Care Home: Monmouth Court Nursing Home

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What the care home does well Residents we met liked the staff, who they described as being "friendly" and "very nice". Residents surveyed told us they received the care and support they need. All agreed that the home is kept clean and fresh, and that "housekeepers does a lovely job". Comments from the residents we met during our visit included "appreciate being here - they look after you", "nice here - care for you" "lovely - wouldn`t be anywhere else". Residents we survey and met told that they liked the nutritious home cooked meals "always make me an alternative if I dislike what is on the menu", and praised the Chef who "always cooks me what I want and comes and see me everyday with the Matron". Residents we asked, told us that they would recommend the home to others. Relatives surveyed when asked, what does the home do well, their replies included "they make you feel like your relative is the most important person in the world which of course they are", "we are very happy with the care he is receiving ", and the unit manager and staff "are always attentive and caring of mum and us", "dad receives a higher level of care than we expected", "they treat everyone like they are family and give them warmth, care and support" and "they treat and respect everyone as you would expect" The home follows safe recruitment procedures to make sure any staff working at the home are allowed to do work with vulnerable people. New staff are given training and support to enable them to undertake their role. then receive on-going `refresher ` training to keep their skills updated. Feedback from residents surveyed, and discussions with residents, visitors and management during our visit, showed that staff listen to what people say and will take action to address any concerns. What has improved since the last inspection? What the care home could do better: The home must ensure that they only admit residents who they are registered to provide care for, as we have assessed the home as being able to provide a service and level of environment to meet the needs of the residents admitted under these categories .Care plans for people who have confusion and dementia, need to give staff more guidance on how they will support the resident, during times of anxiety and increased confusion. Nursing staff must complete medication records correctly, by not signing to say they have witnessed/given the medication until they have actually done it. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Monmouth Court Nursing Home Monmouth Close Off Montgomery Road Ipswich Suffolk IP2 8RS     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: Jill Clarke     Date: 1 8 0 6 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 39 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 39 Information about the care home Name of care home: Address: Monmouth Court Nursing Home Monmouth Close Off Montgomery Road Ipswich Suffolk IP2 8RS 01473685594 01473680785 lyonscl@bupa.com 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) : BUPA Care Homes (CFHCare) Ltd care home 153 Number of places (if applicable): Under 65 Over 65 153 0 old age, not falling within any other category physical disability Additional conditions: 0 153 The maximum number of service users who can be accommodated is: 153 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 Physical disability - Code PD Date of last inspection Brief description of the care home Monmouth Court was built in 1993 and purchased by BUPA Care Homes in 1998. The home is situated next to a pleasant park in the residential Maidenhall area of Ipswich, about 2 miles from the town centre. It is on a local bus route to and from Ipswich town centre, and near a local parade of shops. There is ample parking to the front of the building. Monmouth Court is a modern purpose built care home and consists of four houses (Raglan, Powys , Cilgarren, and Harlech), offering a total of 153 places. All bedrooms are of single occupancy, 33 of which offer en-suite facilities, whilst the Care Homes for Older People Page 4 of 39 Brief description of the care home others have a wash hand basin, and are located close to communal toilets and bathrooms. The new extentions provides the houses, in addition to the previous lounge, dining and conservatory area on each house, a total of 5 extra lounges and 1 quite room. All bedrooms have views of the landscaped gardens. Fees vary depending on room and the level of care provided, and currently ranges form £541.12 to £918.00 per week. Care Homes for Older People Page 5 of 39 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: We (The Commission) visited the home unannounced on the 18th June 2009 to carry out a 2 day key inspection, where we focused on assessing the outcomes (see bar chart above) for people living at the home, against the Key Lines of Regulatory Assessment (KLORA). In undertaking this, it helps us gain an idea, from a residents viewpoint, on what it is like living at the home, and gain feedback on the level of care they receive. The report has been written using accumulated evidence gathered before, and during the inspection. We last inspected the home on the 19th June 2007. A selection of our surveys were sent to the home in March this year to give out. This gives an opportunity for people using, working in, and associated with the service to give their views on how they think it is run. At the time of writing this report we had Care Homes for Older People Page 6 of 39 received surveys back from 23 residents, 3 relatives, and 13 staff. Comments from which have been included in this report. Prior to the inspection the home was asked to complete an Annual Quality Assurance Assessment (AQAA). This provides us with information on how the home is meeting/exceeding the National Minimum Standards. It also provides us with any planned work they are intending to undertake during the next 12 months. Comments from which have also been included in this report. We spent time talking to 8 residents in the privacy of their bedrooms, as well as gaining general feedback whilst meeting residents and their visitors during the 2 days. We looked at a sample of records held at the home which included care