Care Home: Lowmoor Care Home

What the care home does well Since the problems at the home were identified at the beginning of this year, some progress has been made by the people responsible for the running of the home, monitored and supported closely by the statutory agencies, in all areas of operation. Throughout this time people living at the home have continued to be cared for by staff who are knowledgeable about their needs and who are very committed to making sure that the best care is provided. The legal requirements for improvement made at the Random Inspection in September have been met and the things are now starting to work better than they were when contracts were suspended in August. With the help of professionals from the Council and PCT the documentation that supports staff to care properly has been reviewed and instances of poor practice have been responded to and put right. People`s needs are assessed when they come to live at the home and the actions staff need to take to care for them properly are laid out in detailed care plans. The day to day lives of people at the home have been enhanced by a range of activities and leisure pursuits, and individual preferences have been looked at by the activities coordinator to make sure that things are right for everybody. The home has continued to provide a choice of meals and people told us that they are very satisfied with the food provided and that their individual preferences are recognised and respected. Morale amongst the staff group is improving from a low point when the last registered manager left in August, and staff told us that, because staffing levels have been retained to match the level of need amongst the people living at the home, their working day is less hurried, better planned and they have time to talk to people. Staff recruitment systems have been brought back into line with company requirements and the right people are being employed to work there. What has improved since the last inspection? The key area that has supported the improved performance of the home has been better communication at all levels and a much more open and supportive style on the part of the people responsible for running the home; staff told us that the management consultants brought in to run the home on an interim basis and, in turn, the newly appointed manager `have worked hard to turn things around`. All of the requirements made as part of an earlier Improvement Plan were complied with when we made the two recent Random Inspections and this progress formed the basis of the staff`s positive comments. Of particular note is the improved standard of reporting and recording untoward incidents at the home and improvement in response to the safeguarding needs of people. What the care home could do better: We have made a number of legal requirements at this inspection, the most concerning of which relates to continued poor management of medicines which was previously notified to us as a problem in September of this year. We have also made requirements in relation to the homes assessment and care planning documenation and processes, staff training in relation to safeguarding the vulnerable people in their care, the laundry service of the home, staff recruitment, training and support and the overall need for the people responsible for the running of the home to monitor and respond to the standards of quality within the home`s services. We have also recognised that the new manager needs to register with us as is required by law.The identification of these issues at this inspection is reflected in the new quality rating that we have made for the home, whichis lower than that made at the last Key Inspection. Key inspection report Care homes for older people Name: Address: Lowmoor Care Home Lowmoor Road Kirkby In Ashfield Nottinghamshire NG17 7JE     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: Brian Marks     Date: 0 2 1 2 2 0 0 9 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 36 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 36 Information about the care home Name of care home: Address: Lowmoor Care Home Lowmoor Road Kirkby In Ashfield Nottinghamshire NG17 7JE 01623752288 01623752288 Lowmoorcarehome@msn.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Lowmoor Nursing Home (Kirkby) Limited care home 50 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home Lowmoor is a privately run, purpose built two storey 50 bedded care home for people with dementia and mental heath needs. Qualified nursing care is provided throughout the 24 hour period. The home is situated in a semi residential area within half a mile of local amenities and the town centre of Kirkby in Ashfield. It can accommodate up to 50 people in 40 single bedrooms and 5 double bedrooms; 10 of which are en-suite. However, it has been the recent policy of the home to only offer single accommodation so the current maximum people living at the home would be 45. The home has an enclosed garden and a car park for visitors and staff and there is a passenger lift linking the two floors of the home. There are lounges on the ground and first floor and bathrooms are fitted with adapted facilities. Care Homes for Older People Page 4 of 36 Over 65 0 50 50 0 2 5 0 8 2 0 0 9 Brief description of the care home Information about the service is provided in the statement of purpose and service user guide, which are given to people at the start of their stay at the home. Care Homes for Older People Page 5 of 36 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: This was a Key unannounced inspection that took place at the home over two days. We were accompanied on the inspection by our pharmacy inspector and another inspector who spent an extended period of time observing the care being given to a small group of people in one of the lounge areas. This inspection was carried out to follow up a Random Inspection on 30th September 2009 which occurred after urgent meetings and discussions that we had had with professionals from the key authorities who are responsible for financial sponsorship of people living at the home, Nottinghamshire County Council and Nottinghamshire Primary Care Trust (PCT). They had become very concerned with aspects of the way the home was being run, so much so that these authorities had suspended contracts with the homes owners in August 2009. We also