Care Home: Hereford House

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What the care home does well Residents` lifestyle within the service is generally their own choice and we observed some good interactions between staff and residents throughout the site visit. Residents live in a homely environment and are provided with comfortable indoor communal facilities. Some written comments from resident surveys when asked what the home does well were: `Looks after the residents and always kind and helpful to the visitors`, `good food and cleanliness` and ` Everything. Can`t fault the care and consideration given to clients`. Staff surveys reflected in what the service does well was: `does train staff`, `Communication. Listen to residents. Good food` and `caring for resident and staff`. What has improved since the last inspection? This is the first inspection undertaken of Hereford House since registration. What the care home could do better: The below listed areas of improvement are linked to the requirements made within this inspection report. These areas of improvement are linked to areas that have a major impact on the residents` health, safety and welfare. It is advised that the reader should read the full content of this report for all areas in which the home could improve. Action must be taken to ensure that the services as detailed in the Statement of Purpose and Service User`s Guide are provided to ensure people`s expectations are met. Action must be taken to ensure care plans provide clear and consistent information about individuals` health, personal and social care needs. Clear guidance needs to be provided to staff to ensure residents receive their care in a person centred and consistent manner. Clear records need to be maintained to evidence the level of care provided and that the home is meeting the needs of residents. Comprehensive risk assessments must be implemented, provide consistent information and ensure clear guidance is provided to staff on how to reduce the risk to promote residents safety so far as is practicable. Action must be proactive and not reactive. Improvements need to be made in relation the medication procedures to ensure medicine administration chart records are accurate and complete, so that there is clear information of all medical treatment. The controlled drugs cabinet must be attached to the wall correctly to ensure compliance with legislation. The registered providers must take action to ensure that at all times suitably qualified, competent and experienced staff are working to meet the needs of residents. Robust recruitment practices need to be implemented to ensure residents are safeguarded and staff are kept up to date with training. The home needs to reassess their internal monitoring systems to ensure residents are safeguarded, record keeping is improved and to evidence that the home is being well managed, meeting its aims and objectives and being run in the best interest of residents. areas that the service acknowledges they could do better and provides us with information regarding their planned improvements for the next 12 months. When asked what the home could do better, some written comments on resident surveys were: `See the doctor more`, `Could be kept cleaner in room` and `Nowt`. Staff survey comments for areas of improvement were: ` The home is trying its best to meet the standard. May need to improve on wages`, ` add cleaning staff or cleaner` and ` more staff`. Any minor shortfalls noted at the site visit, of which no requirement or recommendation has been made have been highlighted throughout the report. Key inspection report Care homes for older people Name: Address: Hereford House Hereford House Hereford Street Brighton East Sussex BN2 1LF     The quality rating for this care home is:   zero star poor 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: Jennie Williams     Date: 2 0 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © 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 32 Information about the care home Name of care home: Address: Hereford House Hereford House Hereford Street Brighton East Sussex BN2 1LF 000 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Southern Primecare (Brighton) Ltd Name of registered manager (if applicable) Mrs Mary Elhefnawy Type of registration: Number of places registered: care home 29 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 29. The registered person may provide the following category of service : Care Home with nursing (N) to service users of the following gender: Either Whose primary need on admission to the home are within the following category: Old age, not falling within any other category Date of last inspection Brief description of the care home Hereford House is a care home providing nursing care for up to twenty-nine (29) older people. The service is owned by Southern Primecare (Brighton) Ltd. The Responsible Individual acting on behalf of the organisation is Panita Vig. The home is situated in a residential area within Kemptown, Brighton. There are nearby local amenities and the seafront is a short walk from the service. There is Care Homes for Older People Page 4 of 32 Over 65 29 0 Brief description of the care home nearby access to public buses. There is limited parking space at the free and restricted paid parking in adjacent streets. Accommodation is provided over three floors that can be accessed by stairs and a lift. All rooms are for single occupancy and all have en suite facilities. There are communal areas for residents to use and suitable numbers of toilets and assisted bathing facilities located throughout the home. There is a small garden area accessible to residents. Current fees are between £537 to £750 per week. There are additional fees for hairdressing, chiropody, personal toiletries, newspapers/magazines etc. A full list of what is not included in the fees can be obtained from the service. This information was provided to us on the 10 December 2009. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor 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: It should be noted that service users prefer to be called people who use services. For the purpose of this report, people who use the service will be referred to as residents. This site visit was facilitated by the Registered Manager. This unannounced site visit was undertaken over two days over a period of time. The first visit was for five hours on the 10 December 2009. A Pharmacist Inspector visited the service on the second day with the Lead Inspector on the 20 January 2010. This second visit was for four and a quarter hours. Evidence obtained at these site visits, previous information regarding this service and information that we have received since registration forms this key inspection report. Due to the service being a new registration, information is also used from the registration report as part of this inspection. Due to the level of input and monitoring from other health professionals visiting the Care Homes for Older People Page 6 of 32 service, we used our discretion and chose to limit our contact with residents to avoid causing any distress. Ten resident surveys were sent to the home, of which six were returned. Five were completed with assistance from friends/family and one was completed independently. Two care plans were viewed, along with specific areas of care for in a further five care plans. We looked briefly at the selection of care plans/specific areas of care as information shared through the Safeguarding Adults arena identified that there are concerns regarding the level of staff understanding and record keeping/care planning. Medication procedures were inspected. The Registered Manager and two staff were spoken with during the site visit. Ten staff surveys were given to staff for completion of which four were returned. Four staff files were inspected, along with the training matrix and rota. We viewed some areas of the environment whilst walking around the service. The quality assurance system, complaint records and quality monitoring checks in place were viewed/discussed. The procedures in place for handling individual monies were viewed. An annual quality assurance assessment (AQAA) was sent to us by the service, completed on the 31 December 2009, completed by the Registered Manger. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. This service has been operating for a short period of time and Safeguarding Adults concerns of a serious nature have been identified and the local purchasing authority has currently suspended any future placements at this service. Support from other health professionals have been provided to the service and social services are currently having meetings every two weeks to monitor the service and ensure residents are not placed at further risk. This level of support and monitoring should not be required for a fledgling new service. As a result of Safeguarding Adults investigations, this service is currently under investigations by the local authority. A Clinical Quality Review Nurse has been requested to undertake a clinical quality review of this service. Additional information will be available regarding the outcome when their report is published. We will be undertaking management review meetings regarding this service to decide what further action we will need to take to ensure residents are safeguarded. There were eleven residents residing at the service at the first site visit and eight residents at the second site visit. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: The below listed areas of improvement are linked to the requirements made within this inspection report. These areas of improvement are linked to areas that have a major impact on the residents health, safety and welfare. It is advised that the reader should read the full content of this report for all areas in which the home could improve. Action must be taken to ensure that the services as detailed in the Statement of Purpose and Service Users Guide are provided to ensure peoples expectations are met. Action must be taken to ensure care plans provide clear and consistent information about individuals health, personal and social care needs. Clear guidance needs to be provided to staff to ensure residents receive their care in a person centred and consistent manner. Clear records need to be maintained to evidence the level of care provided and that the home is meeting the needs of residents. Comprehensive risk assessments must be implemented, provide consistent information and ensure clear guidance is provided to staff on how to reduce the risk to promote residents safety so far as is practicable. Action must be proactive and not reactive. Improvements need to be made in relation the medication procedures to ensure medicine administration chart records are accurate and complete, so that there is clear information of all medical treatment. The controlled drugs cabinet must be attached to the wall correctly to ensure compliance with legislation. The registered providers must take action to ensure that at all times suitably qualified, competent and experienced staff are working to meet the needs of residents. Robust recruitment practices need to be implemented to ensure residents are safeguarded and staff are kept up to date with training. The home needs to reassess their internal monitoring systems to ensure residents are safeguarded, record keeping is improved and to evidence that the home is being well managed, meeting its aims and objectives and being run in the best interest of residents. Care Homes for Older People Page 8 of 32 areas that the service acknowledges they could do better and provides us with information regarding their planned improvements for the next 12 months. When asked what the home could do better, some written comments on resident surveys were: See the doctor more, Could be kept cleaner in room and Nowt. Staff survey comments for areas of improvement were: The home is trying its best to meet the standard. May need to improve on wages, add cleaning staff or cleaner and more staff. Any minor shortfalls noted at the site visit, of which no requirement or recommendation has been made have been highlighted throughout the report. 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 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs and expectations are at risk of not being fulfilled due to the services advertised in the Statement of Purpose/Service Users Guide not being consistently provided. Evidence: The Statement of Purpose was submitted with the application for registration with us and contained all of the necessary information as required by regulation. We were informed at the site visit that there have been no changes made to the document. 