Care Home: Holt The

What the care home does well Staff know people well, and we saw some good practice when they communicated with individuals. The environment feels homely. The home is well supported by the local doctor`s practice, and the district nursing team visit to assist in meeting people`s health needs, when they are alerted by the home that they need help and support. People can have their visitors whenever they wish. This helps them to maintain contact with those who are important to them. People like the meals, which are cooked fresh each day on the premises. Regular deliveries of meat, fish, fruit and vegetables are made there. Care staff are required to complete National Vocational Qualifications in Care. This will help them understand good practice, and how care should be delivered. The registered provider is available at the home regularly. Staff and relatives appreciate that she is approachable, and that she listens. What has improved since the last inspection? There were no requirements made at the last key inspection. What the care home could do better: More could be written down about people`s assessed needs before they arrive at the home. Their care plans could explain in more detail where they are at risk, what their health needs are, and what needs to be done to meet these, so that their health and safety is maintained. People could be asked more about their social interests, and more support could be offered to help them meet any spiritual needs they may have. They could be asked more about their preferred routines, so they can have more choice and control over their lives. People could be treated with more dignity and respect when they receive personal care from staff. All those who share their bedroom could be offered a privacy screen, so their privacy is better protected. They could be given the opportunity to decide what gender of staff they would like to receive their care from. They could also be asked when they like to rise and retire, so that they can be assured that their needs will take priority over the routine of the home. They could be offered a drink where they have risen before others, and should not have to wait until breakfast time. Some improvements could be made to the way staff store, record and check people`s medication, so that it is managed more safely. Action plans to reduce the risk to people who are vulnerable could be more workable, and could be put into practice. And the complaints procedure could be made more accessible to people and their visitors. The home could check to make sure all staff have completed training in safeguarding, so people can be assured that staff will all know who to report to if they have any concerns about people`s care. The recruitment process could be made more robust, so people can be assured that they are protected from potentially unsuitable workers. Some health and safety matters could be looked at further. For instance, the way people are assisted to move, and whether the training staff receive is appropriate. Creative ways in which people`s views could be sought could be further considered, so they can be given priority when deciding how the home should be run. Key inspection report Care homes for older people Name: Address: Holt The Main Street The Holt Hutton Buscel Scarborough North Yorkshire YO13 9LN     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Anne Prankitt     Date: 2 9 0 4 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 34 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 34 Information about the care home Name of care home: Address: Holt The Main Street The Holt Hutton Buscel Scarborough North Yorkshire YO13 9LN 01723862045 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): theholt@btconnect.com Miss Victoria Louise Towse,Mrs Carol Ann Towse,Mr Herbert Towse Name of registered manager (if applicable) Type of registration: Number of places registered: care home 22 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia dementia Additional conditions: The category DE refers to one named service user under 65 years of age named in application V33321. Date of last inspection Brief description of the care home The Holt is a large house set in its own secure, secluded and well-kept grounds. A former vicarage, it was converted some years ago into a care home. The home is registered to care for twenty two people with dementia. The building is conveniently placed for access to local facilities and a bus service runs from the village. The home is on three floors. A passenger lift gives access to all floors used by those living there. Care Homes for Older People Page 4 of 34 Over 65 0 22 1 0 Brief description of the care home The communal areas and some bedrooms are on the ground floor and there are further bedrooms on the first floor. The top floor is for staff use only. There are sixteen single and three double bedrooms. Ten of the single bedrooms have an en-suite facility. The staff provide personal care, catering, laundry and cleaning services. On the day of the site visit, the registered provider told us that the current weekly fees range from £375.77 to £515. People pay extra for chiropody, toiletries, dental and optical services, newspapers and magazines. A copy of our most recent report is available from the home on request. The home has a service user guide which is also available on request. This gives people information about the home, and what it provides. There is also information about what the home provides on The Holts website. Care Homes for Older People Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: To inform this report, we considered information that has been received since the last key inspection. We also conducted a site visit to The Holt, which took place on 29 April 2010. One inspector spent nine and a half hours there. During our visit, we spent