Care Home: Michaelstowe Hall Residential and Nursing Home

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What the care home does well Residents were generally happy with support and care and told us that their privacy was respected when staff were providing personal care. Some staff had left employment since the previous key inspection and those on duty during the day were found to be friendly and caring. The entrance hall and communal rooms in Oaklands were well decorated and comfortably furnished. The meals provided were of a satisfactory standard that comprised homely type food with choices accommodated and a variety of fresh fruit and vegetables that met residents` expectations. The home is generally clean and well maintained. The gardens to the front of the property are attractive and there are open views over countryside to the rear of the premises. What has improved since the last inspection? The statement of purpose and service user guide had been reviewed since the previous inspection and were on display for residents` and their visitors information. Some care plans had been rewritten but were still not person centred. Residents with high dependency needs were being monitored more closely and turn charts were in place to ensure those with pressure sores or at high risk of developing sores had their position regularly changed. Residents` weight was being recorded on a regular basis and staff had been trained to use the Malnutrition Universal Screening Tool (MUST). Action was being taken when residents had unplanned weight loss or had a low BMI. Referrals had been made to the GPs, dieticians and the tissue viability nurse. Overall medication management was satisfactory. Medication storage and controlled drug storage and risk assessments were satisfactory. In Greenlands Unit, where residents had high dependency needs, a social diary was now provided in each resident`s room that showed staff were now spending more time interacting with them. Additional slings had been purchased to meet residents` individual needs. Two new cookers had been purchased for the kitchen. A pandemic plan was now available for staff use in the event of an outbreak. Staffing levels had increased since the previous key inspection and were now adequate for the number of residents. Action had been taken following the random inspection of 28th January 2010 to ensure all references were now verified prior to appointment. Doors closures had been fitted to individual residents` rooms. Valves had also been fitted to restrict hot water temperatures. A lockable filing cabinet had been provided in the nurses office for the secure storage of records. What the care home could do better: Care plans in Oaklands Unit had been evaluated monthly but had not been fully reviewed since 2007 and 2008. Staff were not randomly monitoring the blood sugar of a person with diabetes. They would therefore benefit from updated training in care of people with diabetes. Medicines prescribed regularly were being given as required and as there was no pain assessment plan and no elimination plan and it was unclear how staff were making decisions with regard to administration of pain relief and laxatives. Prescribed creams were not labelled with the date of opening to ensure they were given before their expiry date. Staff are unsure how to provide appropriate therapeutic activities for residents with high dependency needs. There is therefore a need for staff to have training in activities for people with dementia and following severe strokes. Updated training in safeguarding adults and whistle blowing had been provided since the previous key inspection. However the training matrix showed that some staff had not received safeguard training since 2008. There were no lockable drawers for residents to store their valuables or medication in the event that they chose to self-medicate. Bath hoists are recommended for upgrade and part of nurse call system needs to be upgraded. Staff practice regarding infection control needs to be monitored to ensure best practice is adhered to. Staff supervision need to be developed and strengthened. The process for investigating complaints need to be more transparent and clear records kept with evidence of robust investigation and action taken to improve standards. Action needs to be taken with regard to the legitimacy of the manager reference. A clinical lead must be appointed where the manager is not a registered nurse. A wardrobe was not fixed to the wall of an unoccupied room. In the event that a resident is admitted to the room, a risk assessment should be undertaken to demonstrate that the risk had been minimised. There is no formal consultation with residents and their relatives as part of a Quality Assurance programme. This should therefore be developed to include audits and to produce an annual plan for the home. Key inspection report Care homes for older people Name: Address: Michaelstowe Hall Residential and Nursing Home Ramsey Road Ramsey Harwich Essex CO12 5EP     The quality rating for this care home is:   zero star poor 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: Diana Green     Date: 2 4 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Michaelstowe Hall Residential and Nursing Home Ramsey Road Ramsey Harwich Essex CO12 5EP 01255880308 01255880907 Michaelstowehall@btconnect.com none Handylodge Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: care home 84 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Persons of either sex, aged 40 years and over, who require nursing care by reason of a physical illness/disability (not to exceed 10 persons) Persons of either sex, aged 55 years and over, who require care by reason of dementia (not to exceed 15 persons in woodlands unit) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 15 persons in Woodlands unit) Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 46 persons in Oakland Unit) Persons of either sex, aged 65 years and over, who require nursing