Care Home: Knoll House

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What the care home does well People told us that they are "well looked after"; "if I need any extra help I get it"; "staff are friendly"; "staff are positive and caring"; "good relationships with staff". A relative said "medical needs well dealt with. She is comfortable in the home physically and mentally." They said help was usually available when they need it, and their needs were met. It was very clean. Relatives said that they chose the home because of it`s homeliness and welcoming atmosphere. Surveys had been undertaken and in response there were changes to the menu, activities, better lighting in bedrooms for reading and help to personalise bedrooms. Staff have support to exercise their rights, such as to take risks and to vote. People and relatives had the service user guide, knew how to make a complaint and had confidence this will be addressed. They readily approached the nurse in charge, the manager and staff about requests such as using the phone, and for reassurance about personal matters and changes to more spacious rooms. People have accurate and thorough assessments as well as information about the home and fees so that they can make their own decisions. A very good newsletter was on display about a range of events and celebrations. There are usually three choices for main meals and a diverse menu. Everyone liked the food on our visit. Two new people told us that the home was an improvement on other homes they had come from. Staff said that they share information with each other about people and their care. They have good support, and attend workshops about people`s conditions. Nurses particularly mentioned updates they valued about clinical practice, and supervisory training to run shifts. Staff said: "I`m happy to work here"; "management is very good, does everything properly." What has improved since the last inspection? Many changes have been made since the last key inspection to seek and respond to people`s views, improve quality and smooth running of the home. Best practice in nutrition is used and people improved their health and wellbeing. For example, pressure sores healed. People have the help they need in the morning to get up when they want to. Everyone was dressed in clothing they chose. People who need one to one attention or who are nursed in their rooms are having their stimulation needs assessed. The atmosphere was more vibrant, and the building was used more creatively. The premises are more comfortable and facilities now exceed minimum standards. The manager developed a broader understanding of safeguarding and has made appropriate reports in people`s best interests under the multi-agency protocol. CQC has been kept better informed about events affecting people. Standards of hygiene and infection control improved so much that the home achieved a Primary Care Trust Silver Award. Domestic staff are finding it easier to maintain hygiene due to considerable refurbishment and redecoration. Facilities and equipment better suit people`s needs, and furnishings improved comfort. The roof and guttering were repaired to prevent building decay. Accountability improved by introducing responsive systems. Management capacity improved by more administrative support, new staff roles and a re-organised system for nursing and personal care as well as medication. Staff had external assessment of medication competence. Management have a clear vision of what they want to improve with feasible timescales, prioritised so that people`s needs are foremost. What the care home could do better: People and relatives told us that "at times staffing seems a bit sparse - sometimes at weekends". They want more activities and exercise in the home and community. Staff said that "we are satisfied but want more training, knowledge and more experience of giving good care." The training needs of bank staff particularly need attention. The medication system still has anomalies arise, particularly over weekends and so extra controls introduced will continue to make sure these are followed up speedily for people`s health and wellbeing. A forward planning system is needed for premises maintenance and the replacement of essential equipment to ensure the home continues to run smoothly. We made recommendations to further improve dignity, impressions of the home and to ensure continuous development of staff and the service. CQC are now kept better informed of events affecting people and the running of the home but our guidance needs to be fully followed so that we work together in people`s best interests. Key inspection report Care homes for older people Name: Address: Knoll House The Avenue Penn Wolverhampton West Midlands WV4 5HW     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Tina Smith     Date: 0 5 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 31 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 31 Information about the care home Name of care home: Address: Knoll House The Avenue Penn Wolverhampton West Midlands WV4 5HW 01902335749 01902333575 knollhse@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Elysian Care Limited Name of registered manager (if applicable) Mrs Jill Roberts Type of registration: Number of places registered: care home 32 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 32 The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 32 Physical disability (PD) 32 Date of last inspection Brief description of the care home Knoll House provides accommodation, personal and nursing for up to 32 people with physical disabilities and older people. The care home is near local shops and public transport, and has car parking. The detached property has single and twin bedded rooms, two lounges, dining room and garden, with a passenger lift to the first floor. Care Homes for Older People Page 4 of 31 Over 65 32 0 0 32 1 9 1 1 2 0 0 9 Brief description of the care home Communal bathrooms and toilets are on both floors. Three offices are on the ground floor. Fee information is in the statement of purpose. Weekly fees are £361 for personal care. For nursing care there is an additional contribution paid by the local Primary Care Trust after their assessment. Fee information applied at the time of our visit; up to date enquiries should be made to management. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection on 19/11/09 found quality changed from good to poor as risks were posed to peoples health and safety and by non-compliance. We sent a warning letter about serious concerns with the medication system, poor environmental risk management, and falling standards of hygiene. Management accepted that standards had lapsed and expressed commitment to improve and comply with the law. Management capacity had been reduced by long-standing staff recruitment and retention issues. Since then we visited the home on two occasions. On 17/12/09 the pharmacist inspector found progress but also further non-compliance. On 04/03/10, pharmacist and regulation inspectors checked compliance again and found improvements in the medication system, clinical supervision and the environment. Leadership and management of health and safety also improved. People were safe and well cared for and ten requirements we checked were met. The home was running more smoothly Care Homes for Older People Page 6 of 31 despite fluid staffing. Between visits the home kept us well informed of events and progress, providing six voluntary action plans, information we requested and an improvement plan. Management also worked with a multi-agency safeguarding strategy group and with the council contracts team. Good use was made of this forum, which supported the home to try new ways of organising the home, staff and oversight. Issues arose with health services which were out of the homes control, and the multi-agency group resolved these to benefit people. Prior to this visit, the manager sent us the Annual Quality Assurance Assessment (AQAA). This self-assessment was analytical and shows that management know want they want to continue to improve because they prioritise peoples views and needs and learning from their experience. Information from the AQAA and from other sources was also used when forming judgments on the quality of the service. We had five surveys from people and relatives, and five from staff. These were positive but there were mixed views about food, activities and whether there were enough staff at weekends. The home sent us notifications about legally required events, such as pressure sores, norovirus and an accident using the hoist in the bath. There were no serious injuries. No complaints were made to CQC about the home. On 05/05/10 a regulation inspector visited the home from 8:00 am to 5:00 pm. They did not know we were coming. On all of our visits we have looked around, observed people and staff practice, inspected the medication system and a range of records about people, staff and running the home, including updated policies and procedures about medication, infection control, clinical procedures and human resources. We spoke to many people in the home, visiting friends and relatives, as well as staff and management who have always been transparent and welcoming. We checked on people we had previous concerns about and people new to the home, public information, maintenance certificates and quality monitoring. Opportunity was given to provide information not available within 48 hours before we concluded findings. Management agreed that CQC have taken a proportionate approach over the past few months, when the home made and sustained rapid progress. The manager was present throughout our visit. We spoke briefly to a Director, the responsible individual for Elysian Care Ltd., who was visiting the home. Their personal assistant joined the manager during feedback. An outstanding requirement was met and one was replaced with a recommendation because of assurances given. We now have confidence that the homes systems identify and resolve issues as they arise. One requirement and recommendations are at the end of this report. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? Many changes have been made since the last key inspection to seek and respond to peoples views, improve quality and smooth running of the home. Best practice in nutrition is used and people improved their health and wellbeing. For example, pressure sores healed. People have the help they need in the morning to get up when they want to. Everyone was dressed in clothing they chose. People who need one to one attention or who are nursed in their rooms are having their stimulation needs assessed. The atmosphere was more vibrant, and the building was used more creatively. The premises are more comfortable and facilities now exceed minimum standards. The manager developed a broader understanding of safeguarding and has made appropriate reports in peoples best interests under the multi-agency protocol. CQC has been kept better informed about events affecting people. Standards of hygiene and infection control improved so much that the home achieved a Primary Care Trust Silver Award. Domestic staff are finding it easier to maintain hygiene due to considerable refurbishment and redecoration. Facilities and equipment better suit peoples needs, and furnishings improved comfort. The roof and guttering Care Homes for Older People Page 8 of 31 were repaired to prevent building decay. Accountability improved by introducing responsive systems. Management capacity improved by more administrative support, new staff roles and a re-organised system for nursing and personal care as well as medication. Staff had external assessment of medication competence. Management have a clear vision of what they want to improve with feasible timescales, prioritised so that peoples needs are foremost. What they could do better: 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 31 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 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Accurate information about the home and fees