carried out an earlier Random Inspection on 24th August 2009 because of the same concerns. Time was spent in preparation for this visit, looking at key documents such as previous Care Homes for Older People Page 6 of 36 inspection reports, records held by us, and the written Annual Quality Assurance Assessment document (AQAA), which was prepared and returned to us by the previous Registered Manager before the inspection. For administrative reasons we did not receive any written surveys sent back to us before the inspection. All of the above material assisted with the preparation of a structured plan for the inspection. At the home, apart from examining documents, files and records, time was spent speaking to the homes owner and the newly appointed manager who were there throughout the visit, and a number of staff working on the day shifts. As there were thirty two people living at the home at the time of the inspection, we looked at the care records of four of these in detail. We also interviewed personally a number of relatives and visitors who were at the home during the inspection. The assessment was made against the key National Minimum Standards (NMS) identified at the beginning of each section of this report, as well as other Standards that were felt to be most relevant. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? What they could do better: We have made a number of legal requirements at this inspection, the most concerning of which relates to continued poor management of medicines which was previously notified to us as a problem in September of this year. We have also made requirements in relation to the homes assessment and care planning documenation and processes, staff training in relation to safeguarding the vulnerable people in their care, the laundry service of the home, staff recruitment, training and support and the overall need for the people responsible for the running of the home to monitor and respond to the standards of quality within the homes services. We have also recognised that the new manager needs to register with us as is required by law. Care Homes for Older People Page 8 of 36 The identification of these issues at this inspection is reflected in the new quality rating that we have made for the home, whichis lower than that made at the last Key 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 36 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 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not everybody living at the home has had their needs clearly identified and for some people their legal rights have not been clearly established. Because not enough attention is paid to their social world and background history a person centred approach to care is not being achieved for everybody. Evidence: In the AQAA we were told that the homes Statement of Purpose indicates that the home can meet the needs of prospective residents by providing a safe, homely and multi sensory environment with sensitive care planning and using staff who collectively have the skills, expertise and experience to care for people suffering from dementia, mental illness or challenging behaviour. We were told that people are invited to visit the home in order to make a preliminary decision and this can be followed by a trial period when the assessment process begins. The latter is carried out by experienced senior staff and information about the person is obtained from all relevant professionals, particularly from the sponsoring social worker if there is one. Care Homes for Older People Page 11 of 36 Evidence: The home sometimes accepts people in emergency situations but does not provide intermediate care. At the time of this inspection there was agreement between the homes owners and the main statutory agencies that no new admissions to the home would be arranged, and contracting arrangements were suspended. This has been the state of affairs for some months and follows the identification of serious concerns about the homes ability to provide care and safety to its vulnerabe residents. Because of this we were not fully able to assess the key standards of this section but we were able to reach conclusions about the overall picture. We have recently carried out two Random Inspections of the home and during the first we looked at updated copies of the homes Statement of Purpose, Service Users Guide and Admissions Policy and Procedures. We had required that these be extensively revised so that the criteria for admission to the home were explicit and everybody involved with making an application for accommodation and care at the home could be clear about their rights and responsibilities, and about the capability of the home and its staff to provide the right forms of support. We found that these had been updated to a satisfactory extent. For the purpose of this inspection we looked at the care records of four people living at the home, all of whom had lived at the home for some months or years. Within these records, there were documents that indicated that an assessment of the physical care needs of the person concerned had been carried out, although these had been written up in varying degrees of complexity. One had an assessment from a social worker and brief summary notes of their condition. A second record held a detailed record of the persons medical condition and the problems this presented. A third held documents and transfer assessment details from another setting. The fourth held documents that indicated a reassessment of their needs had taken place as recently as September 2009. Three of the records held assessment documents that related to peoples ability to make decisions for themselves under the Mental Capacity Act, which will help make sure that peoples interests are fully protected. However these were confusing documents and it was not clear from any of them if a conclusion about capacity had been reached. Similarly in two of the files there were documents, one very lengthy, that indicated considerations being made with the Local Authority under Deprivation Of Liberty Safeguards, but again the outcome of these were not clear and did not explain in detail any limitations that may have been agreed. The information in the care records had been obtained from the person concerned, from their family, or from outside professionals such as the family doctor, hospital ward