Care Home: Linford Park Nursing Home

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What the care home does well The service has an effective assessment procedure that includes the provision of good information about the home which it provided to service users and their representative before a decision is made about moving into the home. The home has a range of activities available with an activities coordinator employed to organise a programme of activities to meet the needs of the service users. The care plans are well documented and describe how service users would prefer their needs to be met. Some care plans are signed by service users or relatives and staff sign care plans to say they have been reviewed appropriately. Staff were seen interacting well with service users in general and were observed to be giving them choices. The home has a robust recruitment process to ensure service users are protected. The home is clean and tidy. What has improved since the last inspection? The management of medication and storage of medication is well organised and meets the expected standards. A staff training matrix has been devised to identify the training provided to all staff. All staff have now received training in Safeguarding of vulnerable adults and should have a good understanding about safeguarding the people who live in the home. The home has recruited another driver for the mini-bus which will enable service users to go out into the community in the better weather. What the care home could do better: Care plans must be written to guide the use of all medication that is prescribed on a `as needed` basis (PRN) particularly if the service user has limited capacity to communicate their needs. Care plans must be more person centred to ensure that service users` changing needs are fully documented. The management must ensure that the registered nurses, who are left in charge of the home, are fully aware of the procedure and of their responsibilities to report any safeguarding issues to Social Services at the time it is reported to them. The home does not have a registered manager and has been without one since September 2009. We have been in communication with the provider regarding a replacement. The home needs a manager in place, who is suitable to apply for registration with CQC.All members of staff must ensure that substances that are hazardous to health (COSHH) are maintained safely in a locked environment when not in use. The home must ensure that a quality assurance system is in place and that there is a record of the outcomes of the systems that are audited. A report should be formulated with the results from the surveys distributed by the home to service users and other stakeholders to enable the home to measure the results against the aims and objectives of the home. Regulation 37 notices must be submitted to CQC to report any incident that has had an adverse affect on service users as stated in the regulation. The notices need to contain full information about the occurrence and the action taken and any outcomes from this. The sender must ensure that all text is clear and contained within the box provided. The home must maintain the records of all servicing for electricity and gas systems and records be kept in the home and available for inspection. Key inspection report Care homes for older people Name: Address: Linford Park Nursing Home Linford Road Linford Ringwood Hampshire BH24 3HX     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: Janette Everitt     Date: 2 3 0 2 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 41 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 41 Information about the care home Name of care home: Address: Linford Park Nursing Home Linford Road Linford Ringwood Hampshire BH24 3HX 01425471305 01425471306 linfordpark@googlemail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Northdown Estates Limited Name of registered manager (if applicable) Mr Terence Walter Bailey Type of registration: Number of places registered: care home 80 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users to be accommodated is 80 The registered person may provide the following categories of service: Care home with nursing (N) to service users of the following gender; Either whose primary care needs on admission to the home are within the following categories: Physical disability (PD) Dementia (DE) Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Linford Park nursing home is situated in Linford, a rural area of the New Forest, around three miles from the market town of Ringwood. The home is registered to provide care to people in the older person category with mental health needs, dementia, and Care Homes for Older People Page 4 of 41 3 0 1 1 2 0 0 9 80 0 80 Over 65 0 80 0 Brief description of the care home physical disability. Accommodation is provided in two separate units and is over two floors. A passenger lift in provided. For information on fees contact the home. Care Homes for Older People Page 5 of 41 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: An unannounced visit to the service was undertaken on the 23rd February 2010. Two inspectors carried out this visit and were assisted throughout by the newly appointed senior nurse and the senior nurse, who is currently the acting manager. The process to collect evidence and make judgements included a tour of the service where a number of the bedrooms, communal areas, kitchen, and bathrooms were viewed. We sought views from service users who were able to communicate with us and observed practices throughout the visit. We also spoke with staff on duty and observed how they interacted with the service users. We viewed a sample of four service users care planning records and other records and documentation identified in the report were viewed. We took into account information gathered prior to the visit from the previous inspection report, which took place in June 2009 and the inspection report from the pharmacy inspection of November 2009. Care Homes for Older People Page 6 of 41 Information that had been shared with us from other agencies and the service history correspondence and contact sheets appertaining to the service, were also taken into consideration. For the purpose of this report the CQC representatives will be referred to as we thorughout the report. Care Homes for Older People Page 7 of 41 What the care home does well: What has improved since the last inspection? What they could do better: Care plans must be written to guide the use of all medication that is prescribed on a as needed basis (PRN) particularly if the service user has limited capacity to communicate their needs. Care plans must be more person centred to ensure that service users changing needs are fully documented. The management must ensure that the registered nurses, who are left in charge