care by reason of a Care Homes for Older People Page 4 of 32 Over 65 15 46 23 15 0 10 physical illness/disability (not to exceed 23 persons) Staffing levels to be reviewed within 6 months of registration. The registered person must not admnit persons subject to the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995 The total number of service users accommodated in the home must not exceed 84 persons. Date of last inspection Brief description of the care home Michaelstowe Hall provides personal and nursing care with accommodation for up to 84 older people and can accommodate 10 service users aged 40 years and above with a physical disability. Michaelstowe Hall is owned by a private organisation named Handylodge Ltd. The home is located in the village of Ramsey, Harwich, Essex. The home was opened in 1995 and is a 3 storey Victorian building. The home is divided into 3 separate units: Oaklands, which provides personal care only, Greenlands, which provides personal and nursing care and Woodlands which provides dementia care. There are 64 single rooms including 60 with en-suite toilet facilities and 14 shared rooms, all with en-suite toilet facilities. There is a passenger lift. The home has large attractive gardens overlooking open countryside and a courtyard garden accessible to wheelchair users. Michaelstowe Hall is accessible by road and has good bus links. Parking is available in the car park. The fees range from £390.39-£496.69 for nursing care with other costs indicated by individual needs. Additional costs apply for hairdressing, newspapers and chiropody. This information was provided to CQC on 24/03/2010. 2 1 1 0 2 0 0 9 Care Homes for Older People Page 5 of 32 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: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 0 star. This means that people who use this service experience poor quality outcomes. This unannounced inspection took place on 24th March 2010. Three inspectors including a pharmacist inspector were present on the inspection. All of the Key National Minimum Standards (NMS) for Older People, and the intended outcomes, were assessed in relation to this service during the inspection. This report has been written using accumulated evidence gathered prior to and during the site visit, including the homes Annual Quality Assurance Assessment (AQAA). The Annual Quality Assurance Assessment (AQAA), which is required by law to be completed by the service, is a self assessment that focuses on how well outcomes are being met for people using the service. This was received by the due date but was for Adults (aged 18-65 years) rather than Older People and the appropriate format was therefore forwarded to the Registered Provider for completion. Information received in both documents was not sufficiently detailed to assist us in understanding how the Care Homes for Older People Page 6 of 32 registered persons understand the services strengths and weaknesses and how they intend to address them. Following the poor standard of care and neglect previously found at the home, and in consultation with residents and their representatives, a number of residents had been transferred by the local authority to alternative placements. There was a total of twenty-one residents on the day of this inspection. The inspection process included reviewing documents required under the Care Home Regulations. A number of records were looked at in relation to residents, staff recruitment and training, staff rotas and policies and procedures. Time was spent talking to the recently appointed manager, residents, staff and the Proprietor. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? The statement of purpose and service user guide had been reviewed since the previous inspection and were on display for residents and their visitors information. Some care plans had been rewritten but were still not person centred. Residents with high dependency needs were being monitored more closely and turn charts were in place to ensure those with pressure sores or at high risk of developing sores had their position regularly changed. Residents weight was being recorded on a regular basis and staff had been trained to use the Malnutrition Universal Screening Tool (MUST). Action was being taken when residents had unplanned weight loss or had a low BMI. Referrals had been made to the GPs, dieticians and the tissue viability nurse. Overall medication management was satisfactory. Medication storage and controlled drug storage and risk assessments were satisfactory. In Greenlands Unit, where residents had high dependency needs, a social diary was now provided in each residents room that showed staff were now spending more time interacting with them. Additional slings had been purchased to meet residents individual needs. Two new cookers had been purchased for the kitchen. A pandemic plan was now available for staff use in the event of an outbreak. Staffing levels had increased since the previous key inspection and were now adequate for the number of residents. Action had been taken following the random inspection of 28th January 2010 to ensure all references were now verified prior to appointment. Doors closures had been fitted to individual residents rooms. Valves had also been fitted to restrict hot water temperatures. A lockable filing cabinet had been provided in the nurses office for the secure storage of records. Care Homes for Older People Page 8 of 32 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Care Homes for Older People Page 9 of 32 order line 0870 240 7535. Care Homes for Older People Page 10 of 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 32 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. The assessment process is not sufficiently robust to ensure residents with nursing needs can always be assessed by a registered nurse prior to admission. Evidence: The homes statement of purpose and service user guide were now be available in the home. Copies of both documents