time talking with people who live there, staff, some relatives and the registered provider. We also spent a good deal of time watching the general activity, to see how people and staff interacted with one another. We also looked at some care plans, staff files and some health and safety records, and sampled the medication records and practice. The registered provider was available throughout the day, and we provided her with detailed feedback at the end. Care Homes for Older People Page 6 of 34 What the care home does well: What has improved since the last inspection? What they could do better: More could be written down about peoples assessed needs before they arrive at the home. Their care plans could explain in more detail where they are at risk, what their health needs are, and what needs to be done to meet these, so that their health and safety is maintained. People could be asked more about their social interests, and more support could be offered to help them meet any spiritual needs they may have. They could be asked more about their preferred routines, so they can have more choice and control over their lives. People could be treated with more dignity and respect when they receive personal care from staff. All those who share their bedroom could be offered a privacy screen, so their privacy is better protected. They could be given the opportunity to decide what gender of staff they would like to receive their care from. They could also be asked when they like to rise and retire, so that they can be assured that their needs will take priority over the routine of the home. They could be offered a drink where they have risen before others, and should not have to wait until breakfast time. Some improvements could be made to the way staff store, record and check peoples medication, so that it is managed more safely. Action plans to reduce the risk to people who are vulnerable could be more workable, and could be put into practice. And the complaints procedure could be made more accessible to people and their visitors. The home could check to make sure all staff have completed training in safeguarding, so people can be assured that staff will all know who to report to if they have any concerns about peoples care. The recruitment process could be made more robust, so people can be assured that they are protected Care Homes for Older People Page 7 of 34 from potentially unsuitable workers. Some health and safety matters could be looked at further. For instance, the way people are assisted to move, and whether the training staff receive is appropriate. Creative ways in which peoples views could be sought could be further considered, so they can be given priority when deciding how the home should be run. 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 8 of 34 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 9 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before they are admitted, but more could be written down about this assessment so that staff can be confident that they are giving consistent care to meet the persons current needs. Evidence: Peoples current needs are assessed by one of the managers of The Holt, before deciding whether the home can met these needs, and whether the person would like to live there. As part of this assessment, the home asks other professionals who have been involved in the persons care, for information to help them make their decision. People are also given a copy of the homes brochure. This includes some pictures of the home, which helps people to see whether they like the accommodation, and what facilities the home provides. Although, people who are able, are welcome to visit the home to see for themselves what it is like. They can have a copy of the service users guide, which gives further information, if they ask for it. Care Homes for Older People Page 10 of 34 Evidence: We asked staff whether they get enough information before someone is admitted, so they know what care is needed when they arrive. One staff member referred to the 72 hour care plan, which is put in place until the persons full care plan can be developed. However, this plan is the same duplicated document for everyone, and is more of a to do list for staff. It does not tell staff about peoples individual needs. It is important therefore that as much information as possible is collected on the pre admission assessment form, and shared with the staff. Sometimes the information we saw was limited, and did not provide sufficient information for staff about things they needed to know about prior to the full care plan being completed. The home does not provide intermediate care, therefore standard 6 is not applicable. Care Homes for Older People Page 11 of 34 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Risks to people may not always be consistently recognised and acted upon. And people cannot be assured that their right to privacy and dignified care will be considered over the daily routine of the home. Evidence: Following admission, the managers begins to develop a care plan. The individual files seen were well organised, and plans more recently developed were written in a more individual way than those completed in the past. However, the plans often lacked important information which staff need, to alert them to potential risk, to tell them how to keep this to a minimum, or to maintain continuity of care. For instance: Assessments had been completed to show risk from pressure sores. But where risk had been identified, there was no care plan in place to tell staff how to manage this area of the persons care. Where the assessment alerted staff to contact community professionals, there was sometimes no evidence to show that this had been done. The way staff move people in bed, who are at risk from pressure sores, was not always included in the persons moving