80 of resident surveys received identified that they received enough information about the service to help them decide if it was the right place for them before they moved in. These documents provide information about the facilities and services provided at the home. There was evidence at this inspection that the home did not provide the level of care, competent and experienced staff or other services as detailed in these documents. The registered provider must ensure that the service Care Homes for Older People Page 11 of 32 Evidence: they advertise is complied with. The Registered Manager confirmed that there was no one residing at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. There was evidence of pre admission assessments being undertaken; however the information in these could be expanded and more comprehensive to fully evidence that all needs can be met. A pre admission assessment viewed contained basic information and some sections were not completed. There was evidence that copies of other health professional assessments are obtained wherever possible. There is no dedicated accommodation to provide intermediate care. Respite care is available if there is a spare place. Care Homes for Older People Page 12 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health, personal and social care needs are at risk of not being met or care being consistently provided due to lack of information in the care planning system and conflicting information being provided. Evidence: Information shared with us through Safeguarding Adults procedures prior to our site visit demonstrated that there are concerns regarding the care planning system within the service, care being reactive and not proactive and residents needs being at risk of not being identified and met. Care plans and specific areas of care viewed identified that clear guidance was not being provided to staff on how to meet the needs of individuals. Some care plans and risk assessments were providing conflicting information or some were not in place at all. Some assessment forms in use were tick boxes, with no total scoring identified at the end and it was unclear how the service is using this scoring system to identify or reduce risk and provide consistent care. Care plans should also provide information on ways to improve an individuals independence ie: adding coloured flavouring to water Care Homes for Older People Page 13 of 32 Evidence: for a resident with a sight impairment. An individual told us that this is not regularly done for them and did not feel that staff realised the importance of this. Some examples of poor documentation were: an individual had bed rails and covers in place, however the bed rail policy and risk assessment were not completed. We observed a notice in the front of another individuals care plan advising staff when this person is in their room, hourly checks must be undertaken as the resident is unable to use their call bell. A nurse was unable to show us where the hourly checks were recorded. A nutrition care plan for an individual identified that this person required to be weighed weekly. There were no weights recorded from 19 November 2009 until January 2010. The Registered Manager was unable to advise why no one had noted this since November, despite care plans having been reviewed. Records in use for wound dressing were not being used effectively. The AQAA identifies that two people admitted into the home have since developed pressure ulcers. We observed a lot of forms within care plans that were not completed or not relevant to the individual. The Registered Manager confirmed that she copied and put everything in all files. We discussed with her that this in not reflective of person centred care. The Registered Manager agreed with us. The care planning system is not user friendly. On viewing daily notes, it was observed that some staff were writing all care given or full care given. Daily records are a good source of evidence to show that care is being provided, as detailed in the care plan, however the term All care given is not helpful or adequate, especially when care plans do not reflect accurately all needs. Daily records when well written, help ensure a consistent approach and good quality of care for residents. It is in the homes interests to be able to show what they have done, along with providing the evidence on which to base the monthly review and to record that they are following the assessment of needs. 17 of resident surveys identified that they always received the care and support they need, 66 identified they usually received this support and 17 identified they sometimes received the care and support they need. Some written comments regarding the care were: look after me well and I am quite happy here, very caring staff who are always willing to help and make sure they get ... to the toilet when needed. My ... had to wait far too long when I was visiting once. ... was very frustrated and upset. One had written about what the home could do better was See the doctor more. Due to the concerns raised through Safeguarding Adults and residents needs at risk of Care Homes for Older People Page 14 of 32 Evidence: not being met, the local authority has implemented two weekly support meetings with the home where support, advice and discussions about needs are had, to ensure residents are not placed at further risk. This level of support should not be required for a newly opened service. This home is currently under investigation by the local authority, who has as a result of concerns, requested a clinical audit of the service. Additional information will be available when their report is published, via the Brighton and Hove Council website. The pharmacist inspector from CQC visited the home to assess medicine management. We watched the trained nurse giving the morning medicine and noted that a safe procedure was followed. One resident was on two different eye drops and indicated to us that nurses did not always have the time to wait between giving each eye medicine as would be required. This resident was able to manage their own eye drops and was doing so on occasions. There was discrepancies in the records kept of this medicine. The records indicated that medicine was given twice a day. The resident was quite firm that they had this medicine only at night. The instruction on the medicine was to be used as directed. Some gaps were noted on the Medication Administration Records (MAR) chart where a signature should appear for indicating