staff, social worker/care manager or healthcare therapists. All of care records looked at contained a recent photograph of the person concerned, as well as varying amounts of personal information and signed consent forms, which indicate personalisation of peoples Care Homes for Older People Page 12 of 36 Evidence: records. However none of the records looked at contained anything more than brief amounts of information about the psychological and social worlds of the people concerned, which does not support person centred care for everybody living at the home. All of the care records looked at contained a set of assessments of the general and specific areas of risk that are relevant to the individuals concerned, such as bed safety, safe manual handling, skin breakdown and pressure areas, falls and nutritional difficulties. Some, but not all, indicated high areas of risk and these were directly linked to actions for staff to take when providing care and described the detail of how staff work safely and consistently, and maintain the persons welfare whilst living at the home. Not all of these risk assessments had been looked at regularly to make sure that the information being used by staff is current and that the level of risk has not changed. Care Homes for Older People Page 13 of 36 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 people living at the home have care and risk assessment records that support safety and consistency, but these are inconsistent in standard and do not support person centred care. There were serious flaws in the management of medicines that compromised the safety of people living at the home. Evidence: In the AQAA we were told how the assessment of needs leads to the plan of care which aims to meet the needs of the individual, covering all aspects of health, personal and social care. It should reflect preferences, choices, likes and dislikes and expectations of their lives. People and their families are involved in this process and senior staff at the home review the care plans monthly. We were told about arrangements for health care at the home, involving the homes staff and professionals from outside, and also about arrangements to look after peoples medicines and for any special eqipment they may need. We were assured that the dignity and privacy of everybody is promoted at all times. All the care records that we looked at contained descriptions of the areas where Care Homes for Older People Page 14 of 36 Evidence: people need help or where they experience risk, as well as the areas in which they are independent, and the care and nursing activities to be carried out by staff are identified in a number of areas. For the records we looked at these amounted to at least twelve areas and in one case sixteen; these were all very extensive documents. The specialised feeding arrangements for one person were described in detail, and for another there was a detailed description of the arrangements for 1 to 1 staff support that allowed for his difficult behaviours in public to be managed safely. In all of the records examined the various elements of the care plans had been reviewed completely during August and September 2009 and the manager described this process taking place for everybody living at the home. This had occurred because it had been identified by visiting health and social care professionals that care records had become badly out of date and working practices were in danger of becoming seriously unsafe. The suspension of contracts resulted from this disclosure. No further reviewing work has been carried out, although we we did note in one record that care activities had been rewritten within a new format as circumstamnces had changed. The manager informed us that the change to new documentation was planned for everybody and would involve serious editing of the content of all care plans. As referred to above, the descriptions of social interests and life histories were generally brief in all the records we looked and, although the care plans were comprehensive and well laid out, they were traditional in style and much of the activities of staff were described in terms of problems and needs rather than in ways that promote a person centred approach to care. Discussions held between the key agencies and the homes management during the time since concerns were aired about the homes performance, and contracts suspended, highlighted key areas of poor care practices amd recording of outcomes for a substantial number of people living at the home. At the last such meeting in October 2009, improvements were noted in reports from visiting professionals and these meetings were felt to be no longer needed. Officers from the contracts section of the local Council and the Health Service had visited the home in November 2009 and they spoke to us during the inspection. They had noted specific problems with the care for two people and, from discussions with senior staff and looking at care documents we were able to cnfirm that things had been put right. Staff told us that whilst they consult care plans for information about people living at the home, other communications systems such as daily diaries and shift handovers are the key to managing work on the daily shifts. We were also told that work carried out by the management consultants who were running the home before the appointment of the new manager were good in reestablishing proper day to day care and getting recording systems back in place. We found that records on individual files were up to date and informed the outcomes of care practices. The observations made by us Care Homes for Older People Page 15 of 36 Evidence: around the home during the inspection, the comments received from staff, people living at the home and relatives and information given to us before the inspection from the representatives of the key local statutory agencies indicate that the home has made progress in putting things right, but that there was still progress to be made. We observed that the routines for providing care in the early part of the day worked well and everybody who needed to be up had had their breakfast by 10:00 am; this had been a particular issue previously commented on by visiting professionals and was one of the factors that told to us how the home was performing at that time. The care files we looked at indicated the