of the home, are fully aware of the procedure and of their responsibilities to report any safeguarding issues to Social Services at the time it is reported to them. The home does not have a registered manager and has been without one since September 2009. We have been in communication with the provider regarding a replacement. The home needs a manager in place, who is suitable to apply for registration with CQC. Care Homes for Older People Page 8 of 41 All members of staff must ensure that substances that are hazardous to health (COSHH) are maintained safely in a locked environment when not in use. The home must ensure that a quality assurance system is in place and that there is a record of the outcomes of the systems that are audited. A report should be formulated with the results from the surveys distributed by the home to service users and other stakeholders to enable the home to measure the results against the aims and objectives of the home. Regulation 37 notices must be submitted to CQC to report any incident that has had an adverse affect on service users as stated in the regulation. The notices need to contain full information about the occurrence and the action taken and any outcomes from this. The sender must ensure that all text is clear and contained within the box provided. The home must maintain the records of all servicing for electricity and gas systems and records be kept in the home and available for inspection. 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 41 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 41 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. Service users are fully assessed by a person who has been trained to do so, to ensure their needs can be met before a decision is made about moving into the home. This home does not offer intermediate care. Evidence: A sample of four service users pre admission assessments was viewed. They all contained an assessment made of the persons needs before they moved into the home. The assessments were comprehensive and covered all aspects of a persons physical, psychological and social care. The files viewed contained social service care management assessments. There have not been any recent admissions to the home and the documentation viewed by us was prepared and completed by the registered manager who no longer works at the home. Care Homes for Older People Page 11 of 41 Evidence: The home has recently employed a senior clinical nurse who told us that she will undertake future pre-admission assessments. Care Homes for Older People Page 12 of 41 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. The care planning process ensures that service users health, personal and social care needs are set out in individual plans. However these are not always person centred. Medication practices do not consistently ensure that people using the service have their wellbeing protected. Service users dignity and privacy is usually respected. Evidence: A sample of four service users risk assessments and care plans was viewed. An assessment is undertaken when the service user is admitted to the home. This together with information from the pre-admission assessment and other information that has been shared with the home by care managers and others involved with the admission to the home, contributes to the care planning process to ensure care plans are in place to describe how a persons needs are to be met. The files demonstrated a comprehensive assessment of residents needs. The assessments covered all aspects of the persons physical needs and all care plans Care Homes for Older People Page 13 of 41 Evidence: viewed had psychological assessments in place to describe the service users mental health well being. Care plans had been developed through assessments based on the activities of daily living for each person and how they prefer their daily routines to take place. Care plans were signed by staff to say they had been reviewed monthly. The care plans described how to manage mood swings, behaviours and for one person there was an eleven point care plan that detailed how to manage their anxiety, which could develop into aggressive behaviour and put other service users and staff at risk. Risk assessments were in place for moving and handling, tissue viability, falls and nutritional assessments. Each of the records viewed contained a moving and handling profile and a care plan to describe how the resident was to be moved and handled whilst in bed, in a chair or mobilising. However, it was observed in one case that the equipment used to move a person was not that described on the care plan. The nutritional risk assessment tool is being reviewed, as the assessment tool being used until recently, was outdated and the home is adopting the Malnutrition Universal Screening Tool ( MUST) which all service users will be assessed by in the future, but at the time of this visit the nutritional assessments were not robust. It was noted that for one service user who had been nutritionally risk assessed and found to be at risk, the care plan described their weight being recorded on admission and subsequently every three months. Their weight had only been recorded once since their admission six months previously. This was discussed with the nurse who said that the appropriate course of action would be taken to manage any risk as idientified by the MUST assessment. There was evidence in some care plan records that people are weighed monthly and this is recorded with their other general observations that are recorded at the same time. It was observed that in most cases bed rails were being used on beds, which were covered with bumpers to protect service users from entrapment. The sample of records viewed showed the process of risk assessment for their use and a signed consent by the service user or their representative, if the service user was unable to give informed consent to use them. The home maintains a specific night care plan for each service user. There was an Care Homes for Older People Page 14 of 41 Evidence: assessment for sleeping and bedroom comfort and this described what time the service user liked to go to bed, what their preferred attire was and if they had a bedtime drink or supper in their room and the frequency of being monitoring throughout the night. These care plans were evaluated by the night staff. The care records also document if the service user has an advocate and service users are assessed on their mental capacity under the mental health act and the deprivation of liberty safeguards. One file viewed demonstrated that one service user had been assessed and was waiting for an advocate to be appointed. There was evidence that where possible, care plans had been signed by the service user or their representative. Daily notes are maintained and are task based notes and relative to care plan