were viewed during the site visit and had been reviewed in January 2010 and were seen to meet regulatory requirements. The admission process was discussed with the manager. There had been two new admissions since the previous random inspection, one of whom was on respite stay. We were informed that as the manager was not a registered nurse, the registered nurse on duty would undertake the pre-admission assessment for potential residents with nursing needs. However this would only be acceptable if a second registered nurse was employed in their absence and only as an interim measure until a clinical lead could be appointed to provide nursing expertise and support to the manager. Care Homes for Older People Page 12 of 32 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. Residents can generally be assured that their personal and health care needs will be met by caring staff. However more person centred and robust care planning is needed to ensure residents individual needs and preferences are fully met. Medication not given as prescribed does not safeguard residents. Evidence: Residents we spoke with were generally very happy with the support and care provided. One resident who needed minimal support from staff told us Im happy with the way they treat me. Ive got nothing but praise for the home. Staff we observed had a respectful and friendly manner with residents. Residents told us that staff respected their privacy in their room and we observed staff knocking and waiting to be asked to enter their rooms. At the key inspection in October 2009 we found that care documentation was of a variable standard and this was still the case at the random inspection in January 2010. At this inspection we noted improvements in the monitoring of the more highly dependent residents on the nursing unit. There was documentary evidence that Care Homes for Older People Page 13 of 32 Evidence: residents who could not communicate or request assistance were being monitored on an hourly basis. Turn charts were in place for residents at high risk of developing sores and those with pressure sores. Food charts were being completed for those at particular risk of malnutrition and staff were monitoring fluid intake and output. Some of the care plans on the nursing unit had been rewritten since the random inspection. They generally covered residents needs but were mainly written as tasks for nursing and care staff to carry out and were not written from the residents point of view. For example one care plan stated provide high fibre diet but did not give any indication of the residents ability to eat high fibre foods or which high fibre foods they liked at different meals. Writing care plans from a residents point of view is good practice that encourages individualised rather than task oriented care. Some of the care plans we looked at on the residential unit had been written in 2007 and 2008. They were also mainly written as tasks for care staff to carry out. They had been evaluated monthly but the care plans had generally not been updated when residents needs had changed. The evaluations gave some indication of residents preferences but these had not been used to update the care plans. The evaluation for one resident with dementia stated constantly refuses a bath and does not allow anyone to shave him but the care plan did not reflect this. They had very dry skin but this was not mentioned in the care plan. They also had extremely long finger nails and an ingrained brown deposit under the nails. The care plan did not reflect the difficulties staff had providing care or give any indication of whether any different strategies had been used to encourage the resident to accept the care. Staff had completed a range of assessments to identify potential risks to residents. These included risk of malnutrition, risk of developing pressure sores, potential risk of falls and risks relating to moving and handling. They had generally been reviewed on a monthly basis and there was evidence that staff were now taking appropriate action to reduce risk when assessments indicated that this was needed. However, the bed rail assessment for one resident on the residential unit had been completed in November 2009 and there was no evidence that it had been reviewed despite the fact that the assessment stated should be reviewed regularly. This resident had dementia and was able to move around their bed making it particularly important that the potential risk to their safety should be closely monitored. The moving and handling assessment for one resident on the nursing unit had been written in November 2009 but had not been reviewed until March 2010. The daily care records on both units contained variable detail. Some records were informative but others did not give sufficient information on residents physical and mental health, the care provided or how they had spent their day. Care Homes for Older People Page 14 of 32 Evidence: At the last key inspection in October 2009 we found that residents were nutritionally at risk. At the random inspection in January 2010 residents were still at risk as staff were not always monitoring more highly dependent residents weight or taking action to address unplanned weight loss. At this inspection we noted that residents weight was being recorded on a regular basis. Staff had been trained to use the MUST malnutrition screening tool, so that they could establish the weight and BMI of residents who could not use the chair scales. There was evidence that appropriate action was now being taken when residents had unplanned weight loss or had a low BMI. Referrals had been made to the GPs and dieticians and supplements prescribed when necessary. Nursing staff told us that the home used full cream milk for residents but did not appear to be aware that it would be their responsibility to instruct the kitchen staff to enrich food for residents with a low BMI. Two residents on the nursing unit had grade three and grade four pressure