assists people to make their own decisions. Thorough pre-admission and hospital discharge assessments ensure that the home meets peoples needs. Evidence: We spoke to two people who came to Knoll House recently. Their relatives had visited the home, and both people were satisfied with their choice. One had experience of another home and told us this home is better - better food, better staff, I like my room. People and families had the service user guide, which has accurate information about the service, staff and fees and they took part in care planning. The statement of purpose has more clarity on services provided. Management undertake research on prospective admissions in order to make improvements. People have the information they need to answer their questions in a Welcome Pack, including the service user guide, terms and conditions or contracts. Records were Care Homes for Older People Page 11 of 31 Evidence: stream-lined so that there is less repetition and the process is efficient. On our visit, there were 29 people living in the home of varying age from middle to later years, and there were more men living in the home. Seventeen people were having nursing care. A few people manage independently with minimal support, mainly for their emotional wellbeing. We looked in depth at a number of care records on our visits and on this occasion we looked back at three care records and saw records of one person recently admitted. Thorough assessments were undertaken and reviewed by trained staff and the manager. The AQAA told us that 35 per cent of people have been living in the home for over two years. There have been 25 admissions, 6 discharges and 4 short stays in the past year. People return home when they recover and some people try the home before deciding if they want to move in. There was one placement breakdown we were notified about, when a person was accepted for a long distance hospital discharge without pre-admission assessment. On their arrival it became clear that this was an unsafe hospital discharge and the home rapidly arranged for local hospital admission through a GP. On this visit one person was in hospital. The manager visited and established that their needs had significantly changed and they now needed nursing care. This was agreed by the Primary Care Trust and on our visit the home were preparing for their discharge by arranging a more spacious room for essential equipment. This was good practice and showed us that learning has been applied so that people do not have unnecessary moves. Care Homes for Older People Page 12 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal care is provided in privacy when people want it. Health and wellbeing is monitored and health specialists are involved at early points to prevent deterioration. The medication system has frequent audits and additional controls to protect peoples health. Evidence: The manager re-organised the homes systems so that those needing the most help have more staff deployed in the morning for personal care. People now have flexibility to get up when they want. Everyone was dressed in their preferred clothing and were well groomed. More men were living in the home but only female staff. We spoke to three men who all wanted female staff to assist them. They also confirmed that they go to bed when they want to, and that privacy is maintained. Nurses updated their skills in wound care. We were kept informed if sores or infections such as norovirus developed in the home or hospital. Early advice was sought when necessary from GPs, dieticians and tissue viability specialists to prevent sores or their deterioration. Since March 2010 this affected one person when their appetite reduced. Care Homes for Older People Page 13 of 31 Evidence: A grade 2 sore was healing when the person went into hospital, but they came back without warning or dressings for several grade 4 sores. Rapid action was taken by the home. On this visit no one had pressure sores. The manager now assesses people before hospital discharge. People with diabetes had insulin, tablet and diet control that was effectively managed by the home. One person was also having end of life care. Nurses maintain close monitoring and evaluation, and there has been appropriate liaison and reviews with medical specialists and the hospice about pain management, and when appetite reduced and blood sugar levels fell. This told us that the home maintains effective working relationships with a range of community health specialists and services to assist people with their health conditions. Previously we had serious concerns about management of medicines and the home told us what they intended to do to improve. The pharmacist inspector visited the home twice. In December 2009 progress was too slow and did not meet feasible timescales we set; peoples health was still at risk from medication practices. In March 2010 the manager and staff had made effective progress, and the pharmacist inspector confirmed that the medication system was now safe enough. Medication continued to be stored securely and at the correct temperature. Senior carers were introduced to administer medication to people having personal care, which freed up time for nursing needs to be better met. Nurses and seniors had training refreshed in safe handling of medicines and their competence was externally assessed and confirmed. New medication folders have detailed medication care plans, photographs of people, a full profile of medicines prescribed and any changes, and instructions for as required medication. Count-down systems are used for variable dose and other medication. Anomalies continue to occur but they are quickly picked up by the managers twice weekly random audits, explained and addressed and CQC confirmed that people have medication as prescribed. On this visit we were satisfied that sufficient safeguards continue to protect peoples health. The manager was taking up recurrent error under disciplinary procedures and intends to continue twice weekly audits and additional controls