and handling risk assessment. For instance, staff told Care Homes for Older People Page 12 of 34 Evidence: us that a slide sheet was used for one person, but this information was not written down. Doing so would help make sure practice is consistent, to reduce the risk from further sores occurring. We had not been informed when a person had developed pressure sores. The home has a duty to inform us in writing if pressure sores deteriorate to a certain level. However, the records did not show the grade of the pressure sores, and the registered provider could not give us any details. It is the homes responsibility to know and record this information. Important information about recurrent or ongoing health problems, and how these should be managed, was not always noted in individual care plans. For instance, where people suffered from falls, had problems with their skin, suffered pain, or recurrent infections. In one case, a person had been admitted to hospital because a known problem had reoccurred, but there was still no care plan in place on their return to alert staff to the signs that may indicate that they may need medical attention in the future. Fluid charts had not been completed in sufficient detail for them to be of use to anyone reviewing them. The amount of fluids the person had taken was recorded, but not the amount they had passed. Daily totals were not tallied, or the forms not completed at all, so it was not clear whether, or how, this area of the persons care was being monitored. People are assessed to check they are not nutritionally at risk. We looked at one plan which said this person should be weighed regularly. But there were no scales suitable for staff to do so, although the registered provider plans to buy some sit on scales. We were unable to see a record of peoples weights, because the trainee manager, who was off duty, had this information. This makes it very difficult for staff, or other professionals, to be alerted to any fluctuations in peoples weight which may cause them concern in her absence. The identified risk from choking, and the need for specially prepared meals to reduce this risk, was not included in one individuals care plan. Anyone reading the care plan should be alerted to such risks, and what action they must take, so that anyone reading the plan knows what action they must take to keep risk to a minimum. On the day we visited, we arrived at the home at 7.30am because there have been concerns raised that people are made to get up too early. On arrival, thirteen people were already up and dressed. One person sitting in the lounge was still in their nightdress and dressing gown. Staff said this is because it was their bath day. The registered provider said that people wake up earlier when the mornings are lighter. However, the staff daily task book states 6am - Both Care Assistants to check if any Care Homes for Older People Page 13 of 34 Evidence: service users are awake, ask if they would like to get up, washed and dressed (remember give them choice). A staff member confirmed that they go into peoples rooms, and ask if they would like to get up, if they are awake. Another said that it was normal, expected practice for people to be up this early. Staff must remember that people living at The Holt may not be well orientated in time, and may agree to get up even if it is very early. Some people looked dishevelled, or were not dressed properly, despite just having been given assistance by staff. Some looked as though they had not had their hair brushed. Only one female wearing a dress was wearing tights or stockings. People, who were prescribed special support bandages or stockings were not wearing these. We brought this to the staffs attention, who applied the bandages or stockings later in the morning, but in a public area. This does not protect peoples dignity. Two male staff had been on duty overnight, so people did not have the option to have their care provided by either a male or a female. This is a basic question that should be asked, and recorded, to show how peoples right to dignity has been upheld. We visited one bedroom which is shared. There were no privacy screens in this room, and only one call bell. We looked in the persons care plan and could not see whether their choices and wishes regarding privacy had been discussed. During the day, staff spoke to people with respect, and appeared to know them well. This helps to make people feel included. When we asked about peoples care, we received some very positive comments. One person said I like it here - its nice and quiet - staff are good, and I can help myself. If I want something, they get it, or they get help. They said that staff were very quick to provide them with help when they were unwell recently, and said You couldnt ask for better. We spoke to some relatives. One said they were Very happy with the home. They said Staff are always about, they are very good, and there is direct contact with the manager, which is great. They said they had no problems. Another relative said they were Very happy with the care. They said the registered provider shows great empathy. They said they were very very pleased, and had no complaints. We looked at the way medication is handled. Staff said those who looks after peoples medication have received training about how to do so safely. Generally, the records were up to date, and a spot audit showed that the number of tablets remaining tallied with the stock balance kept by staff. However, there were some matters which needed attention. After speaking with our pharmacy inspector, we have since contacted the service and given them contact details for the Primary Care Trust pharmacist, who is Care Homes for Older People Page 14 of 34 Evidence: available to offer them further advice: Some controlled medication was not being recorded in the register, when