sores. One had developed the sores on the nursing unit and one had been transferred from the residential unit with a pressure sore. Staff were able to demonstrate that they were now taking more active steps to prevent sores and to heal those that had developed. Pressure relief mattresses were in use, nutritional care had improved and dependent residents were being regularly turned. The records for the treatment of the sores contained detail of the condition of the wounds and dressings provided and there were photographs to show progress of healing. There was also evidence that the tissue viability specialist nurse had provided advice on care and treatment. One resident with diabetes was having their blood sugar monitored by staff on the nursing unit. The optimal range was recorded on the form. The records showed that in the majority of times this was carried out before they had their breakfast and not randomly to assess their blood sugar at different times of the day. On a couple of times when this was checked at other times the sugar level was above the optimal range but had not prompted staff to monitor in a more random manner. Residents records confirmed that they were registered with a local GP practice and received visits on request. There were systems in place to ensure that residents received chiropody and optical and dental checkups. Practices and procedures for the safe use, handling and recording of medicines were examined by a pharmacist inspector. Medicines are stored securely for the protection of residents in areas which are temperature controlled to maintain the quality of medicines in use. Dedicated refrigerators are used for those medicines needing cold storage, the temperatures of these were acceptable and are monitored and recorded regularly. In some peoples rooms we found some creams and ointments which did not have a label bearing the persons name it is used for. If such containers do not have a printed label it is Care Homes for Older People Page 15 of 32 Evidence: important that the persons name is written on the container to prevent it being used for the treatment of another person and so reduce the risk of cross infection. We expect this to be managed by the home rather than make a requirement on this occasion. We looked at the records made when medicines are received into the home, when they are given to people and when they are disposed of. In general these were in good order with very few discrepancies. The records account for medicines in use and demonstrate that people receive the medicines prescribed for them. However, we found that some people are prescribed medicines to be given regularly but the records show they are only given them on a when required basis. We could find no record that this variation in instruction had been discussed with the prescriber. We have found this on previous inspections so we have now made a requirement about this. We looked at care plans for medication for people who look after their medicines themselves and these were in good order. We saw that appropriate risk assessments are in place where people use medicines in their rooms. The requirement made about this on the last inspection has been met. Care Homes for Older People Page 16 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents at Michaelstowe are given opportunities to take part in a variety of social activities but more individual therapeutic activities are needed to support dependent residents. Residents enjoy a varied menu of homely type food that satisfies their dietary and cultural expectations. Evidence: A resident told us the activities person is very good. They told us that there were a range of activities each week and outings supported by the Friends of Michaelstowe Hall. The outings included visits to the beach, ten pin bowling and shopping. They said they particularly enjoyed the outside entertainers such as singers and actors who visited the home on a regular basis. At the key inspection in October 2009 we had concerns that highly dependent residents who could not fully communicate their needs were receiving minimal interaction from staff. At this inspection we noted that a social diary was now being held in their rooms. This demonstrated that staff were now spending more time on social interaction with these residents. However the records also identified that staff needed training in the range of stimulation and interaction that would be suitable for residents with, for example advanced dementia or following severe strokes. A record Care Homes for Older People Page 17 of 32 Evidence: in one residents room indicated that care staff had asked them if they wished to go for a walk the next day, but although they had said they would like to go for a walk there was no record that staff had taken them out or offered to take them on the next day. From previous knowledge of the home and the visitors book viewed, it was evident that residents could receive visitors at any reasonable time, during the day, in the evening or at weekends. As a consequence of the number of safeguarding alerts received and the serious concerns for the safety of residents a review of all residents was being undertaken by social workers. However we received information that social workers and advocates had been prevented from entering the home and in one instance a Court Order had been made before access to one resident had been allowed. We were informed that a communion service was arranged for residents and the local church magazine provided to the home. Information provided following the inspection showed that a number of local groups were invited into the home at times throughout the year. Residents were observed to be enabled a choice in where and how they spent their day. Those residents we spoke with confirmed that they were offered a choice in eating in their room or in the dining room and whether they took part in activities or not. Some residents rooms were seen to be personalised with their own