the medicine was given or a code letter to indicate the reason for omitting this medicine. On checking one such gap with the resident for a medicine for that morning, the resident confirmed that this medicine had been given by the night staff as it was a medicine to be had early. The facilities in the home for medicine management are good. The controlled drugs cupboard, although of the correct type, was not attached to the wall in the required manner. Staff were observed to have a good professional rapport with residents and were heard to be calling them by their preferred term. A comment written on a resident survey in what the home does well was Cant fault the care and consideration given to clients. Care Homes for Older People Page 15 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents lifestyle within the service is generally their own choice. Evidence: There is an activities person employed at the home who is currently visiting the service one or two days per week. The Registered Manager confirmed that this person had worked one day a week for the last three weeks. At the first site visit, we observed an entertainer visiting the service to sing with the residents. Visitors/relatives were also observed to be joining in. Residents were observed to enjoy this session. 33 of resident surveys identified that there are usually activities provided at the service that they can take part in, 17 identified always and 17 identified that sometimes there are activities provided. One survey identified that there are never activities provided that they can take part in. One person did not know. No requirement has been made in relation to activities, however the service needs to ensure feedback from residents regarding activities is obtained and action taken if identified as being needed. Care Homes for Older People Page 16 of 32 Evidence: 50 of resident surveys identified that they always liked the meals provided at the home whilst 50 usually liked the meals. A resident and staff survey had both written what the home does well was good food. The home has just commenced monitoring lunch time meals that should assist them to identify any improvements that could be made. A cook was spoken with who confirmed that they are familiar with any specialist dietary requirements. Care Homes for Older People Page 17 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health professionals are currently having to regularly monitor the service to ensure residents are safeguarded and not placed at further risk. Evidence: Whilst three resident surveys identified that there was someone they could speak to informally if they were not happy about something, four people identified that they did not know how to make a formal complaint. The procedures for making formal complaints should be reiterated to residents. All staff surveys identified that they know what to do should anyone raise concerns regarding the service. We were informed that there had been no complaints made to the service since it has been opened. There is a complaints book in place and the Registered Manager told us that she would welcome and encourage complaints. The AQAA identifies that there has been one complaint, of which was upheld. Our address in the complaints procedure in their Statement of Purpose needs to be updated. The AQAA identifies that there have been three Safeguarding Adults referrals made and one investigation. Concerns had been raised with the local authority from a whistle blower. Due to the level of concerns of residents needs not being met, the local purchasing authority has ceased making any further placements at the home and they meet with the service every two weeks to discuss needs and ensure residents are not placed at further risk. Care Homes for Older People Page 18 of 32 Evidence: The AQAA identifies that there are policies and procedures in place for Safeguarding Adults and whistle blowing. The training matrix identifies that half the staff still require this training. An alert was required to be made on the first day of our visit. A social worker was visiting the service to review an individual and a resident provided them with some controlled medication tablets that had been administered by the home, however they had not taken them. They had stored them in a container within their room. Care Homes for Older People Page 19 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in an environment suitable to meet their needs and are provided with comfortable indoor communal facilities. Evidence: The environment was not inspected in detail, however specific areas were observed whilst we walked around the service. The registration report undertaken at the time of registration identifies that the premises are fit for the category of people to be accommodated. The registration report identifies that accommodation is provided over three floors that can be accessed by stairs and a lift. All service user rooms are of the required size and all have en suite facilities. All rooms had been furnished to a good standard with good colour schemes and furnishings. No shortfalls within the environment were noted during the registration with us and we were informed that there has been no major change made to the environment since registration. Care staff are currently undertaking cleaning duties as well as providing care to residents. The home must monitor the effectiveness of this practice to ensure all areas of the home remain clean and that there are sufficient staff on duty to meet all needs of residents. Mixed comments were written by residents. One had written in what the home does well was cleanliness, whilst another identified in what the home could do Care Homes for Older People Page 20 of 32 Evidence: better was could be cleaner in room. Five resident surveys identified that they always found the home fresh and clean and one stated sometimes the home is fresh and clean. A written comment from a staff survey on what the home could do better was add cleaning staff or cleaner. Care Homes for Older People Page 21 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are not being met with the number and competency of staff on duty. Residents are not fully safeguarded by the recruitment procedures in place. Evidence: Whilst we received some positive comments regarding the staff working at the home in resident surveys, information shared with us through Safeguarding Adults procedures identified that the competency levels of management/staffing was not always sufficient to ensure all needs are identified, recorded appropriately and actioned. 