numbers. i.e.meals and drinks taken well pad changed pressure areas checked. The records do not give detailed evaluation of the actual care delivered during each day and does not describe a person centred approach to delivery of care. Records are kept in the care plans of the personal belongings the service users choose to bring with them when they come to the home to live. Care plans also describe the general health needs of the service users. There were care plans to manage wounds, skin rashes, diabetes. Continence management was not individually managed and in some cases pads and pants were being used regardless of whether the client was able to indicate when they wanted to use the toilet. Service users general observations of blood pressure, pulse and weight are monitored monthly, and if indicated as being needed, weekly blood pressure measurements were being recorded. The GP visits the home weekly to undertake review of any service users that need to be seen or medication to be reviewed. GPs will visit the home at other times if requested. Documentation evidenced the contact service users have with doctors and other visiting health care professionals. The date and who visited the service user is recorded. The outcome of the visit is not consistently recorded in the care plan but is part of the daily notes. The day of this visit the service users were being seen by the optician and the dentist and podiatrist is accessible to all service users. The tissue viability nurse and community matron have been visiting the home Care Homes for Older People Page 15 of 41 Evidence: frequently to monitor the management of service users with pressure sores and any other service users who may need further assessment. This is taking place as a result of safeguarding issues and on going practice concerns for the management of wounds. Service users living in the mental health area of Woodlands have access to the community mental health team for assessment and the home receive support from this team for review and advice. Some of the care plans were being written as core care plans and were not personalised for each service user. The care plans are stored in the medication rooms on each of the units and are available to staff to inform and record their daily practices. The trained nurses co-ordinate the ordering, receiving, storage and checking of medications. The prescriptions are checked before they are sent to the pharmacy. This is good practice and ensures the home receives the medicaiton it has ordered. The home is being delivered the blister pack system from the local pharmacist. The medication that is unable to be put into blister packs is delivered in boxes or bottles and is stored in a locked environment with the blister packs. The medication is stored in four areas of the home, each having its own medication room. Two of the areas were visited. The medication is stored in a safe and well organised area. The temperatures of the fridges that are used for storage of medications, were being monitored daily and were being maintained within safe temperatures. The trained nurse on duty talked through the ordering and administration procedures and showed us the trolley and cupboards which were observed to be clean and tidy. There was no evidence in the cupboards of over stocking of medication, which is used on an as needed (PRN) basis only. The medication administration records (MAR) charts were viewed. These showed a photograph of the service user on the front page to ensure safe administration. The records evidenced that generally the MAR charts had been recorded appropriately. Those that had been transcribed had been signed by two people to ensure correct transcription and good practice. A pharmacy inspection was undertaken by CQC on 30th November 2009. The findings of this report said that medication which is prescribed on an as needed (PRN) basis, care plans should be written to describe the trigger factors or process of establishing if a service user needs this medication and to ensure consistency of practice. It was found that some care plans had been written to guide practice with specific PRN Care Homes for Older People Page 16 of 41 Evidence: medications like behavioural medication, but not all medication prescribed on a PRN basis, for example medication for pain, there were no care plans written to guide administration. The senior nurse said that for those service users who are unable to express their feelings or unable to verbalise their needs, there are usually physical indications if they need the medication. It was established with the senior nurse that all PRN medication being prescribed should have documented care plans to describe the trigger factors for when it should be administered. A service user who was prescribed one medication on a regular basis, but was not being stored in blister pack was continually not being given the medication and a code on the MAR chart indicated that it was not required. This was discussed with the senior nurse and acting manager as to reasons why this medication was not being prescribed on an as needed basis and a care plan written to inform when the medication was needed. There was a requirement from the pharmacy inspection that all medications, which includes some night sedations, must be stored in a controlled drug cupboard. This has now been complied with. The controlled drugs cupboards were checked in two areas of the home. The controlled drugs registers were checked and a sample of medication counted. The number of tablets recorded in the register balanced with that being stored in the cupboard. We discussed the controlled register recording method. The index did not identify what page of the book the drug was being registered and did not identify who the medication was prescribed for. This resulted in having to trawl through the register to find the correct page that was currently being used. This was discussed with the nurse on duty as poor practice and she agreed to ensure that, in future, the index would identify the page number the medication was currently being recorded on. The MAR charts are audited weekly by the night staff and the registered nurse on days told us that they self audit the charts each drug round to ensure they are completed appropriately. The weekly results of the audits are sent to the director. Observations of two of the medication rounds at lunchtime, demonstrated that staff are knowledgeable and understand the safe procedures for the administration of medication. It was observed that in Woodlands the dining room was quite cramped and busy and the lunchtime medication was being administered at the same time as the soup was being served. This is not good practice. Mealtimes and the administration of medication are two separate processes and should not happen Care Homes for Older People Page 17 of 41 