belongings (photos, pictures, ornaments etc.). However a number had no personal items and there were no lockable facility for safe storage of their valuables. Information on advocacy services was now seen to be available in the home. The kitchen was viewed and was clean and well organised but the decor remained shabby. However it was good to see that two new cookers had been purchased in recent weeks. We were informed that residents were able to have an alternative choice and soft diets and diabetic diets were provided. Menus were seen to be varied and nutritious, with choices offered and comprising homely type food. Food stocks were viewed and comprised fresh fruit pears, oranges, bananas and vegetables cabbage, broccoli, cauliflower, carrots, parsnips and swede. The cook had been baking cakes and these were seen on plates in preparation for tea. The cook said that sandwiches were made fresh each day and stored in the small fridge to be offered to residents for evening snacks. The menu of the day was seen on display in the kitchen and corridors of the home and in the main dining room.The lunch-time meal was observed being enjoyed by by residents and comprised pork casserole, cabbage, carrots, potatoes and gravy followed by a choice of deserts of rice pudding, fruit or yoghurts. The tables were observed laid with cutlery and condiments and small plants were on each table. Staff were seen assisting residents with eating in a sensitive manner. One resident told us The food is good. I have put on weight here. Care Homes for Older People Page 18 of 32 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their representatives cannot be assured that their concerns and complaints will appropriately investigated and acted upon. Evidence: The complaints procedure was seen on display in the home and a summary was also contained in the statement of purpose. At the previous random inspection the complaints record was not available. At this inspection the complaints record was available and was viewed. This contained nine safeguard alerts that had been received from Essex Social Services together with details of the investigation undertaken by the manager. Feedback was received from Essex Social Services that the investigations were not sufficiently robust. There were no other complaints recorded. The home had safeguarding procedures in place and the records confirmed that updated training had been provided in safeguarding adults and whistle blowing on 8/03/2010. However there were still a number of care workers who had not received updated training. A whistle blowing policy was also available. However staff do not feel confident to use the whistle blowing policy and feedback from some staff indicated there is a blame culture within the home. Care Homes for Older People Page 19 of 32 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 premises were clean and generally well maintained but staff practice with regard to infection control does not provide assurance that they and residents will be safeguarded. Evidence: A tour of the premises was made during the visit to the home. There are two separate entrances to the home. The main entrance to the front of the home leads to the residential part and was securely locked. The rear entrance of the home leads to the nursing unit and the dementia unit (not currently occupied). This had a door entry system in place for security. Several residents rooms, communal rooms, bathrooms, a shower room, medication room, sluice room and laundry were viewed. The premises were generally cleaner than at the previous inspection, although attention to detail was needed in some areas ( light switches, doors etc.). However the sluice room was very untidy. The records seen confirmed that action had been taken to undertake general maintenance and repair. However whilst some residents rooms have been redecorated, net curtains in some rooms were old and very creased. Parts of the premises are in need of refurbishment and several bathrooms were not in use. There are no lockable drawers in the majority of residents rooms. No action had been taken to upgrade baths hoists as recommended by the contractors responsible for their maintenance. Care Homes for Older People Page 20 of 32 Evidence: The nursing unit comprises single storey accommodation only. The residential unit is provided on three floors with residents accommodation on the first and second floors. Stairs and a passenger lift to enable access to the first and second floors of the premises. There were grab rails throughout corridors with aids in bathrooms and toilets to meet the mobility needs of residents. Call systems were provided throughout communal and individual rooms to enable residents and staff to call for assistance. However one call bell located next to the toilet in a bathroom was very old and not in working order. Therefore any resident requiring assistance would not be able to call staff. Specialist pressure relief equipment was in use to meet the needs of individual residents. Some additional slings for hoists had been purchased for residents with mobility needs. A pandemic flu policy was now available staff guidance to be used in the event of an outbreak. The home was generally cleaner than at the previous inspection. However there were three rooms and one en-suite viewed that had a smell of urine. Personal protective clothing (disposable aprons and gloves) were available for staff use when providing personal care. Hand washing facilities (liquid soap and paper towels) were provided throughout to ensure care staff had appropriate equipment to safely provide personal care. However staff practice is of concern as the sluice room was very disorganised, bars of soap were found in the staff toilet, used gloves were disposed of in household waste rather than clinical waste and foot operated bins were located in residents rooms rather than en-suites where they were needed for appropriate disposal of gloves and paper towels. The laundry room