the medication was administered. This meant it was impossible to check whether the amount left in stock was correct. The staff said they would put this right. We also asked the registered provider to check whether the storage arrangements for controlled drugs, and for the medication trolley, need further attention, so they are sufficiently secure, and so that only those staff designated to access the medication have access to these areas. Hand written entries on peoples medication charts had not been checked and countersigned by a second staff member. This needs to be done, to reduce the risk from error. Staff had not checked why a certain medication listed on someones hospital chart, had not been sent with them when they were discharged to The Holt. The staff rang the doctor straight away when we brought this to their attention, to seek their advice. It was not clear how often, since being admitted, one person had received their when required medications, which they used to take regularly, and which were now prescribed. Staff said the person had been given this more regularly than the two times recorded on their medication chart. Staff need to follow this up with the doctor, to make sure they are receiving the medication they should. Care Homes for Older People Page 15 of 34 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. Staff may not know enough about peoples preferences to make sure they are assisted to follow their chosen routine. Evidence: There is a list of general group activities, which staff offer people each morning and afternoon. Outside entertainers also visit to deliver motivation classes, and to provide singing entertainment. Other than nail care, there were no advertised individual activities. On the day of the visit, people played dominoes, I spy, and a floor game, with staff. In between time, the television was switched on, but without sound, whilst country and western music played on the radio. This could be confusing for people who live there. Although one person went out with a staff member while we visited, there was no record on peoples activity chart to suggest that people went out from the home. One staff member said the home could do better by taking people out more. Some people had a completed life plan in their file, and also a form to show what activities they had taken part in. However, there was no care plan to show how their current individual social needs could best be met. The registered provider also confirmed that no religious services take place at the home. The local church should Care Homes for Older People Page 16 of 34 Evidence: be contacted to see whether they are able to offer people some spiritual support, for instance, a church service at the home, if this is something people living there would like. People can however have their visitors whenever they wish. This helps them to maintain important links with their family and friends. We were concerned about how people are offered choice. For instance: Because of the way staff are deployed, we were told some people have to go to bed before 8pm, while there are still enough staff available to observe others. As stated previously, we were also concerned that at 7.25am, thirteen people had already been assisted to get up and dressed. Peoples care plans did not say what time they liked to rise and retire, so we can assume that they or their families have not been asked. Staff said they are not allowed to get people up before 6am. Although they told us that three people were up and dressed at 3.30am, because they were unsettled, and one at 4.20am. When we arrived, nobody had been offered a drink since rising. This is not acceptable. Two male staff had been on duty overnight, so people did not have the option to have their care provided by either a male or a female. Peoples care plans did not say what gender they prefer to receive their care from so we assume that people or their relatives have not been asked this question. This choice should be recorded, and met, so peoples right to dignity is upheld. People said they like the food. They have three meals a day, and we were told they are also offered supper. People are offered in advance a choice for tea time. For lunch, one meal choice is prepared, but staff said people can ask for an alternative if they wish. Staff cater for special diets. For instance, a vegetarian, and also a liquidised diet. Breakfast is at 8am, lunch at midday and tea time at 4pm. There is a considerable interval therefore between tea, and breakfast the next day. The registered provider has given assurance that everyone is offered supper and that they have access to food at any time. Care Homes for Older People Page 17 of 34 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. Complaints and safeguarding matters are not dealt with consistently. Evidence: People do not get their own copy of the complaints procedure, because it is not included in the brochure given to them before they move in. It is however included in the service users guide, which people can ask for a copy of if they want. It is also given to peoples families when they are sent a copy of the contract. When we visited, it was not displayed for people who live at, or visit the home, to see. It is important that people and their families have good access to the complaints procedure, so they are clear about what action will be taken by the home if they raise any concerns. The registered provider said she would make sure a copy was advertised. However, we spoke to two relatives who each said they had no problems with the home. We were told that grumbles were dealt with by the staff, so that any problem did not persist. The registered provider was unable to find the complaints book, so we were unable to see how complaints have been handled by the home, or what they were about. The registered provider