as agency and bank staff are still needed. The manager, nurses and seniors we spoke to understand the necessity for extra recording and find the medication system more manageable. On our visit two sets of keys were accidentally locked in the medication room, immediately reported and the handyperson came back to the home to assist. The Care Homes for Older People Page 14 of 31 Evidence: Manager and Director immediately arranged for another spare set. This showed that responsibilities are taken seriously and rapid action is taken when necessary. We checked controlled drugs which tallied. As required medication was sampled and we queried one pain relieving medication regularly needed. The manager followed this up with the GP during our visit. We fedback that goals on medication care plans could be more individualised to evaluate health conditions with people self-medicating, and with health specialists. We advised that one medication administration record for the month per person should be maintained with hand-written entries for changes and additional receipt of medicines for clarity, and efficiency of audits. The manager said this clarified a misunderstanding. The home are expecting a visit from the Primary Care Trust about community medicine prescribing practice and will be able to explain problems caused when insufficient supply is prescribed. This is a common problem for care homes in Wolverhampton, in our experience. Care Homes for Older People Page 15 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People choose what they do and eat each day, and staff have good relationships with them, their friends and relatives. There are opportunities for stimulation and outings in the community and there is a plan for more variety. Dietary and cultural needs are met and food is freshly prepared. Evidence: We have seen and confirmed with people and visitors on all our visits that staff have good relationships with them. Communication skills of staff were complimented and they treated everyone with considerable respect. The atmosphere in the home is friendly and welcoming to people of all cultures. On this visit three people told us that they get up and go to bed when they want, eat where they choose and knew there were games and activities they could participate with. The manager knew people wanted more variety of activities from their own survey. The home has music and exercise equipment and games, books and DVDs in various languages, and afternoon activities take place at least once a week. At present this is after lunch, when we were told that people do not always want to take part. A care assistant has dedicated hours to spend time with people having nursing care to identify their stimulation needs and preferences. The manager is planning a greater Care Homes for Older People Page 16 of 31 Evidence: variety of activities and one-to-one stimulation. A workshop about dementia care activities was attended but we fedback that learning had not been applied to people recovering from strokes. This was because staff tried to arrange for two people to play dominoes but knew little about the choice of games and had not matched cognitive ability. The television was on in the dining room and two lounges in the morning and people watched, talked to each other and visitors or snoozed. One person preferred to watch people in the dining room from a recliner chair, while another preferred sitting outside to smoke. In the afternoon the hairdresser attended. In reception The Knoll House Gazette reported on outings, events, celebrations, congratulations and condolences. Management want to issue the newsletter more frequently so they can advertise events. A senior carer takes people shopping, to the theatre and on our visit arranged to take people to vote the next day. One person told us about better lighting provided in their room so that they can do puzzles more easily. Two people told us that they like helping, such as laying the tables and with dusting which is best practice so that people continue to lead meaningful lives. Mealtimes were flexible. Menus showed nutritional balance, with variety such as a daily vegetarian option and curry twice a week. There are three choices for main meals, and even choice of how a dish is preferred. There are hot and cold choices for tea. We shared dinner with two people and observed a snack. In March 2010 we saw people having a late cooked breakfast in a lounge, with choice of whatever they wanted. People have unrushed individual support to eat and staff talked to people while feeding or serving them. Three people we spoke to liked the food. We discussed surveys we received with the manager, who said that menus are arranged with people and food is home cooked. We complimented the cook as the food was tasty. Although we saw people give consent for plastic aprons to be used, dignity could be better promoted. The manager wants to promote more independence and has plans to make mealtimes a social occasion by giving people opportunity to help themselves and each other at the table. The television was left on during dinner, which should be avoided as it was hard to hear and make conversation. Refurbishment of hard chairs is still planned, however people now have pressure relief as needed during mealtimes. Care Homes for Older People Page 17 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints and safeguarding are taken seriously and acted upon. People feel safe and their rights are promoted and respected, including the right to take risks. Recruitment checks now ensure staff are safe to work with people. Evidence: People and visitors felt safe, knew how to make a complaint or express a concern and had confidence these would be taken seriously. One complaint was upheld in the past year. The manager took action and the complainant had a written response. The summary log could still improve to reflect upon the homes process and learning. Peoples rights were protected in a number of ways. People took part in the general election by postal votes and in person. There