Care Home: Littledene House

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What the care home does well The home accommodates a maximum of twelve people and is run as a "home from home". We found the home warm and clean and communal areas are comfortably furnished and offer a range of books, pictures and equipment available for residents to use. The staff clearly have excellent relations with the residents and are aware of their individual needs and we found all the residents relaxed and well dressed during the visit. The three family members we spoke with on the day were keen to say how happy they are with the service and praised the staff and the care they provide. One relative said "Its the best care I have seen" and said their relative had bad sores on their hands before moving in but that these sores had "now cleared up." Another relative said "the girls are lovely and the quality of care is very impressive". Since the inspection, two other relatives have contacted the inspector, also anxious to say how happy they are with the home. One relative said "all the staff are very good" and that their relative has improved in health in the two years they have been in the home. All relatives who spoke with us said they were always made welcome in the home and were kept informed of any issues that arose. The residents we spoke with said they enjoyed the food provided and pictorial menus are used to ensure people are clear about the meal choice offered. The staff receive good levels of basic training, with regular updates, as well as appropriate specialist training. This ensures that care staff are able to meet the health needs of people in a professional and appropriate way. Care staff are aware of the home`s procedures for safeguarding residents and for dealing with any complaints. Complaints information is provided for all residents and families and there are forms and a book available in the hall for visitors to use to register a concern or record a compliment about the home. This is in place to ensure that standards of care are maintained and people are protected from the risk of abuse. What has improved since the last inspection? An update of all residents` care plans has taken place. All care planning is now person centred and provides detailed information about individual needs and preferences. This is so that care staff are able to provide appropriate care for people, even if they have a level of confusion and cannot easily voice their likes and dislikes. This was identified as a shortfall in previous inspection reports. The manager has completed a written infection control policy for the home as had been required in previous inspection reports. This policy is now up to date and provides staff with information and guidance so that the risk of the spread of infection is reduced in the home. The manager has also completed an audit of infection control procedures as recommended in current good practice guidelines. A supply of red alginate bags is also now available in the home and a sluice washing machine is in operation. This equipment is seen as essential for reducing the risk of the spread of infection where there is incontinence. A review of the bathroom facilities in the home has taken place and the manager is now considering the recommendations made for improving these facilities. Training in the Mental Capacity Act has been arranged for all staff. This is so that staff are aware of current legislation and are clear about the rights of people who may have a mental impairment. In compliance with previous requirements, procedures for the recruitment of staff have been improved and we found that appropriate evidence has been provided on staff files. The manager has also obtained clarification of the hours the foreign students employed are allowed to work and the staff roster seen accurately reflected these permitted hours and showed a true picture of the staff working week. Procedures for opening the front door of the home had previously been an issue and have now been resolved. The key which opens the front door from the inside is now hanging on a hook over the door. This will enable people in the home to leave in a safe and timely way in the event of an emergency. What the care home could do better: The manager has now complied with all the outstanding statutory requirements and no new requirements have been made as a result of this inspection. However, several requirements had not been addressed within the set time scales and have been carried forward through several previous inspection reports. Some of these requirements reflect issues which could put residents in the home at risk of harm, such as the poor recruitment practices previously found and the poor infection control procedures previously seen. At the recent random inspection we had found that overseas staff who appeared to be students did not have their employment status clarified and were working longer hours than they should have been. This is not acceptable and it is a legislative requirement that the provider ensures people employed to work in the home are fit to do so. The staff roster also did not reflect accurately who and when some people had worked. This was despite requirements and a statutory requirement notice previously being made about implementing thorough recruitment practices. The manager has also had an on-going requirement to implement thorough infection control procedures and introduce an up to date infection control policy for the home. It cannot therefore be assured at this time that the manager will be proactive in implementing and maintaining the procedures required in care homes, to ensure good standards of care are always provided. Currently, people who use the service are having their health needs met and do not appear to want a wider range of stimulation to be provided. However, there are currently only seven residents in the home, which is registered for twelve people. The home may admit people who are confused or who are fully mentally alert. This means that the range of services offered, and especially activity services, will need to be reviewed as new people enter the home. Similarly, present residents have their hair wet cut by a hairdresser on an ad-hoc basis. When more people enter the home professional hairdressing services will need to be offered to people who may well have been used to having this service in the community. The current care workers are clearly very good and professional but there is no senior