Care Home: Manley Court Nursing Home

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What the care home does well The manager is committed, enthusiastic and hard working and motivates the staff team. Staff are generally caring and kind and want to help the residents get the best out of life. The home continues to offer comprehensive support to residents using a variety of specialised services through a range of professionals such as psychiatrists, nutrition specialists and speech therapists ensuring all the needs of residents are met. They are giving individualised care and delivering it in a flexible and personable manner that suits individual needs where possible. There is a comprehensive induction programme in place for new staff and a comprehensive training program for both trained nurses and care staff. There is ongoing training and development as well themed supervision on working practices as part of supervision that has resulted in improved standards of care and the promotion of good care practices. Residents care plans are reviewed on a regular basis and generally health care needs are well met. Staff ensure the privacy and dignity of residents is maintained and residents are supported to exercise choice and control over their own lives as much as possible. Residents are encouraged to maintain contact with relatives and friends and staff encourage them to keep in contact where possible. The home ensures residents are well protected with an effective complaints policy and procedure in place that is accessible to residents. It ensures that all staff are trained and informed about adult abuse. They have effective policies and procedures in place around adult protection and follow policies and procedures when the need arises. What has improved since the last inspection? The manager and staff have worked hard to comply with the requirements made in the previous inspection report. The home has employed a deputy manager and there is a good management team that work well together supporting residents and staff. The home has responded well to the recent loss of a number of staff and has put further systems in place to ensure the recruitment procedures are more robust. What the care home could do better: The home provides a varied menu that offers a choice of meals and specific preferences and cultural needs but these need to be available on a daily basis make sure the food offered is what the residents want and need. Drinks could be offered during the meals not just at the end. The activities co-ordinators could develop activities that are of interest to residentswho are in the younger age bracket and those who need more diverse activities such as the Pat the Dog Scheme. There could be more tailored activity programmes for residents with dementia and learning disabilities and of ensuring that staff are aware and capable of satisfying residents preferences. The expert suggested more equipment such as activity toys, threading boards or other games could be provided as well as better sensory stimulation. Nursing and care staff need to be more aware of the responsibility they have in assisting with residents activities. The expert commented that on paper there appears to be a reasonably good range of activities taking place, and with two full time activity organisers in post it would seem as if the home is making positive steps towards providing a stimulating environment for some residents. They were concerned that no afternoon activities were apparently taking place on one unit despite a programme that seemed to offer three different things and that the member of staff did not initiate activities until the expert asked what would be happening and was told the activity organiser would be leading on this. Other concerns were one resident trying to eat a soft ball that looked like fruit, residents being left alone with only a poorly tuned radio for comfort and the expert was not convinced there was sufficient stimulation for residents with dementia as well as residents overall. The health and safety issue of the slope in the garden needs to be addressed. The home is looking shabby and needs the refurbishment and redecoration program to be implemented fully. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Manley Court Nursing Home Manley Court John Williams` Close, Off Cold Blow Lane New Cross London SE14 5XA     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Lynne Field     Date: 1 9 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 38 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 38 Information about the care home Name of care home: Address: Manley Court Nursing Home John Williams` Close, Off Cold Blow Lane Manley Court New Cross London SE14 5XA 02076354600 02076399433 tamba.lamina@bupa.com www.bupacarehome.co.uk BUPA Care Homes (ANS) Ltd care home 85 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 0 49 0 dementia old age, not falling within any other category physical disability Additional conditions: 36 0 49 The maximum number of service users who can be accommodated is: 85 The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 49) Dementia - Code DE (maximum number of places: 36) Physical disability - Code PD (maximum number of places: 49) Date of last inspection Brief description of the care home Manley Court is a purpose built home providing care and nursing for up to 85 service users, of whom 36 may have dementia, 49 may be frail older people, of whom 6 may be in receipt of palliative care and 14 may be aged over 40 yrs of age and have a chronic illness. Care Homes for Older People Page 4 of 38 Brief description of the care home The private, nationwide company BUPA Care Services took it over from Associated Nursing Services (ANS) owns the home. It is situated in a residential area of New Cross Gate. The nearest shops and railway station are ten minutes walk away. The nearest bus stop is several minutes walk away. The home was opened in 1996 and is on two floors. It is divided into five units of which two provide nursing care. There are two units for people with dementia and a small unit with rooms for people in need of palliative care nursing. All the bedrooms are single with en-suite facilities. There is a passenger lift. The home has two gardens at the rear that are accessible and secure. There is car parking at the front of the building. The home has a brochure and a resident?s guide that is made accessible to all prospective residents and the families. Copies of CSCI reports are kept in the reception area and a copy is given to service users, relatives or a representative on request. The home?s fees range from #570 - 00 to #972-80 a month. Additional charges are made for hairdressing, toiletries, newspapers, outings, taxis and clothing. This information was collected during the May 2009 inspection. Care Homes for Older People Page 5 of 38 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection was conducted by two inspectors, the pharmacy inspector and an expert by experience and this took place over three days in May 2009. The inspection involved observing interaction between residents and staff during the inspection, speaking twenty three residents, eight relatives, the staff on duty on each of the days of the inspection and the manager. Care managers, social workers and advocates were spoken to during the inspection and afterwards on the telephone during and after the inspection