is a good laundry security coding system and clothing does not go missing. Consent is sought and care plans reflect that people make informed decisions to take risks. For example, checks continue to be made for people self medicating to ensure this remains safely managed and their health is monitored. People and relatives were consulted about room changes and one was present and asked to check that the room was set up to the persons preferences as well as their needs. Best interest decisions are made by trained staff, in consultation with nominated representatives and other professionals as necessary. We complimented staff communication with people as they were able to elicit consent and a view when relatives struggled. Care Homes for Older People Page 18 of 31 Evidence: The manager had mental capacity and Deprivation of Liberty Safeguards training and briefed staff. No authorisations have been necessary. We drew the managers attention to a do not resuscitate notice in one record because it was only signed by the doctor, but a meeting had been held with family. Since the last key inspection the manager developed a broader understanding of safeguarding, attended council training along with staff and we checked that remaining staff have training booked. Recruitment checks improved and people now have sufficient protection. The manager worked with the police and improved security when small amounts of money went missing from people and staff. Security could further improve as on our visit we were not challenged when we entered the home through French windows left open while beds were moved. Management took up suggestions of a multi-agency safeguarding strategy group to improve and the matter came to a successful conclusion. They now refer people for re-assessment for nursing care earlier, and re-assesses peoples needs before hospital discharge. The home made three appropriate safeguarding reports under the multiagency protocol about events within the community as well as in the home. For example, about unsafe hospital discharge and CQC made one report about diabetes care. These are followed up with agencies by the council to make people living in care homes safer. The hospital had assumed that people at Knoll were all having nursing care and essential District Nursing services were not arranged for people needing diabetes care. Nurses in the home put peoples needs first and provided essential insulin injections until these services could be arranged, or when they were too late to meet peoples routines and preferences for eating. The manager investigated incidents and analysed these monthly to see if there were any patterns, and prevented recurrence. There is better incident reporting inside the home and to other agencies however there should be incident records for all medication anomalies or errors affecting people. CQC were informed of a few events affecting people but we discussed with the manager that our guidance needs to be fully followed especially for medication anomalies and unexpected hospital attendance. We discussed two incidents we were not aware of from the homes log and confirmed there were no serious injuries. Their support was reviewed to prevent recurrence. In March 2010 we observed both sensitive practice and a near miss involving staff not assisting each other with a persons transfer from a wheelchair to an armchair. The wheelchair had tipped up once the person was out of it, but they were supported by staff. Some else sustained a skin tear from a bathing accident whilst assisted by staff. On this visit we noted no further concerns about moving and handling. Care Homes for Older People Page 19 of 31 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. Knoll House is homely and safe but security and contractor maintenance could be better organised. Comfort improved following refurbishment, and there are high standards of cleanliness and infection control. Rooms suit peoples needs and are personalised. Evidence: More creative and responsive use is being made of the building. For example the dining room now serves multiple purposes and was well used on our visit. People have the choice to move rooms and three rooms were being prepared during our visit. One person will have more independence on the ground floor, and all three people will have more space for hoists and a variety of wheelchairs. We entered the home unchallenged through open French windows in an empty room, so there should be tighter security for peoples safety. There were no obstructions in hallways once rooms were moved. Daily shift checks are keeping the home hazard free. A complaint about ventilation in a bedroom was acted upon by removing designation of a fire door after consultation with the West Midlands Fire Officer. There was extensive building repair, refurbishment and re-decoration in the past six months, which has stopped root causes of building decay and improved facilities to meet peoples needs as well as infection controls. For example, a bedroom, Care Homes for Older People Page 20 of 31 Evidence: two communal bathrooms and the laundry were improved. Staff told us on two occasions that this has helped them to sustain the high standards of cleanliness we saw. The homes Silver Award from the Primary Care Trust in infection prevention was on display. Repairs are timely and furnishings are high quality and comfortable. Training has taken place in bedrail fittings and maintenance; bedrails are checked and were safe on our visits. The homes sign on the outside of the building is worn and should give people confidence that the premises are cared for. Following the last key inspection the Director ensured work needed was undertaken and submitted satisfactory certificates to CQC for a five year electrical circuit check and legionella. There is now an ongoing timetabled refurbishment plan with priorities on health and safety as well as comfort. The AQAA however did not provide dates of all the essential premises maintenance and on this visit we requested those missing or overdue. Certificates