or deputy presently employed and, when the home is full, there may be a need to have such a post for when the manager is not on duty, to ensure that all the management duties of the home are fulfilled. The home also has a history of having a high turn over of staff, and three of the present staff have temporary student work visas and will eventually leave the home. The staffing structure may also need to be reconsidered as the home becomes full. Some of the furnishings and fittings in the bedrooms are also looking tired and will need replacing in the near future. There is currently only one assisted bathroom in the home. Adaptations to this room will need to be made to ensure that residents, who may be physically disabled, can be safely and respectfully assisted with personal care. When the home is full, the manager must also decide how the second bathroom can be used by residents. The manager is aware that when decisions are made about the home`s facilities, and when they are implemented, the home`s Statement of Purpose and Service User`s Guide must reflect the services actually being provided at the home. This is so that new residents can make meaningful choices as to whether the home is the right place for them. Since the inspection the manager has amended the home`s Statement of Purpose and Service User`s Guide and these documents confirm that people`s individual choices and interests will be used to plan and provide activities and services in the future. The Guide also shows that currently there is only one assisted bathroom for the use of residents in the home. Key inspection report Care homes for older people Name: Address: Littledene House 54 Bushey Grove Road Bushey Hertfordshire WD23 2JJ     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: Patricia House     Date: 1 4 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 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) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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: Littledene House 54 Bushey Grove Road Bushey Hertfordshire WD23 2JJ 01923245864 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: m.ang@btopenworld.com Ms Margaret Ang care home 12 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: If the names service user ceases to be accomodated at the home then the variation to the category shall cease. The home may accommodate one named service user under the age of 65 with Dementia. The manager must inform CSCI if the service user permanently leaves the home for any reason. Date of last inspection Brief description of the care home Littledene House is a care home providing personal care and accommodation for twelve elderly people who may also have a dementia. Littledene is privately owned and the proprietor also manages the home. The property is a large detached house, which has been converted to provide single room accommodation. Six of the bedrooms have en-suite toilets. The house is well Care Homes for Older People Page 4 of 31 Over 65 12 12 1 0 2 8 0 6 2 0 0 9 Brief description of the care home presented and provides residents with comfortable surroundings in a homely atmosphere. There is a passenger lift for easy access to the upper floor and an enclosed garden to the rear. The frontage of the property is attractively paved and allows for the parking of several cars. A single storey extension at the back of the house provides living accommodation for three members of the care staff. Littledene is situated in a quiet residential road in the village of Bushey and is approximately two miles from the village High Street and also about two miles from the extensive amenities of Watford Town. There are local shops a short walk away. There are nearby bus and rail services and the home is close to several major roads and motorways. Current charges for the home range from £525.00 to £595.00 per week. Further information can be found in the homes Statement of Purpose and the Service Users Guide, which are displayed in the entrance hall. The home also has an internet web site. 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: 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: The last key inspection of this service was completed on 23rd July 2009. The information in this report is based on an unannounced inspection of the home, which took place over one day with two regulation inspectors carrying out the work of the Commission. For the purposes of this report the Commission will be referred to as we. The registered manager was not on duty at the start of the inspection but returned to the home mid-morning. We spoke with staff, residents and visitors. We visited all parts of the home and checked a variety of records. Since the last key inspection, a random, or short inspection took place on 16th December 2009. This visit was to check compliance with some outstanding statutory requirements which had been made following earlier visits. Care Homes for Older People Page 6 of 31 There is an on-going investigation in progress, co-ordinated by Hertfordshire County Council under the joint agency safeguarding vulnerable adults procedures. Since this key inspection one additional strategy meeting has also been held by the Local Authority to consider a specific issue at the home. We have also reviewed any other information we have received about this service since the last inspection. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? An update of all residents care plans has taken place. All care planning is now person centred and provides detailed information about individual needs and preferences. This is so that care staff are able to provide appropriate care for people, even if they have a level of confusion and cannot easily voice their likes and dislikes. This was identified as a shortfall in previous inspection reports. The manager has completed a written infection control policy for the home as had been required in previous inspection reports. This policy is now up to date and provides staff with information and guidance so that the risk of the spread of infection is reduced in the home. The manager has also completed an audit of infection control procedures as recommended in current good practice guidelines. A supply of red alginate bags is also now available in the home and a sluice washing machine is in operation. This equipment is seen as essential for reducing the risk of the spread of infection where there is incontinence. A review of the bathroom facilities in the home has