as part of the inspection process. The manager returned a standard form, the Annual Quality Assurance Assessment to CQC formally CSCI and this was taken into consideration. He has kept us informed of any incidents and complaints as well what he hopes to achieve in the short and long Care Homes for Older People Page 6 of 38 term. The inspection also involved the case tracking of six residents care, the assessment of a range of the homes records, procedures and forms as well as observation and a tour of the premises. Comments from the expert by experience report and pharmacy inspector report have been incorporated into this report. Overall we found there was an good level of commitment displayed by the registered manager and staff to ensure they were meeting the needs of the residents and complying with the standards and the outcome for residents is good. This was confirmed by most of the comments we had before and during the inspection from residents, their relatives and professionals we spoke to. What the care home does well: What has improved since the last inspection? What they could do better: The home provides a varied menu that offers a choice of meals and specific preferences and cultural needs but these need to be available on a daily basis make sure the food offered is what the residents want and need. Drinks could be offered during the meals not just at the end. The activities co-ordinators could develop activities that are of interest to residents Care Homes for Older People Page 8 of 38 who are in the younger age bracket and those who need more diverse activities such as the Pat the Dog Scheme. There could be more tailored activity programmes for residents with dementia and learning disabilities and of ensuring that staff are aware and capable of satisfying residents preferences. The expert suggested more equipment such as activity toys, threading boards or other games could be provided as well as better sensory stimulation. Nursing and care staff need to be more aware of the responsibility they have in assisting with residents activities. The expert commented that on paper there appears to be a reasonably good range of activities taking place, and with two full time activity organisers in post it would seem as if the home is making positive steps towards providing a stimulating environment for some residents. They were concerned that no afternoon activities were apparently taking place on one unit despite a programme that seemed to offer three different things and that the member of staff did not initiate activities until the expert asked what would be happening and was told the activity organiser would be leading on this. Other concerns were one resident trying to eat a soft ball that looked like fruit, residents being left alone with only a poorly tuned radio for comfort and the expert was not convinced there was sufficient stimulation for residents with dementia as well as residents overall. The health and safety issue of the slope in the garden needs to be addressed. The home is looking shabby and needs the refurbishment and redecoration program to be implemented fully. 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 set out 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 38 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 38 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. The home does not accept people for admission unless they are satisfied they can meet their needs. The admission process is completed in a sensitive manner to ensure a smooth transition with minimal inconvenience to the individual with all the necessary equipment and preparations made in advance. Evidence: We were told by the registered manager a copy of the care assessment would be faxed to the home and where possible the prospective resident and / or their family would visit the home to see if it was suitable. The manager or deputy manager would visit the resident where they were at the time of the assessment and a full needs assessment would be completed to ensure the home could meet the prospective residents needs before a place in the home was offered. We checked the statement of Care Homes for Older People Page 11 of 38 Evidence: purpose and the resident and relatives information pack that is given to residents and their families when they come to visit the home to help them decide if the home can meet their needs. This includes the statement of purpose and the service user guide. The registered manager said these are regularly checked and updated to reflect the changes in the home and the organisation that runs the service. We were told that when residents come to live in the home they are given a copy of the resident and relatives information handbook that records their room number, which unit they are in, their named nurse and named key worker, which is for them to keep in their room. We saw copies of these in each residents bedrooms as we went around the home and there was a general copy on the coffee table in the reception area of the home. The three residents on the palliative care unit described the assistance and support they received prior to and post admission and felt this was very good. They said they found the home is well equipped to meet their needs. They said before their relative moved to the home all the necessary equipment such as oxygen cylinders and appropriate beds were in place to avoid unnecessary disruption. This included the statement of purpose and the service user guide. The registered manager said these are regularly checked and updated to reflect the changes in the home and the organisation that runs the service. We met a prospective residents husband and daughter being shown around the home by the registered manager and saw they had been a given copy of the statement of purpose and service user guide. We were able to view the admission procedure for two people recently admitted to the home on the palliative care unit. When we spoke to them they said they felt that the admission process was made as smooth as possible and that they were involved in the decision making. We were told that when residents come to live in the home they are given a copy of the resident and relatives information handbook that records their room number, which unit they are in, their named nurse and named key worker, which is for them to keep in their room. We saw copies of these in each residents bedrooms and a general copy on the coffee table in the reception area of the home. We were told a copy of the care assessment would be faxed to the home and where possible the prospective resident and / or their family would visit the home to see if it was suitable. The manager would visit the resident and a full needs assessment would be completed to ensure the home could meet the prospective residents needs before a place in the home was offered. Care Homes for Older People Page 12 of 38 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. Care planning has continued to improve with systems in place to ensure that this improvement continues. Residents find that healthcare is promoted but the home needs to have a more robust system in place to ensure consultations that are felt to be necessary by the resident and their families with professionals happen and are not missed. Residents feel they are treated with respect and their right to privacy is upheld. Medicines are handled well, storage facilities are