could not be located and we gave opportunity to present them within 48 hours. After our visit an overdue check on fire extinguishers was arranged for June 2010. Certificates were provided out of the timescale because they were lost. Contractors provided duplicates where possible and one new check was arranged. We were satisfied that the premises and facilities are safe but the manager should be able to tell at a glance whether all essential checks are up to date, and certificates must be available for inspection by a range of regulators. Contractors made recommendations to replace a gas boiler and cooker as soon as possible and fire detection equipment is ageing, but these were not on the refurbishment plan discussed by the Director on our visit. The emergency alarm system was unreliable and needed more frequent checks which we were assured will be undertaken. It was agreed that the home needs a self sufficient way to identify and address these matters, and better security of certificates. Care Homes for Older People Page 21 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment checks usually ensure that staff are safe and fit for their roles. People benefit from new ways in which staff are deployed, supported and overseen. Most staff are qualified, updated training and maintain good relationships with people. There is still a high turnover of staff affecting consistency, particularly at weekends. Evidence: There is now an assistant manager who, along with a senior administers medication and oversees staff responsible for personal care. This has freed up time for nurses to provide and oversee nursing care and the home. Roles and responsibilities have been clarified, with supporting checklists for shifts and regular audits. Good standards of care, treatment, food, laundry and hygiene have maintained. People needing nursing care have particularly benefited at peak times, and more efficiently within constraints of the buildings structural design. Staff gained and renewed clinical, supervisory and medication skills and their competence was internally and externally assessed, which the manager will undertake in future. Staff we spoke to particularly valued training and learning, want more and felt confident in their roles. The manager looks out for local opportunities about peoples conditions and best practice. The staff team work well together and as key workers, and we made compliments over two visits from what we saw and what people and visitors told us. Staff maintain good relationships with people and their Care Homes for Older People Page 22 of 31 Evidence: visitors, and not just in emergencies. On this visit staff reassured people, gave them choice and asked for consent. Staff are sensitive to peoples communication modes, sensory needs, are respectful and give people time to respond. There is more learning needed about cognitive ability and appropriate stimulation. Bank staff need training, for example in moving and handling. The manager confirmed steps are being taken to address this. There are a range of staff meetings. The frequency of supervision is improving, and staff meetings are also used for staff development. Matters found by audits are followed up in supervision, by re-training and through disciplinary processes, for example, recurrent medication errors. The manager intends to keep staff up to date on best practice. Staff can gain additional qualifications, such as NVQ3 and NVQ4. Rotas are accurate. The manager has had challenges posed by staff recruitment and retention and has more to face. During our visit a resignation letter was received in the post, and there is upcoming maternity leave. A number of staff also work elsewhere, which reduces flexibility of staff providing cover. We confirmed that shifts are usually maintained at a level to meet peoples physical needs. There was active recruitment going on at each of our visits, on this occasion for a vacancy on the weekends. We therefore replaced a requirement with a recommendation. Bank staff are used for consistency but when not available, agency staff are used and nurses on duty are aware of how to arrange this. The manager still undertakes three nursing shifts a week. There are diverse staff matched to peoples needs, but we discussed that male staff can be lawfully advertised for if men prefer this for personal care. On this visit we also looked closely at recruitment checks to ensure staff are safe and fit for their roles as there had been non-compliance on our last visit. We saw an improved recruitment policy based upon the care regulations. An administrator assists the process using a new checklist. We advised previously that the manager must determine which references are sought and the checks to be undertaken to determine right to work in the UK. Between visits we had an action plan telling us that staff files have all been reviewed. On this visit four out of five staff records showed robust recruitment checks. In two files police checks had been destroyed with a note made of the number but not the date of issue, which is necessary to record. A bank worker had a short break in employment without refreshed checks, and right to work in the UK was not fully Care Homes for Older People Page 23 of 31 Evidence: established. The manager took appropriate action to protect people pending new checks when we queried this, and provided us with a satisfactory risk assessment the day after our visit. Care Homes for Older People Page 24 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is effective leadership that seeks peoples views in order to be responsive. Updated policies and audits ensure safe systems of work. A formal staff appraisal system would confirm these were followed. Quality control should include all the homes systems to continue development of the service. Evidence: The manager still spends the same amount of time covering shifts. However capacity to undertake all the necessary management tasks has improved with additional administrative support, an Assistant Manager and a new scheme