comprises two separate rooms, one for dirty laundry and one for clean laundry. Both rooms were in need of redecoration. There were two washing machines (one in working order) and two driers. Both washing machines had sluice facilities (able to wash at 65 degrees centigrade for a minimum of 10 minutes) to minimise the risk of infection. The clean room was well organised with shelving, individual boxes and hanging rails to enable staff to organise the sorting and return of residents laundry. Both washing machines had sluice facilities (able to wash at 65 degrees centigrade for a minimum of 10 minutes) to minimise the risk of infection. Since the previous key inspection new sheets, towels and face cloths had been purchased. However should the client group increase additional supplies would be needed. Care Homes for Older People Page 21 of 32 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. Staff are employed in sufficient numbers but a lack of supervision and assessment of competencies does not provide assurance to residents that their needs will be appropriately met. Evidence: The number of residents had depleted since a decision had been made by the local authority to transfer residents to alternative placements. This was due to the large number of safeguard referrals made and the poor standards of care and neglect found at the home. At the time of the inspection there were nine residents in Greenlands (nursing) Unit and twelve residents in Oaklands (residential) Unit. In addition to the manager there was one registered nurse and three care assistants on Greenlands and one senior care assistant and two care assistants on Oaklands Unit. Ancillary staff comprised one administrator, an activities coordinator, one cook, one assistant cook, two domestic staff, one laundry assistant and one maintenance person. The duty rota was seen and confirmed the staffing levels were as discussed. During the visit to the home, residents were observed to have their personal care needs met indicating that staffing levels were adequate. However these levels are at minimum and should the number and dependency of residents at the home increase these levels will need to be increased. We were informed that the home employed a total of twenty-five care staff of which Care Homes for Older People Page 22 of 32 Evidence: eleven had an NVQ level 2 qualification. This is marginally less than the 50 needed to meet the recommended standard. Several staff had been employed for a number of years at the home. However eight staff had left employment in the previous twelve months. A resident told us They have had some dodgy staff here but they have left. During the visit to the home the recruitment files for three recently employed staff were viewed. All files included evidence that the relevant checks (CRB, two satisfactory references, identification etc.) were undertaken prior to appointment. We were informed that a copy of the General Social Care Council (GSCC) Code of Practice was given to all new staff on appointment to ensure they were aware of their responsibilities as a care worker. The files also included staff contract/terms and conditions detailing their legal rights of employment. We were informed that action was now being taken to ensure references were verified prior to appointment. The AQAA informed us that all staff complete an induction to Skills for Care Standards. The training programme was discussed with the manager and records viewed. A copy of the training matrix was provided. This showed that training had been provided in the previous twelve months on fire safety, health and safety, food hygiene, manual handling, nutritional assessment, infection control, safeguarding adults, whistle blowing, COSHH, care planning (five staff), drug administration (4 staff), dementia (9 staff). However with exception of medication (2 staff), there was no record of competencies having been undertaken for other training.The standard of staff practice with regard to infection control was also of concern at the visit to the service. Care Homes for Older People Page 23 of 32 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents cannot be assured the home is well managed or run in their best interests or that their health and safety and that of staff is protected. Evidence: The manager had recently been appointed to the home. We were informed that she holds NVQ level 3 & 4 qualifications and is an NVQ Assessor. Whilst she has experience of managing care homes she was not a registered nurse. As the care home provides nursing care, a clinical lead is required to provide the nursing expertise. We were informed that advertisements had been placed for this position but there had been no response. At the time of this inspection the manager relied on whichever nurse was on duty for clinical support. This is not satisfactory and does not ensure the health and welfare of residents is promoted and safeguarded. Furthermore the recruitment of the the manager brings into question her integrity and the robustness of the recruitment process. Information has been received by the Commission that confirms one of the references obtained on behalf of the manager was not legitimate and there was no system in place by Michaelstowe Hall to ensure that references were Care Homes for Older People Page 24 of 32 Evidence: verified prior to appointment. The homes quality assurance policy and procedures were discussed with the manager. There had been no formal consultation with residents or their representatives in the previous twelve months. There was no annual development plan for the home that reflected the aims and outcomes for service users. Residents meetings had been held by the activities coordinator but there was no structure for planned meetings with residents and their representatives. Recent meetings had however been held at the instigation of the local authority. The AQAA informed us that reports were completed under Regulation 26 following the Registered