thought one complaint had been made recently, which they said had been resolved. This record should be available at all times so staff can document any complaints in the absence of the registered provider or manager. This will help to make sure important information which needs to be dealt with does not get lost. Care Homes for Older People Page 18 of 34 Evidence: The local authority have investigated a number of safeguarding concerns, which have taken place since the end of 2009. We were not informed by The Holt about the incidents that had occurred, which affected some peoples welfare. The manager now makes sure that she informs us about such incidents. But our observations on the day showed that the planned action she told us has been taken to stop a similar occurrence from happening again, is not being put into practice. Action plans in response to such serious matters must be workable, and must protect those vulnerable people who live at The Holt. Not all staff have received safeguarding training in the last year. We asked the registered provider to make sure everyone was updated. However, we asked staff how they would respond if they thought someone was not being treated properly. They were very clear that they must report straight away, and that they could not keep secrets if they believed, or were told, that someone was being abused. They also knew about the role of the local authority, who take the lead when such incidents are investigated. However, they did not know how to contact them. We looked at the abuse policy at the home. It was detailed, but this too did not mention the role of the local authority, or of how to contact them. Staff should be provided with these details, so they can make direct contact if they wish. Care Homes for Older People Page 19 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is homely, and generally meets peoples needs. Evidence: The home is set in a pleasant position in the village of Hutton Buscel. It has attractive gardens. Some of the rooms overlook these, and the nearby church. There is a sitting room with a small conservatory area attached, and a separate dining area. There is lift access to the bedrooms. This helps people who cannot manage the stairs to reach their bedroom more easily. There is one assisted bathroom, and one bath without hoist equipment. We were told that this is not used, because people cannot manage to get in and out safely. There was a malodour when we first arrived, but this disappeared quickly over the course of the morning. The sitting area, which had smelled unpleasant at the last key inspection, has been re decorated and re carpeted. The whole of the first floor corridors and hallways, and a large proportion of the bedrooms have also been decorated. One shared bedroom we visited had two bars of soap on the sink, and staff could not distinguish which soap belonged to which individual. This is not good practice, because it may mean people are not being washed with their own preferred toiletries. It also Care Homes for Older People Page 20 of 34 Evidence: increases the risk from cross infection. The registered provider did not realise there was only one call bell in the room. The person without a bell would have to get out of bed to alert staff if they needed them. This had not been considered in their care plan either. The laundry room is outside of the premises. Peoples clothing looked well cared for. Care Homes for Older People Page 21 of 34 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. The recruitment procedures at the home do not protect people from potentially unsuitable workers. Evidence: Staff work a set rota. There were a mix of male and female staff available during the day. However, as stated previously, there were two males working the night prior to our visit. We told the registered provider she needs to check that this arrangement meets peoples needs and wishes, privacy and dignity. The trainee manager has given assurance that the communal areas will be observed at all times by a member of staff. We have received details of two recent incidents which have happened between these hours, which suggest that this observation should continue. This would also allow people more choice about when they retire, because there will be sufficient staff available to assist them. We looked at the recruitment files of two recruits. These showed that the recruitment procedure does not protect people from potentially unsuitable workers. One staff member had been allowed to provide care before a check had been returned, to confirm whether or not they had been barred from working with vulnerable people. The registered provider could not find the same check for a second member of staff, so we were unable to confirm whether this had been obtained before they were Care Homes for Older People Page 22 of 34 Evidence: deployed. We asked the registered provider on the day we visited, and also during a subsequent telephone call, to confirm whether this had been obtained, but we have received no feedback from her. Neither staff member had a returned police check, and both had been allowed to work unsupervised. There was no record to confirm that issues regarding a persons previous employment, are discussed at interview, or that any gaps in their employment had been explored. This practice is not safe, and must stop. Staff have an induction when they begin to work at the home. One staff member said they had worked with an extra staff member for three days, and had found this very useful. Staff also receive training updates, although the registered provider agreed that training provided previously to staff, about specific mental health issues which could affect people with dementia, needs to be refreshed, especially for those who have not previously received this training. Staff complete National Vocational Qualifications