of roles and delegation which was working well. Everyone readily approached the manager on our visits, and she is valued by staff and the Directors. The AQAA told us about the managers clear plans to continue to develop the service to benefit people, including clinical practice. Elysian Care and the manager have worked together to comply with the law and improve the quality of care, peoples health, safety and the environment in a short Care Homes for Older People Page 25 of 31 Evidence: space of time. In-between visits we have been kept well informed of progress by five action plans and an improvement plan. They consult us appropriately. Although we were told that CQC guidance was obtained the manager needs to review our guidance so it is fully used to continue to work together to keep people safe. The manager expressed intention to do so. Improvements were rapidly made as they have all been committed to providing people with good outcomes. On this visit we confirmed there is a more professional and smooth running service, with mainly robust and responsive systems. Surveys were undertaken with people as well as staff to identify what they could improve, changes were made and plans are progressing. This visit gave us confidence that the home and provider maintains a busy service within constraints, while seeking continuous development. People and other professionals are satisfied and the home has always had a friendly atmosphere. Policies, procedures and systems have been updated in a number of areas which we reviewed in respect of medication, recruitment, professional body reporting and infection control. Audits and checks are regularly undertaken, evaluated and were usually acted upon in a timely way. The manager maintains incident records and introduced a good system of analysis to identify patterns and these were acted upon. A formal appraisal system is needed to ensure procedures are followed. A review of environmental risks is reflected in the timetabled refurbishment plan, which also needs to consider contractor advice to avoid unnecessary disruption of the service. We will report to Environmental Health and the Fire Officer for their information in light of their previous involvement and for future safety. We saw good record keeping about peoples care and treatment and environmental safety. Management told us that they have already designed a forward planning system for essential maintenance, and are planning secure storage of contractor records. The retention and destruction of staff information needs review in accordance with data protection and CQC guidance. The homes legal liability insurance certificate on display had just expired, but we were provided with their new certificate the next day. Directors shared responsibility for unannounced visits to the service to check health, safety and quality. This responsibility is now delegated back to their personal assistant, who has attended Health and Safety Executive training and told us they are enrolled on the NVQ4 leadership and management award, which is proactive. The quality of Regulation 26 reports has improved, with clear actions and follow ups. Directors now ask for specific audits to exercise their responsibilities. We fedback that Care Homes for Older People Page 26 of 31 Evidence: all the homes systems should be included, such as incidents and complaints so that the home continues to maintain high standards of quality and safety self sufficiently. Care Homes for Older People Page 27 of 31 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 31 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 38 23 Reg 23(2)(c)(p)(4): A robust 05/06/2010 system must be in place to ensure timely contractor checks take place, and certificates must be available for inspection by regulators. Health and safety must be protected. 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 9 Each person should have only one MAR per monthly cycle, with carried forward stock and any additional receipts and changes dated and explained so that stock, discontinued and administered medication is clear and auditing can be efficient Goals on medication care plans could be more individual to evaluate health conditions in liaison with with people selfmedicating, and with health specialists and doctors. The use of plastic aprons should be reviewed with people to better promote dignity. 2 9 3 15 Care Homes for Older People Page 29 of 31 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 4 16 The complaints summary log should reflect whether timescales were met, actions taken and how any learning has been applied. CQC guidance should be reviewed so that notifications are made in all applicable circumstances, e.g. significant injuries, contagion, unplanned hospital attendance, medication errors, staff shortage and staff dismissal. Visitors should be challenged if they have not signed in. The sign on the outside of the building should give the public confidence that the premises are cared for. Staffing should be kept under review to ensure that there are sufficient and competent staff at all times. Bank staff need access to training and supervision to ensure their practice develops. Regulation 26 reports and visits should reflect upon all of the homes systems, complaints and incidents to confirm sufficient action was taken and is planned to maintain standards and safety. A formal system of annual review of staff performance should set measurable targets to ensure staff develop and follow policies and procedures. Formats for supervision and formal appraisal would assist continuous learning and staff development from audits and following training, and to confirm that policies and procedures are followed. Replacement of essential facilities such as the cooker, boiler and fire precautions should be timetabled to ensure the home continues to run smoothly. 5 18 6 7 8 9 10 19 25 30 30 33 11 36 12 37 13 38 Care Homes for Older People Page 30 of 31 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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