17 of resident surveys identified that they felt staff are always available when needed, 66 identified they are usually available and 17 identified sometimes staff are available when needed. 75 of staff surveys felt that there was usually enough staff to meet the needs of residents and 25 felt that sometimes there was enough staff. We were informed that at present there may be two or three care staff working during day times. There is always a registered nurse on duty. The Registered Manager said that the numbers of staff is dependent on amount of staff we can get on the day. There is one registered nurse and one carer who work at night time. The Registered Manager confirmed that with additional duties, staff are just managing at present to Care Homes for Older People Page 22 of 32 Evidence: undertake all duties expected of them. When asked, she confirmed that the staffing levels/work duties have no detrimental effect on meeting residents needs. Staffing levels must be kept under regular review to ensure all needs of residents are met. In addition to caring for the residents, this number of staff is also required to undertake cleaning duties, laundry duties and provide activities to residents when the activities person is not working. The AQAA identifies that three residents are bedfast with two residents who require two or more staff to help them with care during the day and at night. The AQAA identified that all people who have started work in the home in the last 12 months had satisfactory pre-employment checks. Files viewed identified that more robust recruitment procedures must be followed to ensure residents are safeguarded. Examples of shortfalls noted were: not all files had two references, there was no evidence to show authenticity of some references or any identification as to who they were from and gaps in employment had not been explored. For staff where records showed that they were working on a student visa, the Registered Manager was not able to confirm who was monitoring the number of hours worked. She confirmed that the service had recently been short staffed and did not think about the hours being worked. Some additional recruitment information had been followed up and provided to us by the second site visit. The AQAA identifies that there are seven permanent care workers of which four have National Vocation Qualification (NVQ) level 2 or above. There was evidence of an in house induction having been undertaken in a staff file. The Registered Manager confirmed that this is being undertaken in line with Skills for Care and records are maintained. Despite being a key standard, the AQAA provided us with no information on training for staff within the service, only stating all staff receive induction training. Staff surveys identified that they are provided with training that is relevant to their role, helps to understand and meet needs, keeps them up to date with new ways of working and gives them enough knowledge regarding health care and medication. A training matrix was viewed at the first site visit, which had not been kept up to date. The training matrix was later e-mailed to us. This identifies that some mandatory training had not been provided. The Registered Manager confirmed that where gaps in training have been identified, training is being arranged. Care Homes for Older People Page 23 of 32 Evidence: We observed in a staff file that manual handling practical training had been provided from another service via DVD training. We asked the Registered Manager to ensure that this practical training provided by only watching a video was suitable. At the second site visit, she confirmed that she had not had time to check the suitability of this training and will be sending all staff on practical manual handling training again. Care Homes for Older People Page 24 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Implementing robust monitoring systems will assist in ensuring residents and staff are safeguarded, the home can meet individual expectations and preferences and evidence that the homes aims and objectives are being met. Evidence: The Registered Manager is registered with us and the registration report identifies that she is a registered nurse and has had various roles and experience at management level. She has current registration with the Nursing and Midwifery Council (NMC) and has completed the Registered Manager Award. The registration report identifies refresher training that is required for the Registered Manager. At the site visits, we were informed that some training dates have been booked and she is aware of other training that needs to be undertaken. The registration report identifies that the Registered Manager understands the need for clinical support and supervision for herself and will ensure that this is in place. We were informed at the site visit that one supervision had been undertaken to date. This Care Homes for Older People Page 25 of 32 Evidence: was regarding managerial issues and not clinical issues. The Registered Manager told us that she needs clinical supervision, however has not requested this to date. After providing feedback to the Registered Manager she stated in all fairness we have only been opened for a few months. We advised her that this is no defence as a new service should be up and running effectively from the beginning, particularly as they are not even running at full capacity. We had found many shortfalls already with the limited number of residents residing within the service. A nurse spoken with felt that they did not receive enough orientation on arrival at the service and felt that there were no clear roles and responsibilities within the service. There was evidence that there is very limited understanding with management and staff in relation to the Mental Capacity Act and Deprivation of Liberty Safeguard. The Registered Manager confirmed she has had no training regarding this, however confirmed that there is currently no application being processed for authorisation. The forms being used for assessments within the service were incorrect, provided conflicting information and correction fluid had been used to amend documentation. We have concerns regarding the monitoring systems in place. The Registered Manager confirmed