Residents health and safety will be up-held by the management systems in the home. Evidence: In their AQAA, the home state that heads of departments and the home manager are visible each day, meeting and talking with relatives and residents and that the open door policy fosters openness and respect. They report on their annual internal and external customer satisfaction survey. Additionally, the home is supported by a national team of quality consultants whose role includes supporting quality issues within the home, auditing and providing guidance on policies, procedures and practice. Regular Health and Safety meetings take place, with a standardised agenda giving staff the opportunity to communicate on Health and Safety issues. The minutes from these go to the regional manager and the operational quality team. The current home manager has only recently come into post and has applied to be registered with us as the manager. The home had a period of time without a permanent manager and we are aware that periods without clear leadership can lead Care Homes for Older People Page 29 of 35 Evidence: to disruptions in service delivery. However it would appear that the providers systems are such that this has been kept to a minimum. The current home manager does not have a deputy and BUPA are actively recruiting for this post, unfortunately they have not been successful to date. The new manager has been fully supported in their role, this has included supports from an experienced manager during the refurbishment programme, so that they could concentrate on service delivery. They have also been supported by regular visits from a senior manager from BUPA, regular management meetings within BUPA and, on the day of the inspection, they were receiving direct support from the experienced manager of a sister home. The new home manager reported to us that they felt supported in their new role by BUPAs systems. BUPA has standard systems for auditing the quality of service provision. Where issues are identified, the manager is required to produce an action plan. The provider also has standard, safe systems for management of residents personal moneys. These are fully auditable. We reviewed minutes of residents meetings and noted issues were raised in relation to staffing levels and staff having adequate time available to sit and talk to residents (this and other comments have been dealt with in Staffing above). Comments were also made about the slow response time when residents used their call bells. People reported to us about the new manager. One resident reported that the manager is always around and says hello. All accidents are regularly audited, using BUPAs systems, and any trends identified so that action can be taken to ensure peoples safety. There are comprehensive environmental risk assessments to ensure that any risk to people is reduced as much as possible. We observed staff performing manual handling during the inspection. We observed that staff, including agency staff, performed manual handling in a safe manner, advising and supporting the resident throughout. On one occasion only we did observe an agency carer transporting a resident in a wheelchair with only one foot plate, so both feet were placed on one foot pedal. We informed the manager of this observation so that she could take action on the situation. It was the only observation of unsafe practice that we observed. This again is to the credit of staff and shows their commitment and effective training of all staff, as manual handling practice has been known to slip when there are not sufficient permanent staff and issues relating to staffing numbers and direct supervision. We reviewed maintenance records and observed that full checks were maintained on the building and equipment in accordance with BUPAs procedures. The fire log book was fully maintained and all residents had individual fire evacuation plans, using a traffic lights system. 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 8 13 Where a resident is assessed 30/07/2010 as being at risk of developing pressure ulcers and has directives in their records relating to how often they need their position changing, there must be full evidence that this is taking place. Pressure ulcers are painful, take and extended period to heal and may present a risk of infection Therefore the emphasis must always be on their prevention. 2 9 13 Where a person is prescribed a topical application or a dietary supplement, there must be clear documentary evidence to show that the person has received their medication in accordance with their doctors instructions. 30/07/2010 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 This to ensure that each resident receives their prescribed medication. 3 9 13 Registered nurses must always follow the homes policy and procedure on omitted medication and document reasons why a particular medicine was omitted. This is to provide evidence of why a resident has not been administered their prescribed medication. 4 26 13 Systems must be put in place to prevent communal use of new underwear. This is to prevent risk of cross infection and to uphold residents dignity. 5 27 18 The provider must perform a 30/07/2010 full audit of staffing and skill mix across the 24 hour period, to ensure that residents needs can be met and staff are able to support emergency situations. This is to ensure that individual residents needs can be met. 30/07/2010 30/07/2010 Care Homes for Older People Page 33 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 6 30 18 A training programme must 31/08/2010 be drawn up to support staff working in the home in caring for common conditions for elderly people. This is to ensure that staff can meet residents needs. 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 2 7 7 All care plans should be reviewed monthly in accordance with the providers policies. Care plans relating to urinary and supra-pubic catheters should state how often the urine bag needs to be changed and how catheter insertion sites are to be cared, for and cleanliness maintained. Care plans should always use precise, measurable language and generalistic wording should be avoided. Records should be made of the benefit or otherwise of different activities for them, to support development of their care plans. Where residents eat in their own rooms, their first course and dessert should be services separately. Systems should be put in place for the regular laundering of Standaid slings. Copies of all relevant recruitment information should be held on staff files in the home in accordance with the providers policies. 3 4 7 12 5 6 7 15 26 29 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 35 of 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!