adequate, medicines are held securely, and the manager and staff in charge of medication on the day of the inspection were knowledgeable on medication issues. Evidence: The home uses a system called QUEST, which is an assessment tool with mandatory fields in the principles of care planning that is used in all BUPA homes. Care plans are Care Homes for Older People Page 13 of 38 Evidence: developed from the residents initial needs assessment to make sure the health and personal care needs of residents are met. The nutritional needs of each resident are assessed using a recognised nutritional assessment tool. These are ongoing with appropriate supplements given if necessary as and when directed by the GP. We saw that on admission all residents are weighed and within six hours of admission a range of risk assessments including Waterlow scores are completed. BUPA assessments for activities of daily living include standard statements, which have a number rating. Included within this documentation are mandatory care plans for nutrition, falls and manual handling. In the files inspected these were completed. We found that in general care plans contain good information in the intervention section which provides staff with a good foundation and guidance to give the care required. The care plans are relevant to current areas of identified need and include supporting documentation such as risk assessments. Issues such as sleeping and end of life were covered in the documentation. This is done as part of the admission process with appropriate relatives involved where possible. We looked at thirteen residents files during the three days of the inspection. Three of those selected are for residents receiving palliative care. We saw the service develops good individualised care plans. Staff use the information recorded on the care plans to develop and deliver appropriate care and support that consider the assistance and the needs of each resident in all areas from social needs to healthcare. There were pain assessments and medication profiles are in place for each resident. Care plans included copies health and safety risk assessments and the actions needed to minimise the risks. They record and report on the treatment of pressure ulcers as well as actions taken to assess and alleviate the risk of pressure ulcers. For residents at risk of pressure sores we found that tissue viability is promoted and that appropriate pressure relieving equipment is in place such as specialist mattresses. Copies of the use of bedrails and the risk assessments were on file and these were either signed by the resident or their relative where appropriate. Residents are given a choice of which GP they see and are seen by the GP as soon after admission as possible, usually within the week of being admitted. There are GP surgeries held at the home every week where the residents can be seen by their GP. If the resident needs to be seen earlier, the home will contact the GP for advice or asked to come to visit the resident if necessary. The health and welfare of residents is promoted. As well as care plans there are copies of health and safety risk assessments. These identify areas of risk and the actions needed to minimise these. We saw examples in records of how care was being given. Daily records confirm the care delivery is given in accordance with current care plans. We saw from the records when a resident becomes unwell their condition and any Care Homes for Older People Page 14 of 38 Evidence: issues that arise from this are monitored more closely with risks highlighted and fluid intake charts used as necessary. Residents are kept comfortable with pain relief managed appropriately. One of the residents we observed had their exercise programme reviewed by the physiotherapist in recent months. As a result of a new regime staff members assist and promote the resident with use of passive movements. The residents and relatives who we spoke to said they have confidence in the service and staff. They said they find that staff carry out their duties diligently. The expert by experience who accompanied us on one of the days of the inspection spoke to one family who felt their relatives dignity is being compromised because in their view the home will not provide enough equipment to meet all the basic needs of every resident. They said there was a lack of access to a standing hoist, an ongoing issue that seemed at one point to have been resolved, only for one hoist to be taken out of use. The registered manager explained this was because it needed to be repaired and unsafe so it left the unit with only one standing hoist between two residents but they hoped it would be repaired as soon as possible. We saw examples in records of how services are performing, following observations we made. For residents unwell conditions and issues are monitored more closely with risks highlighted and fluid intake charts used as necessary. Residents are kept comfortable with pain relief managed appropriately. Daily records are used to summarise residents progress and reflected the care and support that was given. The pharmacy inspector checked the medication records, medication storage areas and medication training on all units. Staff were observed giving medication and completing medication records accurately, providing evidence that staff are following the homes procedures, ensuring medicines are given safely. All prescribed medicines were available at the home, and medication records together with stock checks showed that residents are receiving their medicines on time and as prescribed. Records are kept of the receipt, administration and destruction of medicines, and inspection of these showed that the home can account for all medicines held on behalf of residents. Appropriate checks are being carried out on the syringe drivers used on the palliative care unit and all palliative care intravenous medicines have been pre-authorised by a palliative care specialist. Care Homes for Older People Page 15 of 38 Evidence: All controlled drugs are being stored securely, and recorded in a controlled drugs register according to the Misuse of Drugs Regulations. Stock checks are carried out regularly and destruction is carried out at the home in accordance with the clinical waste regulations. One resident is being supported to keep and take their own medicines. A risk assessment is in place to ensure their safety, this is reviewed regularly and lockable storage is provided in their room. The risk assessment lists the medicines being selfadministered, however this was not up to date and it is recommended that these are updated whenever medicines are changed or added. One resident is on insulin. The blood glucose monitoring records are good and state the frequency of testing and the acceptable range. It would be good practice to add the dose of insulin onto the medication record, as currently the dose is only stated on notes kept in the residents room. One resident is having a medicine administered covertly in tea due to constant refusals. Approval has been obtained from the prescriber and next of kin. The home has sought the advice of the local pharmacist to ensure that this method of administration does not alter the effectiveness of the medicine however this was not documented and would be good practice to do so. We were told the home has protected meal times which means all staff assist in service