Evidence: together. Timing of medication rounds was discussed with the senior nurse and director and it was agreed that for people with dementia, meal times should be a pleasant experience and should not be initiated by administering medication especially if the person was not willing to take it. It was decided that medication would be better administered at a more appropriate time. It was observed whilst looking around the home that the medicine trolley on Linford 2 had not been attached to the wall and demonstrated poor practice. This was identified by us and the senior nurse said it was her fault and locked it to the wall immediately. All trained nurses have undertaken the safe handling and management of medication training. Service users privacy is respected and the nurse was observed to knock on the bedroom door before entering the room. Service users were being called by the preferred name. All personal care, and if a service user is seen by a medical professional, it is within the privacy of their own room. All rooms are currently single occupancy. When speaking to a service user about her room she expressed a wish to have net curtains to the windows to allow her more privacy. This was noted by the senior nurse who said she would arrange this. Care Homes for Older People Page 18 of 41 Evidence: Care Homes for Older People Page 19 of 41 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 living at the home have the opportunity to take part in activities and to maintain contact with their family and friends. People living at the home are able to exercise choice and control over their life within their assessed mental capacity. People living at the home benefit from a varied menu. Evidence: The home employs an activities co-ordinator who has been undertaking this role for some years. She told us that she has received various training through the years on activities for the elderly and those with dementia. She said she is always willing to attend any training that may be advertised to enhance her knowledge. The programme of activities for two weeks was shown to us and was displayed around the home. The programme demonstrated various activities like knitting circle, crossword club, bingo, quiz time and exercise to music. Two hairdressers also visit twice weekly and this is stated as part of the activities programme. The activity co-ordinator was spoken with and she told us that she plans the programmes of activities and is familiar with what service users respond to and enjoy. The home attempts to gain as much social history as possible at the time of Care Homes for Older People Page 20 of 41 Evidence: assessment but the co-ordinator attempts to collect a more detailed social history from service users or their relatives gradually, but this can be difficult at times. The co-ordinator does specific activities with the service users who have dementia or lack mental capacity. She told us they enjoy music. At the time of this visit we observed the co-ordinator sitting with a service user talking about their family and past life. She told us that she does try to do one to one activities with the people who are mentally frail. Also observed in this lounge were two of the care staff playing ball with service users who appeared to be enjoying this. For those people who are confined to their room or choose to stay in their rooms the co-ordinator will visit them and talk to them about their past interests, will give them hand massage, listen to music and told us that residents do respond to one to one contact of voice and touch. The co-ordinator sits with the service users in the large dining room on Linford unit for them to eat their lunch together and to have a general chat with service users. She can observe if they are enjoying their lunch and listens to any comments about the food and says it is quite a social time for service users who chat to one another. We identified that most of the conversation was about the food. The activities co-ordinator records all interaction with service users and the group activities and who attends and their level of participation. The records are kept by the co-ordinator. The records demonstrated detailed information recorded daily about how the service user has been and how they have interacted within the activities they have participated in The files the records are maintained in were seen to be full and when viewed demonstrated records going back two years. The co-ordinator told us that she takes the records home with her every evening to maintain them as she does not have time within her working day. It was discussed with her that the files should be trimmed and some records archived. It was also decided that the records and information about service users must be kept on the premises within the care planning system to ensure that there is a person centred approach to service users care and that information does not become fragmented. It was also identified that there is a confidentiality issue with regards to service users records being taken off of the premises and that she should encompass record keeping into her working day. The outcome of the discussion and the fact that the co-ordinator does not have time in her work hours to record her activity it was evident that there are not sufficient Care Homes for Older People Page 21 of 41 Evidence: activity co-ordinator hours allocated to cover both Linford and Woodlands, whose residents have very different and varied social needs. The home has a mini-bus available to them but service users have not been on outings owing to the recent poor weather. Observations and talking to service users evidenced that activities do take place every week day but the co-ordinators role is very busy and she puts a great deal of effort into her job. Service users spoken to said they do enjoy the activities, one saying We could do with more activities but a lot of the residents just sleep through them. The co-ordinator is lovely and does her best and could not do more than what she does. We were so bored last week when she was on holiday. The co-ordinator said that some service users had requested to play skittles but unfortunately there was insufficient funds to purchase a set but it was something she would try to do in the future. Residents and relatives meetings take place. Minutes of the last meeting was seen advertised on the notice board. It is at these meetings that any issues can be discussed. Service users were seen to be wandering around the area freely and people at the home can choose when to receive their visitors. People living at the home, who we were able to communicate with, told us they are able to have visitors at any time. The home does have some visitors. A visitor was spoken with who told us that he visits his friend when he can and said he could not comment on the level of care they were