taken place and the manager is Care Homes for Older People Page 8 of 31 now considering the recommendations made for improving these facilities. Training in the Mental Capacity Act has been arranged for all staff. This is so that staff are aware of current legislation and are clear about the rights of people who may have a mental impairment. In compliance with previous requirements, procedures for the recruitment of staff have been improved and we found that appropriate evidence has been provided on staff files. The manager has also obtained clarification of the hours the foreign students employed are allowed to work and the staff roster seen accurately reflected these permitted hours and showed a true picture of the staff working week. Procedures for opening the front door of the home had previously been an issue and have now been resolved. The key which opens the front door from the inside is now hanging on a hook over the door. This will enable people in the home to leave in a safe and timely way in the event of an emergency. What they could do better: The manager has now complied with all the outstanding statutory requirements and no new requirements have been made as a result of this inspection. However, several requirements had not been addressed within the set time scales and have been carried forward through several previous inspection reports. Some of these requirements reflect issues which could put residents in the home at risk of harm, such as the poor recruitment practices previously found and the poor infection control procedures previously seen. At the recent random inspection we had found that overseas staff who appeared to be students did not have their employment status clarified and were working longer hours than they should have been. This is not acceptable and it is a legislative requirement that the provider ensures people employed to work in the home are fit to do so. The staff roster also did not reflect accurately who and when some people had worked. This was despite requirements and a statutory requirement notice previously being made about implementing thorough recruitment practices. The manager has also had an on-going requirement to implement thorough infection control procedures and introduce an up to date infection control policy for the home. It cannot therefore be assured at this time that the manager will be proactive in implementing and maintaining the procedures required in care homes, to ensure good standards of care are always provided. Currently, people who use the service are having their health needs met and do not appear to want a wider range of stimulation to be provided. However, there are currently only seven residents in the home, which is registered for twelve people. The home may admit people who are confused or who are fully mentally alert. This means that the range of services offered, and especially activity services, will need to be reviewed as new people enter the home. Similarly, present residents have their hair wet cut by a hairdresser on an ad-hoc basis. When more people enter the home professional hairdressing services will need to be offered to people who may well have been used to having this service in the community. The current care workers are clearly very good and professional but there is no senior or deputy presently employed and, when the home is full, there may be a need to have such a post for when the manager is not on duty, to ensure that all the management Care Homes for Older People Page 9 of 31 duties of the home are fulfilled. The home also has a history of having a high turn over of staff, and three of the present staff have temporary student work visas and will eventually leave the home. The staffing structure may also need to be reconsidered as the home becomes full. Some of the furnishings and fittings in the bedrooms are also looking tired and will need replacing in the near future. There is currently only one assisted bathroom in the home. Adaptations to this room will need to be made to ensure that residents, who may be physically disabled, can be safely and respectfully assisted with personal care. When the home is full, the manager must also decide how the second bathroom can be used by residents. The manager is aware that when decisions are made about the homes facilities, and when they are implemented, the homes Statement of Purpose and Service Users Guide must reflect the services actually being provided at the home. This is so that new residents can make meaningful choices as to whether the home is the right place for them. Since the inspection the manager has amended the homes Statement of Purpose and Service Users Guide and these documents confirm that peoples individual choices and interests will be used to plan and provide activities and services in the future. The Guide also shows that currently there is only one assisted bathroom for the use of residents in the home. 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 10 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 11 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. People who use the service are provided with much of the information needed to make decisions about entering the home but some information needs clarifying at this time. Detailed assessments take place for each new resident to ensure their individual needs can be met although services may need to be adapted as more people with differing needs enter the home. Evidence: Copies of the Statement of Purpose and Service Users Guide for the home are displayed in the entrance hall. However, some entries included in this information are now out of date. Current activity provision in the home does not include monthly religious services, music for health and gentle exercises or the external musical entertainment, as advertised. The manager said that the current residents do not want to have any of these activities provided and so they have stopped. The Service Users Guide needs to be amended to show that activities may take place when new residents enter the home if this is the case. The manager said that amendments would Care Homes for Older People Page 12 of 31 Evidence: be made to the information. Similarly the information states that there are two bathrooms with toilets for residents to use. However one of these bathrooms and toilet has only been used by staff and visitors for over a year. When the manager has finalised future planning for the home the bathroom availability will need to be clarified in the