the meals and help with residents who need assistance with eating and no medication is to be dispensed during this time. During the inspection we noticed medication was being given during this time. It is obviously happening regularly because the sister in charge of the unit started to give out medication and when another member of staff noticed us there, indicated to her she should stop. We discussed this with the registered manager and as stated above some medication needs to be given this way and some medication needs to be given with food. While it is a priority that as many staff assist residents with eating as possible, there needs to be a flexible approach to protected meal times and this should be overridden depending on the needs of the resident, but this needs to be written in the care plan. There were a number of missing signatures for administration on one unit. When we checked the stocks we found these medicines had been given. Staff must ensure that all doses of medication given are signed for at the time of administration. See Requirement 1. One prescribed medicine, a food replacement drink, has been prescribed to be given Care Homes for Older People Page 16 of 38 Evidence: twice a day however staff are only signing once a day so it was not clear whether this was being given as prescribed. The home must ensure that staff record when all prescribed medicines are used. See Requirement One One supply of medication, rectal tubes used for emergency treatment of epileptic fits, had expired. Staff must ensure that expiry dates of medicines are checked regularly. See Requirement Two It would be good practice to add the area of application of creams to the medication record as some residents have two or more prescribed creams to be used on different areas. See Recommendation One It would be good practice to add the quantities of medicines carried forward from one month to the next, for example painkillers, creams and other medicines that are used on a when required basis which do not need to be ordered every month to the medication record to enable stock checks to be carried out more easily. See Recommendation Two Care Homes for Older People Page 17 of 38 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. The home needs to relook at a broader range of activities to interest all the age groups and disabilities of the residents. Residents are encouraged to maintain contact with family and friends. Residents are generally supported to exercise control and choice over their lives. Residents receive a varied and balanced diet and are supported in a sensitive manner to choose and eat food they like but variety needs to be widened to include a more comprehensive range of ethnic foods at every meal. Staff need to record on the menu charts health conditions that could be detrimental and affected by what the resident eats. Evidence: We spoke to twenty three residents as well as their relatives and generally they said they have confidence in the service, they find that staff carry out their duties diligently. We spoke to nine residents relatives and friends as well as the expert by Care Homes for Older People Page 18 of 38 Evidence: experience speaking to three different relatives during the inspection. The residents who spoke to us on the palliative care unit, said they found the home to be sensitive to their individual needs. Two residents are happy with nursing care provided and currently require tender loving care. They said they felt unable and did not want to take part in house activities. One resident has a strong family network with relatives present every day without unnecessary restriction. The relatives said they like to feel included in the care and support delivered. Family members who we spoke to said they had cared for their father at home before he was admitted and they like to continue with this involvement while he is at the home. We saw that visitors are free to come and go throughout the day without restriction. They said they were made to feel welcome and all but one spoke positively about the care given to residents. The three residents we spoke to on the palliative care unit, all said they found the home to be sensitive to their individual needs. Two residents are happy with nursing care provided and currently require tender loving care. They said they felt unable and did not want to take part in house activities. Part of the brief for the expert by experience was to was to observe how staff relate to residents, their attitude and what happens when residents make requests. The expert observed staff interacting with residents and thought the carers, on Lavender showed kindness, humour and concern for the residents. Another carer told the expert she enjoyed working with older people very much. They observed this was evident in their interactions with residents. The expert joined the residents on the unit for lunch and said staff serving food also seemed to like the residents and enjoyed working with residents. They said they caught a glimpse through a doorway of a carer with a resident in their room at one point and thought the carer was very pleasant and gentle towards the resident. Another carer also impressed them with their competent and sensible manner. The expert said one very active gentleman told them that the home was very good and he thought the carers were excellent. Relatives of two recently admitted residents said their impressions so far, although limited, were very favourable. There was one relative more cautious in their comments. They said they often found their mother carelessly dressed, sometimes a bit dirty and with saliva dribbling copiously from their mouth. The recommendation from a dietitian for pureed food was not a success as the resident did not enjoy the homes pureed food but would eat soft Caribbean food brought in by the family. The expert wondered why this food was not given to the resident if this was what they would eat and passed on these comments on in the feed back they gave to the registered manager at the end of the time they spent in the home to follow up. We were told by the registered manager that one younger resident has funding for additional hours and youth support workers from Access to Living Centre come to work Care Homes for Older People Page 19 of 38 Evidence: with him on an individual basis. Other residents told us they have observed how this resident benefits from this additional help and it has helped them to pursue their interests both in the home and in the community. On the second day of the inspection we spoke to the activities coordinators who told us what they had planned for the first part of the day. This was going around the home to residents rooms doing hand massages or nail painting. We visited the activities room on the second day. We spoke to residents to ask them what they thought about the activities provided by the home. One younger resident felt the activities were geared towards the older residents and would like to have access to a computer and a printer. The activities room is well equipped but activities take place in all parts of the home depending on what type of activity it is. Some residents said they loved going there and enjoyed all the activities put on by the activities staff. Each resident has an activities folder with a written record of their interests and what they have attended. We saw a number of activities had been