receiving. Interaction observed throughout the day indicated that the staff interacted well with the service users. A service user told us that staff respect my wishes for getting up early and the carers are very good and know I like to go to bed at 10 oclock. They also know I cannot get in a bath and help me have a good wash every day and I am happy with that. They also told us that they had been able to bring their own furniture to the home and although they did not get a downstairs room as they had requested, they were now very happy with the room they occupied. It was observed in the care plans that the service users religious preferences were documented and if they wished to worship. Care Homes for Older People Page 22 of 41 Evidence: A large dining area in the Linford wing is available for people living on that wing to take their meals or they can take them in the privacy of their own bedrooms. We observed the lunchtime meal in the main dining room. The tables were pleasantly presented with table clothes, napkins and flowers. The menus observed were giving choice at each meal time. The selection of meals available was also on display in an album with photographs of the various meals provided at the home to aid people visually with meal choices. Service user spoken to living on Linford wing confirmed that they have choices at meal times. On the day of this visit there was a choice between fish pie or omelette and salad. The meal was well presented and drinks were being offered regularly. Service users spoken to at the time of this meal reported that the fish pie was very good, but another said it was too dry. Another resident said they did not like fish and chose to have an omelette. One service user spoken to said: This is the best place I have been in, the food could be better. I have a large appetite and sometimes I am hungry when I have left the table. I eat a lot of salad and omelette as I do not like some of the meals but today is fish pie and I enjoy that. The service user reported that they also have a cooked breakfast of bacon and egg every morning. On observing their meal at lunchtime it was evident that the cook had listened to the service user and had served a meal of adequate proportion. People living at the home, if they are able, can make choices where they take their meals. The lunchtime meal was observed by us in one of Woodlands two dining rooms, which are much smaller than the communal one on Linford and an L shaped room with tables around the outside walls. On entering the room it was observed that some service users had been pushed into the dining room in preparation for lunch and were sat alone at a table facing a wall. Another service user had fallen forward onto their hands resting their head on the table. There was not much space to manoeuvre wheelchairs and hoists, but service users were being given the choice of being transferred to a dining chair from their wheelchair. It was also observed that the tables were not laid with cutlery or napkins and we were informed by the senior nurse that this would not be appropriate for this area as the residents would not leave them on the table and would move them around, so serviettes and cutlery are given out as service users meals are served. Care plans details the assistance people need at meal times, whether they need assistance with feeding or if they need their food prepared in a certain way that enables them to eat their meals independently. Care Homes for Older People Page 23 of 41 Evidence: A number of service users in this area needed assistance with their eating. One carer was sitting beside the person engaging with them whilst feeding them. Conversely, another service user was being fed by a carer who was standing up and over the person whilst helping them eat, albeit that there was little space for the carer to sit beside the service user, but gave the appearance of being discourteous. Another service user was being fed by a carer in the lounge area in a recliner chair. The nurse in charge told us that it is possible to move recliner chairs into the dining room but this gentleman was not being given the choice of being pushed into the dining room to eat, as his chair was not movable and he was unable to express his choice about where he would like to eat. It was observed during the preparation for lunch that service users were being offered an apron to wear to protect their clothes and being given choice of where they would like to sit and what they would like to drink. The cook told us that she is aware of the service users food likes and dislikes and is able to prepare special diets if needed. She said she prepares the menus taking into consideration what has been discussed at the residents meeting and what service users surveys say about the food. One service user told us that the menu had been discussed at a meeting and as a result there was now less mince dishes being put on the menu and added it is not home cooking though. It was observed that those who needed their diet pureed, this had been presented in separate portions to allow service users to experience different tastes and textures. Care Homes for Older People Page 24 of 41 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. The service has a complaints procedure that is displayed in the home and service users are confident they will be listened to. The service has policy and procedures in place for the safeguarding of service user from abuse. However, there have been a number of safeguarding investigations with regards to the welfare and safety of the service users. Evidence: The homes complaints procedure is on display in the reception area of the home and the procedure is detailed in the Statement of Purpose and service user guide which is given to the service users when they move into the home. The complaints log was viewed and demonstrated that two complaints had been recorded since the last inspection and have been resolved. CQC have received two complaints that have been investigated by the registered manager at the time. Those service users able to communicate said they would talk to a staff member if they had a complaint. There are a number of safeguarding investigations being undertaken by the Social Services safeguarding team and a multi agency team of professionals at the present time. As a consequence of this the home is currently not admitting any new service users until the investigations are concluded and placing authorities can be satisfied Care Homes for Older People Page 25 of 41 Evidence: that service users placed there will be cared for appropriately and will be safe. The training matrix demonstrated that all staff have received training on safeguarding and abuse over the last year. The new clinical lead nurse has not yet undertaken this as she only commenced employment the previous day to this visit. A