guide so that potential residents are clear about the facilities in the home. The Service Users Guide includes written information about the extra charges made for services which are not included in the basic fees, such as those for chiropody and hairdressing so that residents and families are clear about charges. However the address of the Commission is now out of date and the manager said this would be rectified. The homes last CQC inspection report is also not displayed for potential residents to see, but the relatives we spoke with confirmed that the manager had given them information about the report and explained how all CQC reports about the home can be accessed. Since the inspection the manager has amended the homes Statement of Purpose and Service Users Guide and these documents now clearly set out the facilities available in the home. Photographs of residents and staff are also displayed in the hall so that visitors have this information. These photographs are still showing people who have left Littledene and the manager said the pictures would be updated. We checked residents records during the inspection and in all cases needs assessments, and care summaries from referring agencies where appropriate, had been completed. From this information initial care plans had been completed so that all staff could be sure of peoples needs and how best to meet them. All the staff have completed basic dementia care training and the manager has completed an advanced course for providing dementia care. However, as the care staff provide all activities in the home, we had previously required that one of the permanent staff complete specialist training in dementia activity provision. This has not taken place and the manager is aware that future planning must include a wider range of dementia activity as more residents enter the home. However, a considerable amount of equipment appropriate for those who are confused has been provided for the home and care staff do endeavour to use this to provide stimulation for the current residents. The manager has provided a communal memory box aimed at stimulating peoples memories of past times. However, good practice shows that memory boxes are usually completed for each individual, and often fixed outside peoples bedroom doors to assist people who are confused to find their own rooms and remain as independent as possible. The manager will consider whether these Care Homes for Older People Page 13 of 31 Evidence: individual boxes would be beneficial to any of the present residents. An external visitor is also employed and visits the home twice each week to provide reminiscence sessions for residents. The manager has also provided the Commission with a copy of a dementia Development Plan for the home and this should be used in future planning for this specialist service provision. Care Homes for Older People Page 14 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. People who use the service have their health needs met in a timely and appropriate way and procedures followed for administering medication in the home is thorough and helps to protect residents from the risk of harm. Evidence: We spoke with and observed the residents in the home and tracked the corresponding care plans. All the care plans have now been rewritten and are now in a person centred format. Details of all individual needs and preferences have been recorded and family input has been made part of the planning in most cases. We saw appropriate risk assessments in place including management plans for how best to assist people to transfer. Monthly reviews are now well documented. We had been told recently about two residents who had each developed a pressure sore. One sore has now healed and the district nurse is treating the second wound. In both cases appropriate documentation showed the treatment and progress of the wounds. The care staff we spoke with confirmed that, currently, they use the hoist to transfer two residents and that two residents are turned by staff during the night. We saw details of this assistance recorded in the care plans and saw written evidence of the two Care Homes for Older People Page 15 of 31 Evidence: hourly night checks staff undertake for these residents. Sit-on scales are provided in the home and care staff confirmed everyone is weighed regularly and any weight loss is reported and action is taken. We saw that three residents currently have their food and fluid intake recorded and monitored to ensure their good health is maintained. Two residents have diabetes, the district nurse checks the blood sugar for one and the manager, who is a registered nurse, checks and records the sugar levels of the second resident. One of the relatives we spoke with during the inspection said that their relative had bad sores on their hands when they entered the home but that these had now healed. The relatives we spoke with during and after the inspection all said that the care their relatives received was excellent and that the residents health needs were always met in a timely way. We checked the system for administering medication and the storage and recording of the drugs was appropriate and we found no errors. The staff we spoke with confirmed that they can only administer medication in the home after they have been trained. We saw the record of names of staff who administer medication and all these care workers had medication administration training certificates on their staff files. The manager confirmed that she checks and signs off the competency of each member of staff to administer medication annually. We spoke with five relatives of people who live in the home, some on the day and some after the inspection. All said that their relative was treated with dignity, respect and great kindness at all times. The improvements seen in the care provided and in the records maintained must now be sustained and improved where possible for the benefit of present and future residents. Care Homes for Older People Page 16 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 who use the service are enabled to spend their days as they choose and are supported to maintain strong links with their families. Residents enjoy the food provided and this helps to maintain their well being. Evidence: During this visit we observed how people living in the home spent their time and spoke with some residents, although all current residents have a limited means of communication. We also spoke with five relatives who all