planned and information about these was on the notice board advertising them. The expert by experience said during the initial tour of the home in the morning they were shown residents engaged in an art and craft activity, decorating cardboard boxes, which would later be sold at a forthcoming fete. They said this activity was being led by an activity organiser. In the afternoon the expert visited the lounges on Lavender and Primrose units. According to the activity timetable, hand massages, play with stress balls and Arts and Crafts were all scheduled for the afternoon but when the expert went into the Lavender lounge after lunch there was no activity going on. They asked about this and were told by the carer that the Activity Organiser leads this. After some delay, the carer began to play with the residents with soft balls. Some of the residents seemed happy with this but others, less so. When the expert went upstairs in Primrose, the same activity schedule was posted. They found the lounge was completely empty the first time they visited it after lunch. They revisited at a short time later and there were only two residents in the room. One resident was positioned so that they could look out of the window. Another resident sat with an empty tumbler. A music station was playing on a poorly tuned radio and the expert said the effect was quite unpleasant. There were no staff present. The expert said they also witnessed another resident in bed and enduring Classic FM, their favourite station on a radio that was very badly tuned. One younger resident told the expert she did not join in with organised activities because they did not think they were suitable for them. They were a very keen animal-lover and had been used to an outdoor life, exercising dogs. When this was fed back to the registered manager the expert suggested exploring ways of bringing a pet into the home, perhaps through the Pat a Pet scheme, or by making links with local animal charities. Care Homes for Older People Page 20 of 38 Evidence: The nutritional needs of residents are regularly monitored from time of admission. Those residents at risk due to poor nutrition are identified and their conditions monitored closely. Appropriate action is taken as required if there is a weight loss. This was evident from the records held for a resident recently admitted. Appropriate referrals were made to relevant health professionals to seek advice on how to promote the residents health further. Food supplements are supplied to those who are not eating well or who have difficulty eating through swallowing problems. However we saw that one resident whose care plan said they were diabetic that is controlled by diet and noted her BM levels fluctuated and tended to be high. We checked the meals list record and found there was no record on this that they needed a low sugar diet. There was no record that a diabetic diet was being given and we noted the meals they chose were ordinary meals. Staff did not seem to give them guidance about what they could eat. This was pointed out to the person in charge and the manager and we were told they would amend the meals list to include this information. We joined the residents for their lunch on the second day of the inspection and observed the residents enjoying their meals. Staff were seen assisting and supporting residents to eat and this was being done in a sensitive way. We were told the home had protected meals times, where no medication is dispensed during meal times and all available staff assists in serving meals and support residents who need help to eat. See Standard 9. The expert ate lunch in the dining room of the Primrose Unit. The unit manager explained that there was no music playing in the background because one of the residents had objected to this, however, this meant the atmosphere was quiet and restful. The seven residents who ate there were calm and seemed to enjoy their lunch. The food which was sausage casserole with onion, mashed potatoes and green vegetables, followed by a sponge cake dessert with cream was pleasant. Some residents chose an alternative course of pasta. Residents were assisted to eat by the Unit Manager and another resident was also given the occasional help by staff. The expert said they were surprised that no drinks were offered until the end of the meal as they felt drinks can help people with dementia to accept and swallow their food. One resident who said she could not eat all the food that was on her plate was told to just eat what she could. The expert said one carer seemed to be quite stressed during the mealtime. They were trying to assist one resident to eat as well as keeping an eye on another resident and checking that meals were going to the right residents. One other carer, the expert thought was from an agency, was feeding another resident and keeping an eye on a second resident. Towards the end of the meal other carers appeared including one who was supposed to be off duty. The expert observed this carer to be caring and competent and felt they immediately took the pressure off the situation by helping to feed the residents. The expert said they did not know how long it took to feed the other, possibly ten absent residents but when they visited a resident in their room after lunch had ended in the dining room, the residents first course had Care Homes for Older People Page 21 of 38 Evidence: only just arrived. Although most residents seemed happy with the food, some were not and said the quality of the food had gone down. We were told the cook was on long term sick leave. We spoke to the assistant cook who comes around after lunch to see what residents thought about the meal. She had been ill herself and said it was difficult managing on her own. We saw copies of the menu displayed on the wall of each unit but they were for that day. We observed members of staff going around asking residents who could not see the menu what they would like to eat. Residents and relatives said they were asked what they wanted to eat but did not always get what they asked for. The assistant cook said they use what is called the BUPA Menu Master that helps them to ensure the menu meets the nutritional needs of the residents and adapt this to develop a menu that the residents like and meets their cultural tastes. As stated earlier by the expert by experience, residents do not always get their cultural food needs met each day. As residents are given a choice of food each day could one of the choices to be an ethnic style dish Care Homes for Older People Page 22 of 38 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. Residents and their families are given information on how to complain to the home and to independent bodies. Their complaints are taken seriously and investigated fully. Complaints within the home are handled properly and residents feel confident that their concerns will be listened to. Records of complaints investigations indicate they are taken seriously and are acted upon. Residents are protected from abuse. Evidence: We were told the company has a clearly defined complaints policy with agreed timescales for managing complaints. The registered manager said Bupa Care Homes has robust allegation of abuse and neglect policies. This allows staff to raise concern within the home or to senior staff outside the home that they would follow if a concern was raised. There are well-documented procedures