that she has received very little support from external management when setting up this new service, however phone support was available. When discussing the care planning system with the Registered Manager, she stated that the quality of nurses was not good. Some nurses are recruited from overseas via an agency. She confirmed that she has addressed this with the Responsible Individual, however is not aware of any action being taken to address these concerns. The Registered Manager confirmed that two monthly visits by the registered providers had been undertaken since the service opened. At the second site visit we found monthly reports in a folder. The Registered Manager being unaware of the number of reports evidences that this self monitoring system is not being used effectively. These reports are to assist the registered providers in monitoring practices within their care home and to identify to the Registered Manager areas of improvement. One report had only numbers with ticks by them. No explanation had been provided as to how this monthly report was meant to be used. Concerns have been raised throughout Safeguarding Adults investigations regarding the management of the service and the ability of staff and management being able to meet needs and make/sustain necessary improvements. Regular monitoring of this service was required by the local authority to ensure residents were not placed at Care Homes for Older People Page 26 of 32 Evidence: further risk. Management needs to be more proactive in ensuring needs are identified and met and that effective monitoring takes place. The Registered Manager confirmed that she hasnt had time to do effective monitoring of care plans etc. We were told that a random selection is being monitored more recently due to errors being noted. The Registered Manager informed us that as part of their quality monitoring lunch time monitoring has commenced, relative surveys have been sent and she will be doing stakeholders surveys that will include GP and social workers etc. She confirmed that there is currently no formal feedback process for residents. They currently speak with individual residents. All evidence highlighted previously throughout this report, clearly identifies that the home was not being well managed and not in the best interest of residents. Action must be taken to ensure that the AQAA returned contains information that is correct and reflective of what is currently being done within the service. Information and evidence for at least all key standards must be provided. The evidence in some sections could be expanded. The Registered Manager confirmed that no staff at the service is an appointee for any resident. The home holds small amounts of personal allowance for residents if they wish. Records viewed identified that a more robust system should be implemented to further safeguard residents and staff. People should be encouraged to record and sign when money is taken out of residents funds. The Registered Manager confirmed that money is only accessible when she is on duty. This information must be iterated to residents. We observed a resident being transported across a corridor in a chair with no foot rests in place. Management must take action to address this unsafe practice or ensure risk assessments are in place to clearly demonstrate why foot rests are not in place. All relevant health and safety certificates were provided to us during the registration process to demonstrate that the new build complies with all relevant building regulations and legislation. The Registered Manager confirmed that health and safety checks are undertaken regularly. The AQAA identifies that equipment in use has been serviced or tested as recommended by the manufacturer or other regulatory body. The AQAA identifies that there is a fire risk assessment in place and they have written assessments on hazardous substances, Control of Substances Hazardous to Health (COSHH). We have received no information to identify that these processes have changed. Care Homes for Older People Page 27 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 28 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 4 That services detailed in the Statement of Purpose and Service Users Guide are provided. To ensure living at the home meets the individuals/representatives expectations. 16/04/2010 2 7 13 That all relevant risk 16/04/2010 assessments be implemented for individuals. They must provide clear and consistent information for staff on how to reduce the risks. To ensure service users and staff are safeguarded so far as is practicable. 3 7 15 Care plans must provide 16/04/2010 clear consistent information and guidance for staff on how to meet the social, health and personal needs of individuals. Clear records must be maintained to Page 29 of 32 Care Homes for Older People 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 evidence the level of care provided and that the home is meeting the needs of service users. To ensure that needs are met and care provided in a person centred and consistent manner. 4 9 13 The provider must ensure 28/02/2010 that the controlled drugs cupboard is attached to the wall according to the requirement of the Misuse of drugs [safe custody] regulations 1973 and its amendments to comply with the law. 5 9 13 The provider must ensure 16/04/2010 that medicine administration chart records are accurate and complete So that there is clear information of medical treatment. 6 27 18 To ensure at all times 16/04/2010 suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. Care Homes for Older People Page 30 of 32 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 will ensure that all needs for all individuals are met and service users are not placed at risk. 7 29 19 That robust recruitment procedures are followed. To ensure that residents are safeguarded. 8 33 24 That robust internal quality monitoring systems are implemented and used effectively. This will ensure residents are safeguarded and assist in evidencing the home is well managed. 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 16/04/2010 16/04/2010 Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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). 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. Care Homes for Older People Page 32 of 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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