in Care, and there is a rolling programme in place to help them achieve this. Care Homes for Older People Page 23 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some aspects of the management of the home need to be improved, so people receive a consistent service which meets their needs and choices. Evidence: There is no registered manager at the home. The registered provider is present there regularly, and has a trainee manager in position, who is learning the role. Staff said they see both regularly, and that the registered provider listens. They said they like working at The Holt. One said I love it. We have asked the registered provider to consider the long term management plans for the service. The home is in the process of setting up a quality assurance system, which will help the management to measure the homes performance. This will include seeking the views of peoples families and professionals who visit. It is important that people remain central to this, and that effective ways of collecting their views are also sought. We suggested that the management think of ways in which peoples views can be captured. For instance, currently there are no resident or relative meetings. Care Homes for Older People Page 24 of 34 Evidence: The home does not manage peoples money. Therefore standard 35 is not applicable. Staff records showed they are supervised by the manager. We had asked the manager prior to the inspection to carry out some specific supervision work. The records suggested this had not been completed as we had requested. The records we looked at showed that services are carried out on major equipment, to make sure it remains in good working order. In house checks are also completed, for instance, to check the water people have access to is not too hot. The registered provider needs to check with a suitably qualified person that hot water is being stored at a temperature which is hot enough to reduce the risk to people from Legionella. Some of the records showed the temperature was low, where water was not regulated. Normally the fire alarm is checked weekly, to make sure it remains in working order. Although this weekly check had not always taken place. We also asked the registered provider to check that work had been completed to the gas system, as the last service report said some needed to be done. She has provided feedback that this work has been completed. Staff have received training in manual handling. However, they do not move people in a safe way. There is no hoist available at the home to assist people from the floor if they fall. We asked staff how they would assist someone who had fallen. The method they described was not a safe manouvre, and must be improved. This again was discussed with the registered provider, who should check the quality of the training provided to staff, and whether this is being followed in practice. We were told that the Environmental Health Officer has visited recently, and that the outcome from this visit was satisfactory. The registered provider told us that the recommendations made following this visit have been followed. The last report on file was dated March 2009, which commented Premises found to be very clean and all logs up to date. The fire officer last visited in 2007, when they found the systems at the home to be satisfactory. The home has also completed a fire safety risk assessment On speaking with staff, it would appear that some are awaiting their update with regards to compulsory training. We told the registered provider to check that everyone was up to date, and to arrange further training where they are not. Care Homes for Older People Page 25 of 34 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 26 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Peoples care plans must 31/08/2010 contain all areas of current care needs, and how these, and risks to the persons health and welfare, are to be met. This will help to make sure staff work in a consistent way, which supports the individuals current needs, minimises risk to them, and so that staff can be clear when further professional support is needed. 2 8 17 The incidence of pressure sores, their treatment, the action to prevent further damage, and the outcome, must be recorded in the individuals file, and kept under review. This is so staff know what action to take to prevent further problems, and when they may need to seek 31/07/2010 Care Homes for Older People Page 27 of 34 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 further advice from the professionals supporting the person. 3 9 13 Controlled medication must be stored securely to conform with the law, and the register to record what has been received and administered must be completed. This is so anyone auditing the medication can check to make sure the stock balance is correct, and that the medication has been administered as prescribed. 4 9 13 Arrangements must be made to make sure medication is stored safely and securely. This is so only staff who are authorised to handle medication have access to those storage areas. 5 10 12 People must be always be supported by staff to be properly dressed, and their personal care attanded to in full, where they need assistance from staff. This is so that their right to privacy, dignity and respect is upheld. 31/05/2010 31/05/2010 31/05/2010 Care Homes for Older People Page 28 of 34 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 14 12 People and/or their representatives must be given the opportunity to express peoples individual choices regarding their chosen lifestyle. Steps must be taken to help people meet these needs. This is so people can exercise choice and control over their lives wherever possible. 