medical and health needs of people living at the home being regularly monitored, and also of visits by outside professionals such as G.P, chiropodist, optician and dentist. We also noted specialist support being arranged with visits to or by the psychiatrist, speech and language therapist, breast screening and oxygen clinics. Additionally in the written records, from the direct observations of the communal areas and from what people told us, it was clear that the staff at the home work hard to care in sensitive and dignified ways, and within the confines of the home to keep people independent. One person told us that their privacy was respected, that they held the key to their room and were able to have a bath each day. Staff told us that we try and treat people as you would your own and that staffing levels mean you have time to treat people properly and not to rush things. All the staff we spoke to said that they carry more responsibility and are more accountable for their actions and that this is particularly true with recording responsibilities. One of the carers told us were working well together now and better communication and handovers have improved everything. A full inspection of medicines practice was carried out with our pharmacy inspector. We looked at storage facilities for medicines and a sample of medicine charts and found medicines were stored in locked medicine cupboards and trolleys. However we found that a medicine for one person was stored with medicines belonging to someone else. The medicine refrigerator could not be locked and records suggested that medicines in the fridge were not always stored at the correct temperature. We found that one person had not received one of their medicines for four days as staff could not find the medicine container. When we looked at medicine charts we found a number of instances where the administration record had not been filled in, and occasions where the reason for a medicine not being given was not recorded. We also found two discrepancies between the number of tablets signed for as administered on a persons medicine chart and the quantity of tablets left in stock. We were pleased to note that the manager had started to address some of these issues before the inspection had ended. Care Homes for Older People Page 16 of 36 Evidence: We also watched medicines being given to people after lunch. We saw that people were treated with respect and that medicine charts were signed after people had taken their medicines. However, medicines were not always locked up when the person administering medicines moved away from the medicine trolley. One medicine that was prescribed to be taken on an empty stomach was administered an hour after lunch. We saw that a copy of the medicine policy was on display in the medicines storage room, but were told by the manager that this was not the up-to-date version of the policy. We saw that a record is kept of the disposal of medicines but found that medicines are not disposed of promptly when no longer required. We found that the receipt of medicines in the last month had been recorded but any medicines remaining from earlier months had not been counted and recorded. This meant that medicines could not always be accounted for. Care Homes for Older People Page 17 of 36 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 at the home enjoy lifestyles and routines that suit them and have good opportunities to take part in organised leisure and social activities. Evidence: In the AQAA we were told about the range of activities that take place at the home and how special occasions such as birthdays are celebrated for all who want to. We were told about the importance of retaining contact with community life and about outings that people have taken part in and visits to the home to support church attendance, by the mobile library and hairdresser. Contact with families is encouraged and family members are encouraged to join in with the life of the home. During the inspection we spoke to the homes activities coordinator who works on a full time basis. A schedule of events for the month of November was on display which anyone could take part in, and there were also some people in the home who had dedicated one to one staff time to help them participate in activities individually or with the other people living there. These are funded by statutory agencies. During our visit a sing along session was held which people told us they enjoyed, and we spoke to staff about activities and what was on offer. They told us that regular activities included reminiscence, bingo, chair based exercises, music and baking. Where people Care Homes for Older People Page 18 of 36 Evidence: were not able to join in general activities or chose not to, staff told us individual time was spent with people, doing nails, talking or reading newspapers to them as well as spending time in the sensory room if people liked this. We were told that peoples religious needs were met in the home by visits from local clergy who offered communion to residents if this was important to them; staff were able to tell us who valued this and usually took part. A hairdresser also visited each Wednesday to attend to peoples hair, and this service is very popular. Our observational inspection informed us there was a lot of interaction between the people living at the home and its staff. Whilst largely these were discussions, banter and exchanges between them, others communications were less interactive. Some residents at times shouted out and appeared restless and whilst staff did frequently ask are you alright, whats the matter this was mostly at a distance and no direct approaches that waited for a response from the person were seen. Our main conclusion from this exercise was that the people who were more able to communicate had more staff time spent with them chatting and playing cards or dominoes. There were photographs on a board which showed different events that had been celebrated such Halloween, Easter and peoples birthdays, and there was an orientation board in place which informed people of the time, date and weather. Fundraising events had been held which included a Summer Fayre, and a Christmas Fayre was planned. Staff told us that peoples birthdays were always celebrated with a cake and a gift. We noted that the home had some pets, including a large