for reporting under POVA should the need arise. The present policy has agreed timescales for managing complaints and Bupa Care Homes is currently reviewing its complaints policy for the whole organisation to reflect any changes in legislation. Care Homes for Older People Page 23 of 38 Evidence: We were told the management of the home had robust training in and for raising staff awareness on all aspects of Adult Safeguarding. This was addressed in staff meetings and formal supervision. There are robust investigation systems and actions in place that are used to address concerns raised by residents, relatives and staff. All residents are issued with an information pack which we saw in their rooms. This includes a copy of the homes complaint policy and procedure and information about advocacy services. The information that accompanies the policy is prominently displayed in the home. The policy includes a three-tier framework including the home, the regional management team and the national Quality and Compliance department. BUPA Care Homes has appointed a Director of Quality and Compliance and has developed a national Quality and Compliance team of experts. The manager sends reports of all complaints received by the home to formally CSCI and now CQC as well as liaising with the appropriate professionals, which demonstrate that detailed investigations are always conducted and appropriate action is taken. We saw the complaints and complements book. This records the complaint the action taken and the outcome. Since the last inspection in May 2008 the home has had eleven complaints and one adult protection issue. In respect to adult protection the home has a robust policy and procedure. The whistle blowing policy is included in the staff handbook as well as an employee guide regarding the Protection of Vulnerable Adults list to which referrals of staff implicated in abuse of residents are made to prevent them from continuing to work with vulnerable adults. Employee responsibilities to report abuse are also addressed in the handbook. In the past CSCI has received complaints about the service or environment. We have relayed these back to the registered manager of home to deal with and have always found him receptive and has dealt with the complaint immediately. We were told adult protection training was part of the staff induction training and they have POVA awareness courses annually. We were told POVA is discussed at residents and staff meetings as well as it being discussed in supervision. The manager said keeping residents safe is given very high priority and there is no room for complacency any allegation is treated very seriously. Care Homes for Older People Page 24 of 38 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. Residents live in a safe environment within the home but the slope in the garden poses a health and safety risk to residents and their relatives who are unstable on their feet or unaware of potential danger to themselves because of their deteriorating mental condition. The home is generally homely and reasonably well maintained but some areas are shabby and some repairs and renewals need to be carried out. Evidence: The home is purpose built and offers single en suite accommodation with adequate personal and communal space. The home is divided into five separate units. There is a lounge and dining area on each unit and a number of these are being refurbished but in one dining room there were gouges on the walls. The home had purchased new dining tables and chairs for the dining rooms before the last inspection in 2008 and these were attractively set at meal times. The entrance hall is comfortably furnished with two settees that were new at the time of the last inspection. The seats in the corridors have been attractively recovered, where residents can rest as they walk around or an alternative sitting area to meet with their relatives. One bathroom on the lower ground floor and one on the first floor had a ceiling hoist installed. We checked a Care Homes for Older People Page 25 of 38 Evidence: number of shower rooms, toilets and bathrooms and noted there was a lot of equipment being stored in them. There was one in particular that had two hoists stored in it making it inaccessible to use. We discussed storage space with the registered manager who said there was limited storage space in the home for this type of equipment. One resident complained about a mobility scooter being stored outside her room. She said it blocked her access and she wanted to put her own equipment there. We discussed this with the manager and as it is in the main corridor said the access should be kept clear as it was a health and safety and could block access in the event of a fire. The manager said they have redecorated two units and continued to improve on the homes security system and lighting. When bedroom becomes vacant it is refurbished and redecorated in readiness of a new resident. Most bedrooms are homely and residents have brought in a number of personal possessions, such as small items of furniture, pictures and photographs but the expert felt a number of bedrooms lacked personal touches, saying the walls were bare of anything, even a clock. A number of bedroom carpets have been replaced and the floors in all of the shower rooms have been replaced. One nursing station had been refurbished and the maintenance man said he was about to refurbish another one on another unit. We found many areas of the home are starting to look shabby again and residents spoke about their concerns about broken furniture and they said there was poor temperature control on the radiator in their relatives room. The expert by experience observed the bed table in one residents room had a rough corner to it, which could hurt the hand of a resident with frail skin, a chest of drawers had a drawer missing and the walls were bare of anything, even a clock. They felt walls of lounges and dining rooms were reasonably well decorated but devoid of pictures. One family said it was not what you would expect a Bupa home to look like. Another lady said her mothers bedroom was very shabby and needed to be redecorated as she had been at the home for over five years. The manager said it was on his list and he would make sure it was done as soon as possible when there was a vacant room they could move her mother to while it was being redecorated. We were told the home is supported in maintaining the environment by a central team of experts within BUPA Care Homes. They have a specialist property and estates department as well as a hotel services department. The manager said regional managers visits focus on the standard of housekeeping. The in house maintenance man decorates the bedrooms as they become vacant as well as undertaking the ongoing daily maintenance as well as doing a number of tasks to keep the home safe and well maintained. At the last two inspections in October 2007 and 2008 we were told BUPA had allocated money to buy identified pieces of furniture and redecorate Care Homes for Older People Page 26 of 38 Evidence: areas of the home. This seems not to have happened to the extent the residents and staff had hoped. We saw each unit had a number of different types of hoists and assisted bathing facilities. Each unit has two standing hoists and two other types of hoist that were used with slings. One resident and their family who complained and said