Provider visits to the home and copies of these were provided at the visit to the service. The manager said that she had undertaken audits for health and safety and care planning and the records were viewed, however these did not include an action plan that detailed the findings and action required to improve standards. The arrangements for handling residents monies were discussed with the administrator. Neither the manager nor representative were appointee for any resident. We were informed that seven residents managed their own financial affairs. All other residents had a representative to manage their finances on their behalf. Personal allowances were held in secure facilities on their behalf. The personal allowances and records were inspected for three residents. The amounts of money were present and correct for all three residents with records of transactions made and receipts held as evidence. The recently appointed manager said that a system of supervision had been implemented that was planned to be provided at two monthly intervals to discuss care practice and performance and that she had carried out observation of practice for each discipline (i.e. care worker, domestic, maintenance and activities) but had not included nursing staff. We were informed that medication competencies had also been undertaken for two staff. The AQAA informed us that the home had a health and safety policy and procedures in place for staff guidance that were reviewed during 2009. The records confirmed that staff had attended health and safety training following appointment. Evidence of a sample of records viewed showed that equipment (hoists, sling etc.) had been serviced. Systems were in place for maintenance of electrical safety and gas appliances and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g.checks on fire equipment, fire alarms and emergency lighting etc.). Since the previous key inspection action had been taken to install door closures for fire safety and some pre-set valves fitted to ensure water was supplied close to 43 Care Homes for Older People Page 25 of 32 Evidence: degrees centigrade. Care Homes for Older People Page 26 of 32 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 13 Risk assessments must demonstrate how risks have been minimised. This will safeguard residents. 31/12/2009 2 16 22 Complaints must be fully investigated in line with the homes procedures and a record made available for inspection. This will ensure issues of concern are appropriately addressed and used to improve the service. 31/12/2009 3 18 12 Staff must be supported and 31/12/2009 confident to use whistle blowing procedures. This will safeguard residents. Care Homes for Older People Page 27 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 Risk assessments must be regularly reviewed This will ensure that risks to residents are regularly monitored and action is taken to minimise the risk. 30/04/2010 2 7 15 Staff must ensure that care plans are kept up to date and that residents, and relatives where appropriate, are involved in their development. In order that the plans reflect residents current needs, preferences and wishes. 30/04/2010 3 9 13 People must only be given medicines in accordance with prescribed instructions, any variation to these instructions must be discussed with the prescriber. 30/04/2010 Care Homes for Older People Page 28 of 32 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 This will ensure people are only given medicines as prescribed. 4 16 22 All complaints must be recorded and fully investigated in line with the homes complaints procedure. This will ensure residents and their representatives views are listened to and acted upon. 5 18 21 All staff must receive updated training in safeguarding adults and whistle blowing. This will enable them to feel confidant to report any issues of concern and safeguard residents. 6 26 13 The smell of urine must be removed from the rooms identified at inspection. This will ensure that residents are safeguarded from infection. 7 31 18 A clinical lead must be 30/06/2010 appointed to provide support where the manager is not a registered nurse. 07/05/2010 31/05/2010 30/04/2010 Care Homes for Older People Page 29 of 32 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 This will ensure that nursing advice and support is available to meet residents nursing needs. 8 33 23 The quality assurance programme must be developed to include service user and stakeholder consultation and to produce an annual plan for the home. This will promote continued quality improvement for the benefit of residents and staff. 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 30/06/2010 1 3 An additional registered nurse should be available to undertake assessment of residents in hospital or their home prior to admission. Staff should obtain guidance from the dieticians on the different ways of enriching food when residents have unplanned weight loss or low BMI. Staff should receive updated training in care of residents with diabetes. Staff should receive training in the range of activities suitable for residents with conditions such as advanced dementia or severe stroke, in order that they can provide appropriate stimulation. A plan of redecoration and refurbishment of the premises with timescales should be provided to the Commission. Page 30 of 32 2 8 3 4 8 12 5 19 Care Homes for Older People 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 6 7 26 28 Staff infection control competencies should be assessed and their practice monitored to ensure they are adhered to. All care staff should undertake NVQ level 2 training to ensure they are skilled and competent to appropriately care for residents. Staff should have their competencies assessed following all training to ensure they have understood the course content. 8 29 Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 32 of 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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