fish tank in each lounge and two budgies. One resident seemed visibly more relaxed when watching the fish than they had earlier in the morning. We spoke to some relatives during our visit who said they were always made welcome and offered a drink and occasionally a meal. Relatives also told us that the home communicated well with them if there had been any accidents or illnesses affecting their relatives. We observed lunch served where a choice of meals was offered to people and, where people needed help, staff were seen to individually sit with them with them to offer the assistance they needed. Each person had a drink of their choice and where people asked for something different this was provided to them. Each person has different portion sizes and used cutlery appropriate to their skills to eat independently wherever possible. One person told us that cooked breakfasts were offered 3 times each week but they would like this more often. Care Homes for Older People Page 19 of 36 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 home responds to complaints made by residents and their representatives according to a written procedure, and the systems have been improved so that they are protected people from harm. However staff have not received any recent training to remind them of their responsibilities to recognise and report suspected abuse. Evidence: In the AQAA we were told that complaints are seen as an opportunity to learn, adapt, improve and provide better services and that any complaint is taken seriously and processed properly. We were told that the complaints procedure is contained in information given out to people and is also displayed at the home. We were also told about policies and procedures, arrangements around the building and staff training that are in place to ensure peoples safety and to protect them from harm. We were told by the homes owner that there had been no formal complaints recorded since the last key inspection of the home and that informal complaints are recorded on individual files. The relatives we spoke to told us they did know who to approach with complaints and examples were given to us where they had asked staff to look for missing clothing although no records of these concerns were seen. We noted that details of the complaints procedure were on display in the entrance hall and included in the homes Service Users Guide. Since the last key inspection there have been a higher than average number of Care Homes for Older People Page 20 of 36 Evidence: situations reported to the Adult Social Care Department of Nottinghamshire County Council under safeguarding procedures, and these were the core subject for discussion at the multiagency meetings referred to above. These were all investigated by officers from the statutory agencies with the full cooperation of the homes management and involved failures in care and medicines systems as well as incidents between people living at the home. It was noted at the time of these investigations that the reporting of incidents did not follow the accepted route and records were not being properly maintained for internal and external audit and monitoring. The investigations have now been concluded and we received information at the last meeting that all the required actions had been taken by the home to get things right and that care plans have been changed to ensure that staff always act in safe and consistent ways. We noted at this inspection that the recording of incidents is now very thorough and that the pattern of their occurrence has reduced. The staff we spoke to knew about the safeguarding adult procedures and a signed sheet in the office confirmed they had read the procedure. The staff told us they would report concerns to senior staff if they had any. However staff training records were unclear about the occurrence of any recent formal training in this subject. The manager informed us that everybody would be receiving a relaunched training programme in December; this was a requirement made at the last Random Inspection of the home. The policies and procedures in place are in line with the statutory procedures on safeguarding vulnerable adults and these had were revised earlier in 2009 to eliminate any confusion from the homes dealings with the different statutory agencies involved. Care Homes for Older People Page 21 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is purpose built and standards of maintenace, decoration and physical comfort have been reestablished after problems had been identified by visiting professionals. Whilst the laundry service is generally efficient problems routinely occur to reduce resident comfort, dignity and hygiene. Evidence: In the AQAA we were told that the home provides private single accommodation with good furnishings and decor, giving it a homely look. The facilities were described in full and we were told about maintenance, planned refurbishments, fire safety and other services available to make the home as homely and safe as possible. During this inspection we noted that the home is purpose built with lounges and other communal areas on both floors. Two lifts were available to assist people with mobility problems move around the home and the decor and maintenance of the home was in generally good order. There were some sensory stimulating pictures and wall sculptures around the home with different textures and moving parts that encouraged people to touch and feel them. Some picture signage on toilet doors was also in place to aid orientation. Pictures from a bygone era of movie stars were on the walls and the music played in one lounge was suitable for the age group of the people in the home. However we noted that the television was on in one lounge despite no one watching it. An addition to the home since our last visit was also a small sensory room with fibre Care Homes for Older People Page 22 of 36 Evidence: optic lights and sensory stimulating equipment. Staff told us that some people liked to use this room to relax and it was mainly used for individual sessions with staff in support. Each persons bedroom that we viewed had personal possessions in them to make them homely. One relative told us that brightly coloured wall murals had been placed at a suitable height where the person could see them. There are some double rooms in the home but these were currently