31/08/2010 7 18 13 The action plans produced to 31/05/2010 minimise the risk from incidents occurring at the home, which may affect peoples welfare, must be workable, and put into practice. This is so people can be assured that every effort has been made to protect them from potential harm. 8 27 11 The way staff are deployed at the home must be reviewed. This is to make sure that there are always staff of the appropriate gender on duty to meet peoples preferences with regards to how they wish to have their personal care met, and to make sure there are sufficient of them 31/05/2010 Care Homes for Older People Page 29 of 34 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 to provide appropriate supervision and observation. 9 28 19 Staff must not be allowed to provide care at the home until full and proper checks have been completed to make sure they are not barred from providing care. All information or issues regarding their previous employment must be fully explored, and the outcome recorded. Those staff deployed before the full police check is returned must be supervised at all times until this is received. This is so that people are protected from potentially unsuitable workers. 10 30 18 Staff must receive training in how to support people with dementia and associated mental health needs. This is to assist them in planning the best way to meet these needs, and providing consistent ongoing support. 30/06/2010 12/05/2010 Care Homes for Older People Page 30 of 34 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 11 37 13 Staff training in moving and 30/06/2010 handling must provide them with the right skills so they know how to assist people to move in a safe way. This is so people are protected from harm caused by unsafe manouvres, which must cease immediately. 12 38 13 Advice must be sought about the correct storage temperature for hot water. This is to make sure that it is sufficiently hot to reduce the risk to people from Legionella. 31/05/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 3 Peoples pre admission assessments should be completed in more detail, so staff have good information on which to rely when providing care, and until the care plan is completed in full. Peoples fluid charts should always be completed properly where these have been ordered. This is so professionals have the information they need when reviewing the person, and when deciding whether the treatment given is appropriate and effective. Hand written entires made on medication charts should be checked by a second member of staff, and countersigned. This is to reduce the risk to people from errors. Discrepancies in peoples medication records on return from 2 8 3 9 Care Homes for Older People Page 31 of 34 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 hospital should always be checked with their doctor, to make sure they are receiving the medication prescribed to them. 4 10 People who share their bedroom should be provided with privacy screens, so their privacy is not compromised, unless these have been declined by the people concerned, and this decision recorded in their care plan. Peoples care plans should state what gender of staff they prefer to receive care from, so the appropriate staff can be available to deliver this care at all times. The activities programme should be developed further, in line with peoples individual interests, to make sure that their social needs are being properly met. Further thought should be given to peoples individual spiritual needs, and how they can be supported in meeting these. For instance, by forging links with the local religious community. 7 8 15 16 People who rise early should not have to wait long periods of time before being offered a drink. It is recommended that the brochure supplied to people includes a copy of the complaints procedure, in a suitable format, so they know who to contact, and what action will be taken, if they need to raise any concerns. The complaints book should be available at all times, so that information received when the management are not available can be recorded properly at the time by staff, and acted upon. This will help to stop information from becoming lost, or forgotten, and will reassure people that their complaints are being taken seriously. 9 18 A check should be made to make sure all staff working at the home have received recent training in safeguarding people, so everyone has up to date information about what to do, and who to contact, if they have concerns about the welfare of anyone living there. People who share a bedroom should have access to a call bell, so they do not have to leave their bed in order to alert staff if they need their attention. Where this facility is not available, this should be risk assessed, so that people have the access they need to staff, when they need them. Page 32 of 34 5 10 6 12 10 22 Care Homes for Older People 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 11 26 It should be clear to staff which toiletries belong to each individual, so staff assisting them use the toiletries of their choice, and so that the risk from cross infection is kept to a minimum. Effective ways of collecting the views of people who live at the home should be developed, so they are central to the quality assurance system, when deciding what the home needs to do to ensure it is operating in accordance with their best interests and wishes. Staff supervision should capture issues which have been highlighted in their performance, so this can be discussed openly with them, and their progress better monitored with them. An audit of the compulsory training staff have received should be carried out and training provided where this has fallen behind. This is so that all staff are up to date about the correct way to work, so that they support people in a safe way. 12 33 13 36 14 38 Care Homes for Older People Page 33 of 34 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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