they felt two standing hoists for the number of residents who needed to use them was not enough at the last inspection were still unhappy. Another hoist had been purchase but unfortunately the original one had broken and they still had the same number. We were told there were now only two residents who needed a standing hoist and the manager said he would try to have it repaired as soon as possible. We checked the enclosed gardens at the rear of the premises that slope away from the home which the manager and staff have had concerns about. This had been inspected by the organisations health and safety office who had arranged to visit the home. The manager said the visit had gone well. He said the areas of concern that he had highlighted had been agreed and would be addressed, such as the slope in the garden that is causing concern. This was to be leveled for the safety of the residents using the garden and the garden was to be made more accessible. Unfortunately this still has not been addressed by the organisation and is still a cause for concern because of the sudden steep slope. The expert felt the two gardens seemed small for the number of residents who might want to use them and observed the slope along one side which had been commented on in last years report had not been leveled. They felt this would make the garden hazardous for residents who were unsteady on their feet. We found the home was clean and hygienic and generally there were no unpleasant smells on the days the inspection took place. The expert said they detected a smelt of urine in the bedroom where there was a used incontinence pad on the floor. The manager said unfortunately this resident tended to remove their pad and throw it on the floor but they try to be vigilant and remove them as well as keep cleaning the carpet. The home has robust policies and procedures around infection control and staff receive training around infection control as part of their induction. Care Homes for Older People Page 27 of 38 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The organisation has audited all staff files and has clear recruitment procedures to protect and keep the residents safe. Professional references for staff from previous employers should preferably be written on headed note paper or be stamped with the organisations company stamp. Staff are trained and competent to do their jobs Evidence: We examined recruitment procedures by checking eleven staff of recently recruited staff. We had been informed before the inspection earlier in the year that the home had experienced difficulties with recruitment procedures in relation to the incorrect immigration status of a number of staff. We were informed of issues in relation to the staff team. This did not just relate to newly recruited staff but to some staff who had been recruited by the previous organisation. As a result of this the home for a short period managed this situation appropriately and relied on bank and agency staff to cover short term vacancies. For a time relatives contacted us and said they were concerned about the staffing levels in the home. The manager said they tried to keep the staffing levels by employing extra bank and agency staff to cover the short falls and they had endeavored to maintain agreed staffing levels at all times. We were kept Care Homes for Older People Page 28 of 38 Evidence: informed of issues in relation to the staff team. We were told the organisation had audited all staff files to ensure they comply with legislation relating to recruitment and immigration procedures as well as following their own recruitment procedures. We spoke to eight staff and three were new staff who told us about their experience of their recruitment and the types of experiences they had had as part of their induction into the service and they felt they had been well inducted and supported during this time. They said they had been vetted and had to supply a number of documents as part of their recruitment before they started to work at the home. Enhanced disclosures with POVA checks, previous employment records and references were available for all new staff. Three of the staff are registered nurses. The administrator went through the system with us. All staff files have a checklist at the front of each file to ensure all information needed is there and has been checked. They had systematically audited all the staff files. They followed up any short falls by asking staff to supply any missing data, such as gaps in employment history and in references and current immigration status. All staff had CRB with Enhanced disclosures. The home is following good practice and is up dating CRBs if any staff has CRBs over three years old. Although appropriate references were received prior to start of employment we found some professional references did not have the organisations stamp which would verify authenticity. A recommendation has been made that when seeking references the service should endeavor to seek stamped references or letterheads from previous employers. The files contained copies of relevant training certificates. The manager said all staff has individual induction booklets that record their induction. The qualified nurses have been issued with a Qualified Nurse Learning Portfolio that is given to all BUPA trained staff. This incorporates BUPA induction, ongoing training records and supervision records. We spoke to twenty staff during the course of the inspection who had different roles in the home. This included the home manager, unit managers, trained nursing staff, care staff, catering and domestic staff, the maintenance man, clerical and administration staff as well as the activities staff. This gave us a broad spectrum of staff views of the home. All staff were positive about the home. The maintenance man stated he would like to develop his skills and hope the company would send him on an electrical or plumbing course and this could possibly save the organisation money. We were given a copy of the training plan for 2009. The registered manager felt they have an improved skill-mix and they now have three registered mental health nurses to provide advice and help manage Mental Health issues. Staff told us about the range of training they had undertaken. This included having regular updates in mandatory topics, such as moving and handling, fire training and health and safety. They said they had recently had training in adult protection and food hygiene, meeting the nutritional needs of residents and end of life care with the palliative care nurse specialist. This promotes the Gold Standard Framework. Care Homes for Older People Page 29 of 38 Evidence: Throughout the inspection we observed staff treating residents well. Staff seemed more friendly and helpful, not only with us but with the residents. The expert by experience said they thought that the staff in this home showed plenty of good skills and caring attitudes. Care Homes for Older People Page 30 of 38 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is well qualified, experienced and runs the home well. They are open and supportive in their management approach. The residents live in a home that is continuing to develop their management and staff team to ensure the home is well run and in the best interests of the residents, which continues to be promoted. Staff have regular supervision and are supported in their professional