said they frequently visit the home. The staff and manager confirmed that the external entertainers who had previously provided music sessions in the home were no longer visiting. The manager said that this is because the current residents did not enjoy this activity. We saw evidence that the external visitor who provides reminiscence sessions in the home is continuing to visit twice weekly. Other than this, all activities are provided by the care staff. From our observations, and from relatives comments it is clear that the present staff go out of their way to provide the daily activities that they feel people want and the residents we saw appeared happy during the inspection. Records are completed daily showing any activities that residents take part in. Most of the activities noted consist of listening to music, chatting, walking to their bedroom and sometimes being read to or playing cards. There were no entries seen recently of any planned or Care Homes for Older People Page 17 of 31 Evidence: structured activity sessions and no trips out or religious services had taken place. It is acknowledged that the information provided for us shows that the present level of activities is what is wanted by current residents. However, we discussed with the manager that, when more people enter the home, activity planning will need to reflect any of the additional social needs which are identified for new people, especially as the home is registered to admit people who are not confused and who may enjoy trips out and want more stimulation. Guidelines for providing good care in residential homes also suggests that gentle exercise is beneficial for all residents, including those who are confused, and the manager should consider how this activity can be successfully introduced in the home. We also asked about hairdresser visits to the home. The manager said that a hairdresser visits the home when asked, on an ad hoc or monthly basis. However the hairdresser does not wash residents hair but sprays the residents hair with water and cuts the hair when required. The manager said that care staff wash peoples hair in the home. Again, we suggested that the manager ensures that none of the current residents would enjoy having their hair washed and set professionally, as some residents would have had in the past, and also ensures that this facility is offered to any new resident who might enter the home. Since the inspection the manager has amended the homes Service Users Guide to show that everyones individual preferences and choices will be assessed on entering the home and that new services may be provided to meet these needs and these will be adaptable and flexible as appropriate. The relatives we spoke with said that they were welcomed in the home at all times and kept fully informed of issues and events in the home. Care staff told us that residents were able to get up and go to bed when they chose. During the inspection, one physically able resident got up and dressed independently and came from their room to the dining room mid-morning. Staff also said that families manage all their relatives finances and said that no money is held in the home for residents. We were told that some visitors buy their relatives toiletries and sundries and that the manager purchases toiletries for others and families are then invoiced for the cost. The manager must be able to evidence that people resident in the home are having input into these arrangements and receiving items of their choice. Such arrangements will also need clarification for any new residents who enter the home. During the inspection we saw the mid-day meal prepared and served. The menu for the days meals was displayed in the dining room in written and pictorial form to enable all residents to understand what they would be eating. We saw details of the Care Homes for Older People Page 18 of 31 Evidence: three weekly menu plan and, although no choices of meals are shown, staff said that alternative food is prepared if people do not want the main meal. Care staff said that one care worker asks residents what they want to eat the day before, and we saw records showing what people had eaten if this differed from the main meal. The care staff confirmed that all residents are weighed monthly and that any weight loss is monitored and acted on. Currently three residents have details of their food and fluid intake recorded to ensure adequate nutrition is maintained. During the morning we saw a tray of sectioned fruit taken round and offered to residents and saw staff frequently offer people drinks and cups of tea. We saw lists of residents food and drink preferences and needs displayed on the kitchen wall to ensure all care staff are reminded of individual needs as all care staff are involved with preparing the food in the home. Care Homes for Older People Page 19 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. People who use the service can be confident that any concern they might have will be listened to and that procedures followed in the home will help to protect them from the risk of abuse. Evidence: The home has written policies covering adult safeguarding, whistle blowing and making a complaint. We spoke with care staff and all were aware of these policies and were clear about their implications. Forms which can be used for anyone to make a complaint are displayed in the entrance hall and are available for anyone to complete. We checked the complaints record and no complaints had been made to the home. The relatives we spoke with confirmed that they were aware of the homes complaints procedures but had no concerns to express. Training certificates in staff records showed that all employees have completed up to date safeguarding training. The manager took part in a recent Local Authority safeguarding investigation, which showed that there were no concerns to consider about a specific issue. There is a continuing investigation taking place about the home under the Hertfordshire County Council Adult Care Services joint agency safeguarding vulnerable adults procedures. Care Homes for Older People Page 20 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. People who currently use this service live in a comfortable home where infection control procedures have improved and help to protect residents from the risk of harm. Changes to the environment will be needed to ensure new residents have all their needs met. Evidence: During the inspection we visited all areas in the home. Everywhere