registered nurse was spoken with at the time of this visit and was asked about the safeguarding procedures. She was knowledgeable to a degree and understood her role in reporting any incidences, suspicions of abuse or poor practice. However, she was not sure of her role and what she should do if she were solely in charge of the home and an incident occurred. It was discussed with the senior nurses and director to ensure that all nurses are aware of their responsibility in practice should a safeguarding issue arise whilst they are in charge of the home. Service users are risk assessed before any form of restraint i.e. bed rails, are used to ensure that they are only being used in the best interest of their safety. Care Homes for Older People Page 26 of 41 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. Service users live in a clean environment which is adequately furnished and maintained. However there are risks to service users safety in some areas. Evidence: The home is divided into two distinctive areas. One called Linford for general nursing and the other called Woodlands that accommodates people with dementia. Both areas are over two floors. We looked around the environment, looking at a sample of bedrooms, bathing facilities, communal areas, kitchen and the laundry. Bedrooms were to varying degrees personalised with the persons own belongings such as ornaments, pictures and small items of furniture. One service user told us that she had been pleased she could bring some of her own furniture. She said she was happy with the room but would like a more comfortable bed and a net curtain hung to her window for privacy. The new senior nurse took note of this. We visited a service users room, which was a double room but had single occupancy. The service user had two beds and preferred to lay on one bed during the day and the other bed at night. This persons bed had a pressure relieving mattress in place but it was observed that the sheets were so thin and worn and were generally in a poor state of repair. This was highlighted to the senior nurse as an indication that service Care Homes for Older People Page 27 of 41 Evidence: users dignity was not being respected. The senior nurse said he would arrange for the sheets to be replaced. We also looked in unoccupied rooms, some of which were full of old equipment and outdated apparatus that is no longer used. An area outside the home was observed where there was a large pile of rubbish that needed to be got rid of. The surrounding area of the home has no formal gardens except for a patio area on Linford that accommodate some garden furniture and a seating area. The other surrounding grounds are woodland and the New Forest and most rooms have lovely views over this area. The old aviary, that was meant to be dismantled last year, is still in position although no birds are in residence. A number of residents had bird feeding platforms outside their windows and some take delight in feeding the birds and watching them. There are a variety of communal areas for the use of people living at the home including separate lounge areas on Linford and Woodlands wing of the home, a large dining area service the people living on the Linford wing. This area is also used as a recreation and activity area. The lounge areas in Linford were not being used on the day of this visit as service users were choosing to be in their rooms or in the dining room. The lounges in this area were quite cold although the heaters were on they were not very effective as the day was cold. The two lounges on Woodlands accommodated a number of service users, most of who were sleeping or just sitting. The lounges overlook lovely countryside. It was observed that zimmer frames were parked in one of the lounges and were said to belong to service users but were observed to be very dirty. There was an old sideboard that was broken and unstable in front of the window. It contained old papers, puzzles and rubbish. The curtains in this room had been cleaned and had fallen into shreds. The director told us that she had ordered new curtains and was awaiting their delivery and that she would ensure the old sideboard was removed. The senior nurse told us he would supervise the cleaning of equipment. It was also noted in Woodlands lounge that one of the heaters had not been fitted with a cover. This could present a risk to service users. The walls of Woodlands lounge were heavily marked by the backs of chairs scraping against them and the senior nurse said this area is to be redecorated this year when Care Homes for Older People Page 28 of 41 Evidence: the downstairs lounge was completed. It was observed that there was no signage up on doors to help service users orientate themselves to different rooms. On Woodlands, doors are kept locked throughout the day if service users are not in their rooms because of other service users wandering into them. A number of service users are unable to consent to this owing to their mental capacity. Separate dining areas in the Woodlands wing are for the use of people living in those wings, although people are able to eat their meals in the large dining room if they wish. We observed that one service user from Woodlands was taken over to the Linford dining room for lunch and socialised with the service user she shared a table with. The two smaller dining rooms on Woodlands become very busy and cramped during meal times and the arrangement of the room was not conducive to comfortable dining. We observed people who use the service moving freely with or without support from the staff between the communal areas and their bedrooms, making the choice about where to sit and how to occupy themselves. Most of the rooms used are single occupancy and have en-suite bathrooms. Most of the baths in the en-suites are not used but there are other bathrooms and shower rooms available. It was observed that a bath list was displayed identifying on what day each service user is allocated a bath. This was discussed with the senior nurse as being undignified and lacking respect for the privacy of the service users. This information should be part of the personal care plan for care staff to follow. The senior nurse told us that the service users do get a bath on the stipulated day unless they refuse or they can have a bath at other times if it is necessary. The bathroom visited on Woodlands was found to be very cold with no heating on in the room. The senior nurse said that if a service user is to have a bath the heating is put on beforehand. We observed a bathroom temperature list and this indicated that the room temperature was recorded to be between 18 and 21 degrees. The outside temperature for the day was cold and the home felt generally cold in some areas. Policies and procedures are in place about hygiene practices and the control of infection. A team of