being used for single occupancy due to market preferences for this. We noted throughout the day of the inspection that staff appeared to routinely lock bedrooms when people were not in them but also for two peole this occurred when they were still in occupation. We found that two people held the key to their rooms but other people had to ask to be let in by staff. Staff also told us that some people liked the room door to be locked when they were resting in their rooms. The reason we were given for locking of rooms was to stop some individuals wandering into other peoples rooms and taking or damaging their property. However the practice is restrictive for people living in the home. We could find no reference to these arrangements in the relevant care records we looked at, nor any general or specific assesment of the potential risks involved. One small dining room on the first floor was also locked when not in use therefore restricting people from using this room. A member of staff we spoke to who had returned to work at the home after some years absence told us that I dont understand why there are all the keys being used now. We never used to do this and the people living here are not that very different from before. We saw some specialist beds and equipment in use and relatives told us they had been consulted about the use of some equipment such as bedrails. We also saw relevant assessments of the risks from using specialised equipment, retained on the care records of the person concerned. From our tour of the building we found the home to be largely clean apart from one toilet. Staff attended to this quickly to ensure this was cleaned. Relatives we spoke with told us they found the home to be clean and fresh and staff told us that gloves and aprons were available for them to use. We noted that aspects of infection control practices had scope to improve as there were some toilet and bathroom areas with no waste bin or with bins with no lids. In one toilet it was not possible to get to the hand wash basin as a hoist and slings was being stored in the toilet. The kitchen staff talked to us about the Environmental Health Officers report and told us that the findings had been actioned which included a new refrigerator. The laundry was equipped with a good range of functioning washers and dryers and we were told by staff that all of the laundry was completed each day by dedicated Care Homes for Older People Page 23 of 36 Evidence: laundry staff. However two different relatives we spoke with told us of mix ups and loss of clothing and it was pointed out to us during our visit that one person was wearing another persons cardigan and another relative said they had tidied out a wardrobe and found half a dozen items or so which didnt belong to their relative. We were told that by one relative that laundered clothing was clean but another said sometimes stains were still evident. Staff told us there was sufficient bedlinen and towels in the home but that a completely new batch had been recently delivered. Care Homes for Older People Page 24 of 36 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. The home has adequate numbers of staff to carry out the physical care needs of the people living there but they have not been recruited and trained to do their jobs properly and in a professional way. Evidence: In the AQAA we were told about arrangements for the homes staff regarding their induction, training and supervision. We were also told that a lot of staff have worked at the home for long periods of time and how they are very committed to the home and the care being given. Trained staff are available to support care being given and all the staff are encouraged to air their views at regular staff meetings. As we have noted elsewhere in this report the raising of concerns about the homes functioning resulted in the suspension of contracts with the statutory agencies and of further admissions to the home. There has been a steady decline in the numbers of people living at the home, which numbered 32 at the time of this visit. From our discussions with the homes staff and managers and from feedback from some of the people living at the home and their relatives, we have been told that the home is functioning at an improved level and peoples needs are generally being attended to. We looked at the duty rosters for nursing and care staff and found that stability had been regained with minimal use of agency staff and sufficient numbers deployed on both floors of the building. There were two qualified staff on the day shifts with the Care Homes for Older People Page 25 of 36 Evidence: manager in attendance during weekdays; she told us that she works hands on during unexpected shortfalls. We also noted that at the present time there are usually eight or nine seniors and carers during the day shifts and a separate group of staff covering the night shifts. Most staff have opted to work long twelve hour shifts and those we spoke to did not find any problems with this arrangement. They also told us that the way they are deployed to work the whole shift on one floor has resulted in better continuity and a more satisfactory way of working. We also noted that there are currently four care staff on extended sick leave and staff have been recruited in their place on temporary contracts, until the position is clarified. The qualified staff group has been the one with most changes recently and the homes owner has seen recruitment here as a priority so as to avoid using too many agency staff. New staff have been appointed and they have a range of different qualifications to give an improved skill mix. The home has used some agency nurses and carers on occasions to maintain staffing levels but staff told us that wherever possible the same staff were used to improve the continuity of care. Staff also told us that there were occasions when staffing levels fell due to sickness or holidays but that it had been better lately. We were told that the people who required one to one staff time always had this and their staff were arranged on a separate roster. However when staffing levels were lower than usual this impacted on the staff available for the majority of people in the home. The staff we spoke with demonstrated a good knowledge of people in the home and their needs, for example knowing one person didnt like noise and knowing