was warm and clean and we saw the recorded checks which are regularly made by staff and which show that hot water is being delivered at appropriate temperatures. Some of the bedroom furniture in residents bedrooms is looking quite tired and some furniture and fittings will need replacing before too long. Many of the bedrooms have been fitted with laminate flooring, which the staff said is suitable for most of the present residents who all have some levels of incontinence. However the manager is aware that any future residents need to be given a choice of flooring for their bedrooms. The manager confirmed that empty rooms are decorated before new residents move in. We visited the laundry and saw the sluice washing machine in use. We saw supplies of red alginate bags for use with soiled laundry and saw the supplies of disposable gloves and aprons, all seen as essential for maintaining good infection control. The staff we asked confirmed that the bath is decontaminated between uses and all communal bathrooms and toilets contained liquid soap and paper towels, also recommended for Care Homes for Older People Page 21 of 31 Evidence: good infection control. As required at previous inspections, the manager has now obtained a copy of the publication, Essential Steps, and has completed the audit tool included in the document. This ensures that staff in the home are following good infection control procedures for the benefit of the residents. This has been an on-going area of concern and it is positive to note that appropriate action to address this has now been taken. We saw the report from a recent visit made by an occupational therapist about the ground floor bathroom. Currently the manager has arranged for the bathroom door to open outwards and a curtain has been installed just outside. This is so that there is more room for staff to assist residents who need a wheel chair to get to the bath and who need assistance to transfer to the bath hoist. However, care staff told us that it is still difficult to assist people in this space when two care staff are needed and residents need to use a wheel chair and the hoist. The manager said she is considering the options suggested by the occupational therapist and will be making decisions about adapting the bathroom soon. The homes Statement of Purpose and Service Users Guide lists the home as having two bathrooms with toilets. However, one of these bathrooms is on the first floor and adjacent to a bedroom which is currently unoccupied and away from the remaining bedrooms. It is not an assisted bathroom and is currently used by staff and visitors. If the home was full, there would only be one assisted bathroom, on the ground floor, for twelve residents. The manager is aware that a decision must be made about bathroom facilities in the home and especially about the bathroom and adjacent bedroom set apart from the other rooms on the first floor. The Statement of Purpose and Service Users Guide must also be amended to show accurately what facilities are in place for people who may want to use the service. Since the inspection the manager has amended the homes Statement of Purpose and Service Users Guide to show that currently there is only one assisted bathroom for residents use in the home. Care Homes for Older People Page 22 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. People who live at the home have their needs met by a professional and well trained workforce. Procedures for recruiting staff are now thorough and help to protect residents from the risk of harm. Evidence: During the inspection we observed staff interaction with the residents, all of whom have some level of confusion. We also spoke with relatives during the visit and after the inspection. It is clear that the present staff group are very aware of peoples individual needs and know how best to meet these needs. We saw that relations between staff and residents are very good and the residents clearly trust and feel confident in all the staff and the manager. We checked the staff roster and saw that there were always at least two members of staff on duty at all times and that often the manager is supernumerary to these staff. The care workers we spoke with confirmed that there are always two waking night staff on duty. The manager said that the senior who was employed at the home, now works as a bank worker when needed. We also noted that agency staff had been used to cover some work shifts. Since the last inspection three new care workers have started work at the home. These staff are from abroad and are students. We checked the staff rosters and spoke with the staff and they confirmed they were now working the appropriate hours to comply with their student visas, although they had previously been working for longer Care Homes for Older People Page 23 of 31 Evidence: times than they were allowed to. The manager said that the working hours on these students staff contracts would now also be amended. The new staff confirmed they had received induction training and we saw records of this on their staff files. The care workers also said they received pay slips with appropriate deductions recorded and one who currently lives in the accommodation at the home, has their rent deducted at source and shown on their pay slip. We checked all the staff files and saw evidence that all basic training, seen as essential to a care workers role, had been provided. This training included courses on dementia care and Equality and Diversity. The manager had arranged for all staff to receive training in the Mental Capacity Act and its associated regulations on the afternoon of the inspection. Because of our visit, the training was postponed for another week. We also saw evidence that staff received regular supervision with the manager. Currently three members of staff have completed NVQ2 training and the five part time staff are all doing NVQ3 training. We checked the recruitment files for all the staff. We saw the student visas of the new staff and their student contracts with a local college. We had made a requirement at the previous inspection that the manager obtain evidence of one member of staffs right to work in the country. The manager said that this persons passport was currently being amended by the Home Office and evidence would be sent to the Commission when it was available. We saw evidence that all other recruitment checks were in place for the current staff. We have awarded a rating of adequate for this standard as it has taken over one year for the current good recruitment practice to be established and this good practice must continue over time to ensure the protection of the residents in the home. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have their views reflected in the running of the home and procedures followed by staff ensure that good health and safety practices help to protect people from the risk of harm. However, people cannot yet be assured that the manager will be proactive in ensuring all legislative and regulatory guidance will be followed in a timely manner at all times. This could mean that people who use the service do not always receive good outcomes. Evidence: Since the last inspection the manager has worked to ensure that the outstanding requirements made at previous inspections have been met. However, at the previous random inspection visit, made in December 2009, there were still requirements outstanding which had not been addressed, despite being highlighted on several occasions. In particular, shortfalls in staff employment checks, essential for the safety of residents in the home, had been highlighted, but compliance has only been completed by this visit. Issues affecting good infection control have also taken a considerable time to be addressed. We have also continued to recommend that a Care Homes for Older People Page 25 of 31 Evidence: member of staff is trained as a dementia specialist for the home. The manager has provided written planning for the Commission showing how training for this specialism would take place. However this training did not take place and the Journal for Dementia Care and other planning seen in the homes Development Plan for dementia care has also not been actioned. Thus, a concern still exists that the manager is not proactive in ensuring essential standards are met in the home, but only reacts when the Commission or other agencies are checking service provision. The manager must continue to demonstrate a proactive approach to managing a care service and must ensure she keeps up to date with all current legislation and good practice recommendations for care provision. In the near future the manager will need to decide on future planning for the home so that, as the empty rooms are filled, people have their varying needs met in an appropriate way. Services offered to people and facilities provided must be clearly set out in the homes Statement of Purpose and Service Users Guide. As already described in this report, adaptations and decisions need to be made to and about the bathroom facilities in the home and planning for activities and specialist activities must be made to ensure that any new residents are able to have all their social needs met. The manager is aware that this planning is now needed. As noted already in this report, since this inspection the manager has amended the homes Statement of Purpose and Service Users Guide to clarify the situation regarding service provision in the home and has shown that there is one bathroom available for the people who use the service. The manager has introduced quality surveys for residents and relatives and we saw completed forms and their positive comments during the inspection. We also saw the minutes of recently held residents and relatives meetings and again no concerns had been raised and everyone said they were happy with services in the home. There is also a Comments Book in the hall and in this we saw a large number of signed comments made by visitors to the home. All comments were positive and showed satisfaction with the services provided. In one planning document the manager had told the Commission she will provide information about advocacy services for any residents who might need this. This information should be provided and included in amendments made to the Service Users Guide. During the visit we checked the fire safety records for the home and all details had been appropriately recorded. Staff confirmed they had taken part in a fire drill recently Care Homes for Older People Page 26 of 31 Evidence: and the home has a written fire safety policy. The manager has now completed a written policy on Infection Control in the home and we saw this during the visit. The front door key, to open the door from the inside, is now hanging on a hook over the door and is easily accessible to staff in an emergency. We saw no hazardous substances left accessible to residents during the inspection but call alarms, where appropriate, were accessible in residents bedrooms. Risk assessments have been completed for the use of recliner chairs in the home, for the safety of the residents. We also saw that electrical appliance testing and hoist servicing has also taken place at appropriate times in the home. Care Homes for Older People Page 27 of 31 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 26 13 Red alginate bags must be available in the home at all times and used for all soiled laundry. This is to ensure good infection control is maintained in the home. 08/01/2010 2 26 13 An up to date written policy 08/01/2010 on good infection control in the home must be available at all times together with the publication Essential Steps and the corresponding infection control audits must be completed. This is to ensure that people living in the home are protected from the risk of the spread of infection at all times. 3 29 19 Evidence must be provided and kept of the status of all staffs right to work in the home before employment commences. This is to ensure that all staff are fit and legally able to work at the home. 08/01/2010 4 30 18 All staff must receive training 08/01/2010 in, and understand the implications of, the Mental Capacity Act and Deprivation Page 28 of 31 Care Homes for Older People 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 of Liberty legislation. This is for the continuing protection of the rights of people living in the home. Care Homes for Older People Page 29 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 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 32 The manager needs to establish a future plan for the home which sets out the homes aims and purpose and demonstrates how the home will be developed and what the future staff structure of the home will be so that any new residents can be clear about how their needs will be met. 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. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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