housekeepers are responsible for the cleaning of the home. During this visit the home was observed to be clean and tidy and only one room had a slight odour. The housekeeper was observed to be cleaning carpets and told us that they have a carpet cleaning schedule and that carpets are cleaned at regular intervals Care Homes for Older People Page 29 of 41 Evidence: and more frequently if an accident occurs. The training matrix evidenced that all staff have received infection control training in recent months. Housekeeping staff spoken to were aware of the infection control principles and gloves, aprons and hand washing facilities were available for use. The homes laundering facilities are on the ground floor. The position of laundry and good laundry practices reduce the risks of cross infection from dirty laundry. The laundry floors and walls are easily cleanable. A service user spoken to told us that she is pleased with the laundry service and told us just a couple of here things had gone missing but she made sure her clothes were marked. The home does employ one maintenance gentleman to undertake the day to day repairs to the home. He was present in the home on the day of this visit. Whilst visiting Woodlands dining room it was observed that the cupboard under the sink was open with an open padlock hanging from the door. The cupboard contained washing up liquid, tile grout, two buckets of dishwasher powder and a spray bottle that was not labelled. This presented a high risk to service users who lack mental capacity and the COSHH guidelines were not being followed. This is addressed in standard 38 under Health and Safety. Care Homes for Older People Page 30 of 41 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users care needs are met by sufficient numbers of staff who have received training to enable them to fulfil their roles. Service users are protected by the homes recruitment policies and procedures when recruiting staff. Evidence: The number of service users in residence at the time of this visit was 43. The last admission being in December 2009. There were 14 service users in residence on Linford and 29 residents being accommodated on Woodlands. The staff rotas identified that on the day of this visit there was one mental health trained nurse on duty on Woodlands along with 6 care staff. The registered mental health nurse on duty at this time is currently acting as the senior nurse and manager whilst the home appoints a new manager. The rotas demonstrated that one trained nurse and 4 care staff are on duty during the night hours. Linford rotas demonstrated that one registered general nurse was on duty and 3 carers during the day. One trained nurse and 2 carers are on duty throughout the night. Staff spoken to told us that they consider there is sufficient staff on duty each day and service users said the staff were always available and very kind. A director of the company does attend the home for 3-4 days a week and is in a nonCare Homes for Older People Page 31 of 41 Evidence: clinical role. The home has recently appointed a new senior registered nurse who is currently undertaking their induction and is not included in the staff rotas yet. The home employs a separate housekeeping staff of cleaners, four of which are on duty every day of the week, a laundry person, cook, kitchen assistant, a maintenance person and activities co-ordinator. The home has two administrative staff in the home during the week days. From observations of the day and staff practices there was no evidence to suggest that there were not sufficient staff on duty to meet the service users needs. The training programme and matrix were viewed. The training programme and observing memorandums on notice boards advertising forthcoming training, suggests that there is a variety of appropriate training available to all staff. The training programme advertised a training session for every week from January 2010 until the middle of March and the subjects included mandatory fire training, moving and handling, infection control, emergency first aid, wound care, dementia, protection of vulnerable adults and skills for care. Most of these had been undertaken by a number of staff by the time of this visit. The emergency first aid training, which is to include CPR (cardiac pulmonary resusitation), is to be held in March 2010. The training matrix recorded all the training that staff have undertaken. A carer and registered nurse were spoken with. They told us that they have attended a variety of training in the last two months and are well supported by the home to do so. The staff supervision records were viewed. There was evidence that the senior nurse had undertaken some staff supervision and but not all staff had received supervision or an appraisal at the appropriate intervals. The programme for supervision and appraisals is to be decided and the new senior nurse will have a role to play in implementing this. A sample of four recruitment files was viewed. Those tracked demonstrated good recruitment practices. However, for some staff the administrator had not stamped the date of when references were received and was advised to do this in the future to validate the document. There was evidence that the criminal record bureau (CRB) and the protection of vulnerable adults (POVA) has been undertaken and cleared. The files contained two references and an application form and interview notes. Care Homes for Older People Page 32 of 41 Evidence: The recruitment files also contained the induction programme. A staff member spoken to said she had done a local induction lasting three days and during this she was supernumerary and this had been followed by the skill for care programme which took approximately twelve weeks. She said she had been well supported by the senior nurse but had not quite completed this programme to date. The newly employed senior registered nurse, who accompanied us on this visit, had commenced employment the previous day and was on her local induction of the home. The director reports that over 50 of care staff have achieved the national vocational qualification (NVQ)level 2 and above. Care Homes for Older People Page 33 of 41 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. The home has no manager currently, which is effecting the provision of quality care. The service is not being effectively quality assured. Robust procedures ensure that the finances of people using the service are protected. Health and safety practices do not fully protect service users living at the home. Evidence: The previous registered manager resigned from his post in September 2009. Another manager was appointed but left the homes employ in December 2009. The home is again without a manager. CQC has communicated with the responsible individual, Mr M Joseph, who has informed CQC that he and the senior nurse