that some people liked to be independent wherever possible. One relative told us they felt there was always enough staff on duty. The staff we spoke to said that opportunities for training had occurred in the past but that training has gone on the back burner since August and is not so prevalent recently. We looked at the staff training record and this indicated up to date achievements in safe manual handling and emergency first aid, but shortfalls in dementia care awareness and substantial shortfalls in food safety, infection control, managing challenging behaviours and supporting people with mental health problems. A programme of awareness about the implications of the newly introduced Mental Capacity Act has almost been completed. The AQQA told us that the national target for care staff achieving the National Vocational Qualification (NVQ) level 2 has been reached and this was confirmed by the records, which indicated 15 out of 22 care staff passed at this level and a further 3 completing at level 3. The file of two recently appointed carers indicated that they had been subject to a basic programme of induction to the work of the home but that a more extensive workbook remained unused. The files of two recently appointed staff that we looked at supported that their Care Homes for Older People Page 26 of 36 Evidence: recruitment had been carried out in systematic way and checks by the Criminial Records Bureau (CRB) had been carried out. However neither contained a written reference about past employment performance or an indication that an overall assessment of their suitability had been carried out if the latter were not available. As at the previous inspections we were impressed by the attitudes and honest reporting from the homes staff. They spoke frankly about the difficulties they had faced throughout most of 2009 and how they had been left in the lurch by management in the past when they would always pass the buck and not deal with things. All those that we spoke to told us positively about the current operation of the home and how theyre trying to turn it around and restore the homes reputation and that were now moving forward. They talked about increasing levels of responsibility being given to seniors and carers, that teamwork and morale is slowly improving. They told us and that the homes new senior staff were very approachable and that management is responsive and much needed leadership is now being provided. Care Homes for Older People Page 27 of 36 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 management of the home is improving but there are not systems in place to ensure that quality of the homes services are managed properly and the health and welfare needs of the people living there are safely met. Evidence: The Annual Quality Assurance Assessment (AQAA) document that we have been quoting from throughout this report was prepared by the previous Registered Manager and is perhaps less relavant to this section, which aims to describe current arrangements for the running of the home. The propretor has owned the home for many years and is a senior medical practicioner whose speciality is the care of older people, particularly those with mental ill health. The previous Registered Manager left the home in August 2009 and the proprietor had transferred the manager of another of his homes on a temporaray basis at this point, when serious concerns about the running of the home were identified by the statutory agencies. Contracts for new admissions to the home were suspended at this point. A new manager was appointed in September, only to be relieved of her duties after a very short tenure following the Care Homes for Older People Page 28 of 36 Evidence: discovery of serious problems with the management of medicines. A further consultant manager was appointed at this time, again as an interim measure, and both were given the brief to urgently get the homes care and safety systems in order. These two interim managers have carried out the review of all of the care plans of people living at the home and as a priority addressed communication systems between staff so that care practices were correctly followed through and properly recorded. Staff we spoke to told us that the interim managers were good in establishing proper standards of day to day care; these had been allowed to slip badly and that they got the foundations right so we could all go in the right direction. The new manager was appointed in early November and the two interim consultants have largely relinquished their roles at the home. The former has extensive previous experience of running care homes before she came to Lowmoor, had been registered with the Commission during that time and has achieved a number of nationally recognised managers qualifications. She was present throughout thes inspection, along with the proprietor and another of his colleagues who may be assisting with the development of the home. In the short time that the new manager has been at the home she has made a positive impact and was seen throughout the inspection working directly with staff and residents and demonstrating a very hands on approach. Staff told us that we are now getting the leadership that was needed and that is better for all of us, the new manager has made a positive impact in a short time; she has her finger on the button, the new manager is very personable and doesnt lack people skills, and the new manager is always working the floor, shes like a breath of fresh air. Relatives we spoke to made positive comments about the running of the home but there have been no recent meetings where they or people living at the home have been able to speak as a group about how things are going. Although staff told us that day to day suppport with problems was good, none had had any recent individual meetings with the managers or senior staff and discussions with the manager indicated that that the redevelopment of a formal system for meeting with staff (supervision) and for appraisal was another priority task. This will ensure that staff are properly supported and their work is being positively monitored. Throughout this difficult time for the home the proprietor has been very open in his dealings with all of the statutory agencies and as a result has become more actively involved than before. Reports from outside professionals who