and personal development. Working practices and associated records ensure that the residents finances and health and safety are safe guarded. Evidence: The manager of the home is well qualified and has many years experience in the Care Homes for Older People Page 31 of 38 Evidence: health care profession and managing staff. At the last inspection in May 2008 the manager told us that he has appointed a deputy manager who was due to take up their post in June 2008. This has given the home the stability it needs and they work well together. Residents and their families we spoke to all said he managed the service well and things had improved since he had taken over. One resident said the managers not afraid of taking his coat off and digging in. The majority of residents and relatives we spoke to during the inspection said they had confidence in the manager. They said they felt the care in the home was continuing to improve. Even the lady who complained about the shortage of staff stressed she was not complaining about the staff and said they did a wonderful job and she was concerned for them as well as her husband. We spoke to three professionals who came into the home and all stated the home had improved and the manager ran the home for the residents and had their best interests at heart. The expert by experience said considering the recent loss of so many staff and an alarming event in 2007 when a carer was shot outside the home by gunmen, it is imperative that ways are found of attracting, retaining and supporting staff at the home. They feel it is remarkable that the remaining staff seem so happy and well motivated. They attribute this to good staff management by the registered manager of the home. There are regular relatives meetings but only about ten sets of relatives attend. The manager said they had tried different times and they write to all the relatives to inform them of the meetings. We saw documentation that indicated there were regular Health and Safety meetings taking place with a standardised agenda giving staff the opportunity to communicate on Health and Safety issues. The minutes from there go to the Regional Manager and the home is supported by a national team of Quality and Compliance Officers, whose role includes supporting quality issues within the home, auditing and providing guidance on policies, procedures and practice. The dedicated health and safety staff within the organisations region is supported by a National Quality and Compliance team. This includes Health and Safety and Fire Management Leadership. The organisation for Bupa Care Homes has a comprehensive suite of policy and procedure manuals that are regularly reviewed by experts and updated when required. The registered manager said they have an annual internal and external customer satisfaction survey. These feed back to the quality and compliance officers and the organisation conducts regular regulation 26 visits, which are recorded and were available for us to view. Staff continued to say they felt supported by the homes immediate management but Care Homes for Older People Page 32 of 38 Evidence: would like more from the organisation, such as free lunches and more money for working weekends. We spoke to the home administrator who records any financial transactions for residents who are unable to manage the day to day aspects of their finances. This is held on the homes IT system and is audited by senior management as part of the ongoing audit procedure in the home. We were able to check three residents financial transactions and these were correct. Full details of the system used by the home have not been disclosed in this report for security reasons. The manager and staff we spoke to said they had regular supervision that was recorded and kept on file. Staff and their manager signed the supervision records we saw. The manager told us he encouraged staff development and this would be discussed in supervision. We were shown the records and spoke to the maintenance man who has the responsibility for carrying out many of the health and safety measures and servicing of the equipment and we found these were well kept. The home has robust policies and procedures around health and safety. Fire safety records evidenced that fire alarm call points are carried out weekly. Regular fire drills are now taking place at different times to ensure all staff is familiar with the process. Care Homes for Older People Page 33 of 38 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 34 of 38 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 8 17 The home must ensure that staff record when all prescribed medicines are used. One prescribed medicine, a food replacement drink, has been prescribed to be given twice a day however staff are only signing once a day so it was not clear whether this was being given as prescribed. 10/07/2009 2 9 17 The Registered Provider must ensure that staff record when all prescribed medicines are used or given at the time of administration, and that all prescribed medicines are in date. Staff must ensure that all doses of medication given are signed for at the time of administration. 10/07/2009 Care Homes for Older People Page 35 of 38 3 15 16 The registered person should ensure the residents have choice of food to meet their cultural needs. Residents should be offered food they like and will eat. 16/07/2009 4 15 17 The registered person should ensure staff keep adequate records of medicate conditions which can be detrimental and affected by what they eat. A clear record of residents conditions must be recorded on the food chart. 16/07/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 9 The Registered Provider should ensure that staff record the quantities of medicines carried forward from one month to the next on the medication record to help in carrying out stock checks The Registered Provider should ensure that medication records for creams and external products carry full instructions for use including the area of application. There needs to be a flexible approach to protected meal times. this should be overridden when the medication needs to be given with food and depending on the needs of the resident and this needs to be written in the care plan. The registered person should ensure that the activities cocoordinators audit and reassess what other activities the residents would like to have. The activities co-coordinators should re look at developing activities that are of interest to residents who are in the younger age bracket. The refurbishment program of the home needs to be more robust and the redecoration of the home carried out to 2 9 3 9 4 12 5 12 6 19 Care Homes for Older People Page 36 of 38 bring the home up to the standard expected of a Bupa home. 7 20 The organisation needs to address the health and safety implications and should look at ways it can reduce the risk of a resident or possibly a family member injuring themselves by falling down the slope in the garden. Staff need to find out if residents would like to personalise their bedrooms and help them do this if this is their wish. Professional references for staff from previous employers should preferably be written on headed note paper or be stamped with the organisations company stamp. 8 9 24 29 Care Homes for Older People Page 37 of 38 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. 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