on the mental health area of the home are managing the home between them until a new manager is appointed. He has subsequently responded to correspondence to inform CQC that he is in the process of registering a manager. No application or registration activity has been recorded with CQC to date. Care Homes for Older People Page 34 of 41 Evidence: On the day of this visit we were introduced to a newly employed nurse who had commenced her employment the previous day. She told us that she had seen an advert for a registered nurse post and had applied and the director had invited her to be the clinical lead nurse. She had accepted this post. We asked her if she was to be the manager and was she going to be registered with CQC she replied I did not apply for the registered managers job but I may well do so. I do not think we have established if I am going to be registered manager or if someone else will come in in three months time. There was confusion around who was to be the new manager, as the director informed us at the feedback discussion that this nurse was the new manager and would be being registered. She requested we send an application form to her. We informed the director of the correct procedures to follow for registering a manager and directed her to the CQC website. The home has no formal quality assurance system in place. The medication system is audited weekly and a report is sent to the director. Service user and relative surveys are distributed every three months. A number have been returned by not analysed with any results, although generally the comments returned were positive. We identified that on the questionnaires being distributed, there was no stated option for choosing to remain anonymous and this should be made clear on questionnaires in the future. There are records of accidents in the home. These have not been analysed as part of the quality assurance to identify any emerging themes or identify trigger factors that may cause accidents. The home does look after some service users monies. Three service users monies were checked and found to be in order with records balancing with the monies held. The monies are stored separately and are secured in a locked environment. A sample of servicing certificates was viewed. These demonstrated that hoists, bath hoists had been serviced within timescales. The electricity and gas safety certificates were not in the home. The director told us that the other director, who is the RI, had these records and were not on the premises. These records should be stored in the home and made available to be inspected. The training matrix evidenced that the staff have received the mandatory health and safety training within the past year. The fire log was viewed and evidenced that the Care Homes for Older People Page 35 of 41 Evidence: fire system is serviced and checked at appropriate intervals. The home has a policy to guide the control of substances hazardous to health (COSHH), which says that such chemicals must be stored in a secure locked environment when not in use. A cupboard door under a sink in the dining room in Woodlands was found left unlocked and open to expose a number of chemicals that would put service users health at risk if they had attempted to handle or ingest them. This was brought to the senior nurses attention and discussed as being very unsafe for service users. The nurse locked the cupboard immediately. They told us that this door is usually locked and that they would speak to the carer responsible. They were later observed to be talking to a carer on duty about this. The regulation 37 notices that CQC receive to report incidences, deaths, etc are not of good quality. The notices need to contain more information about the occurrence and the action taken and any outcomes from this. The sender must ensure that all text is clear and contained within the box provided on the form or an extra page be sent to give full information about the incident. It was also identified through records that the reporting of incidences that adversely affects the well being and safety of the service users have not been reported to CQC on every occasion. Care Homes for Older People Page 36 of 41 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 37 of 41 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 Care plans must be more person centred and describe in the daily records how service users specific needs are being met in an individual way and not task orientated. Staff must be informed in care plans of how a service users needs are to be met in a person centred approach with daily records identifying how this is happening. 30/04/2010 2 31 8 The registered provider must appoint an individual to manager the home and inform CQC the name of the person appointed and the date this takes effect. The home must have clear lines of accountability within the home and with any external management and must appoint a registered 30/04/2010 Care Homes for Older People Page 38 of 41 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 manager who meets all standards applying to the registered managers role. 3 33 24 The quality assurance system must be more formalised with records maintained of all audits undertaken and an analyses of any questionnaires that have been distributed to service users and other stakeholders to ensure the service is meeting the aims and objectives of the home as stated in the Statement of Purpose. The home must have a quality assurance system in place that feeds into the annual development plan of the home to reflect the aims and outcomes for service users. 4 38 13 Records must be maintained 30/04/2010 in the home as evidence that all electrical systems and equipment have been certified as being safe. There must be records in the home to evidence that checks on the electrical systems and any electrical equipment used for service users has been certified as being safe to use. 31/05/2010 Care Homes for Older People Page 39 of 41 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 5 38 37 Regulation 37 notices must be submitted to CQC to report all incidences that adversely affect the service users well-being and safety. The registered person must without delay report to CQC on a Regulation 37 notice of all events that affects service users safety and well-being. 30/04/2010 6 38 12 It is required that all cleaning chemicals under the COSHH regulations are maintained at all times in a locked environment and must not be left exposed to vulnerable service users. Cleaning chemicals must be stored in a locked environment at all times to ensure vulnerable service users do not have exposure to them. 30/04/2010 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 Care Homes for Older People Page 40 of 41 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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