have continued to be in regular contact with the home have indicated total cooperation with action and improvement plans that have been set down. However, the last report in relation to a monitoring visit by officers from the Adult Social Care Department made in November indicated ongoing problems with the homes cleanliness, bedlinen and health care practices for specific individuals; the people responsible for the running of the home Care Homes for Older People Page 29 of 36 Evidence: have been fully aware of the need to change in order to protect the future of the home. We were told at the last Random Inspection that a further more detailed Action Plan was being developed and a number of positive steps have been taken as a result of this. Additionally the homes management have audited progress for themselves and have introduced systems that will continue to tell them how well things are going into the future. However, the results of our inspection of medicines for example, which identified problems similar to those occurring in September, would indicate that any systems that have been introduced are not yet making a full impact on the delivery of day to day services. The systems in place for looking after residents money were found to be satisfactory at previous inspections and remain unchanged so a full assessment of this was not carried out. Similarly, standards of health and safety activity and regular servicing of equipment had been maintained, and a full audit of health and safety matters was also not carried out. Observations made around the building and a sample of fire safety activity and equipment records supported that the home was hazard free at the time of the inspection. At the last Random Inspection visit we noted that, although problems persisted, steps had been taken to reverse this trend and that progress was being made to address the serious shortfalls in care practice and levels of risk within the home. We noted that the appointment, and then suspension, of a replacement manager has been an unfortunate course of events that can only serve to have had a negative impact on the running of the home, but the confirmation of the two consultant managers in post for an extended period allowed for the development of consistency at the home which is partly borne out at this inspection. The concluding words of our last inspection reports that a move from a reactive to a more proactive style of management needs to be made, and that the real test for the home will be sustainability of improvements in the longer term is still valid at the conclusion of this inspection. Care Homes for Older People Page 30 of 36 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 31 of 36 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 3 14 The needs of everybody 31/03/2010 must be fully asessed at the point of coming to the home, and information about any risks involving their care must be kept up to date. Additionally, any assessments that relate to limitations of freedom under statutory guidelines must be clearly documented, and the conclusions presented at the front of the persons care records. This is so that everybody involved with the persons care is clear about the persons needs and capabilities and all rights and responsibilities are given a suitably high profile. 2 7 15 The homes managers must 21/12/2009 review and renew all care documentation that does not help staff carry out their work efficiently, and this Page 32 of 36 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action must be kept up to date on a monthly basis. This so that everybodys care is planned to a consistent pattern and is person centred. 3 9 13 Medicines must be administered as prescribed and must be demonstrated by record keeping practices. This is so that the health and well being of people living in the home is maintained. 4 18 13 All staff working at the home 31/01/2010 must be given instruction or training in relation to their responsibilities for the safeguarding of vulnerable adults and be made fully aware of the homes policies and procedures that relate to this. This is so that the guidance given to all staff working at the home makes clear their responsibilities to Alert and Report any instances occurring at the home that might be considered under these policies and procedures. 21/12/2009 Care Homes for Older People Page 33 of 36 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 26 16 The management must ensure that the laundry service operates in an efficient manner. So that the confort, dignity and hygiene of residents is maintained. 31/03/2010 6 29 19 Staff should not be employed at the home without all the required checks and referenecs being obtained. This is so that the homes managers can be sure that only the right peole for the job work at the home, 31/01/2010 7 30 18 All staff working at the home 31/03/2010 must receive training that helps them do their jobs more effectively and professionally. This is so that the health, welfare and safety of people living at the home is maintained. 8 31 8 The homes manager must apply to register with the Commision. So that profssional leadership can be establshed and to comply with the law. 31/12/2009 9 33 23 The people responsible for the running of the home 31/03/2010 Care Homes for Older People Page 34 of 36 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 must develop systems for regularly looking at the quality of the homes administrative systems and standards of care being provided. So that any flaws, poor or unsafe practices and unprofessional attitudes can be identified and improvements made and to ensure the safe running of the home. 10 36 18 All staff must receive formal 1 to 1 supervision from the homes senior staff, at intervals of every two months. This will ensure the opportunity for regular consultation about and monitoring of their work. 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 31/01/2010 1 2 3 9 9 9 The medicine refrigerator should be locked and the fridge temperature should be accurately monitored. Medicines should be stored safely at all times during the medicine round. The medicine policy should reflect current practice in the home and be available for staff to consult. Care Homes for Older People Page 35 of 36 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). 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