plans, staff recruitment paperwork, training records, menus, contracts, incident forms and medication administration records. By doing this we can see whether staff are keeping their records up to date, and reflects current practise, to ensure the safe running of the home. Everyone we met during the 2 days (residents, staff, and visiting relatives) was very helpful and participated in the inspection by giving us feedback and providing information when asked. People living at the home prefer to be described as residents; therefore this report reflects their wishes. What the care home does well: What has improved since the last inspection? What they could do better: The home must ensure that they only admit residents who they are registered to provide care for, as we have assessed the home as being able to provide a service and level of environment to meet the needs of the residents admitted under these categories . Care Homes for Older People Page 8 of 39 Care plans for people who have confusion and dementia, need to give staff more guidance on how they will support the resident, during times of anxiety and increased confusion. Nursing staff must complete medication records correctly, by not signing to say they have witnessed/given the medication until they have actually done it. 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 39 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 39 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. People thinking of using this service will be given sufficient information to support them in deciding if the home will be able to provide the level of care and environment they are looking for. It cannot be assured that the homes own pre-admission procedures are robust enough to ensure that they do not admit people who they are not registered to care for. Evidence: As we entered the home, we found a selection of useful information for people to learn about BUPA as an organisation and what it has to offer. There is also more localised information about Monmouth Court, so prospective residents know what the home is able to offer. When we asked residents surveyed, if they felt they were given enough information before they moved in, to support them in identifying if it was the right home for them, all but 3 replied yes. Comments included my family came and looked round for me and decided it was nice, they were very helpful and informative Care Homes for Older People Page 11 of 39 Evidence: and my daughter decided it was right for me and I agree. Some residents get to know the home and level of service provided during short respite breaks. We managed to speak to a resident who so far has road tested 2 of the 4 houses, and they shared their views on which they personally preferred, and why. Discussions with the Administrator, identified that the majority of the residents are social funded, therefore will not have a contract direct with the home, but with Adult Care Services. However the home does ensure that all social care funded residents are given the same level of information on what is included in the fees they are paying, as private paying residents are given. Where residents are paying privately for their care, 2 completed contracts seen, showed they are informed how much it will cost them to stay at the home, and given a copy of the homes terms and conditions before they move in. All 23 residents completing our survey, replied yes when asked if they had received a contract. This reflected our findings during the inspection, when a resident was able to tell us how much they are paying a month, which they felt was not bad. When we arrived at the home, we were informed that the Registered Manager was out visiting prospective residents at a local hospital, to carry out the homes preassessment. Later in the day, whilst visiting 1 of the houses, we saw a copy of the preassessment undertaken that morning, which involved a social worker as part of the persons integrated discharge planning team assessment. Staff had started putting together a care plan, whilst awaiting the admission of the new resident later in the day. Discussions with staff, confirmed that the manager or another experienced trained person, will visit all prospective residents. This enables them to speak to the person, and those involved in their care, to support them identifying if they are able to provide the level of care and support the person is needing/looking for. In a thank you letter to the home is stated thank you for coming to talk to us before (name of resident) was admitted to your nursing home, this gave him the assurance that he would be moving to a home from home, rather then to an impersonal institution. By the home undertaking their own pre-assessment, it should ensure that they do not accept a resident who they are not registered to care for. The homes registration Care Homes for Older People Page 12 of 39 Evidence: certificate displayed in the reception area, shows that they are registered to take people whose primary care needs on admission to the home are within the following categories OP (Older People) and PD (Physical Disability). However, during our inspection we identified that the home had recently admitted a resident who does not fall within their registration category, as their primary needs are dementia care. The manager was informed that we would write formally, following the inspection, which would enable them to tell us what action they would be taking to address the situation. Feedback from relatives showed that the home is able to meet the needs of their next of kin, comments included we are very happy with the care he is receiving , and the unit manager and staff are always attentive and caring of mum and us. However, spending time with a resident, and reading 2 care plans, we identified where the home was not fully supporting the 2 people with their mental health needs (see Health and Personal Care section of this report). When we asked the relatives if they felt the home gives the level of support they expected, their replies included dad receives a higher level of care than we expected and they treat everyone like they are family and give them warmth, care and support. Residents surveyed when asked if they receive the level of care and support you need, all but 5 (who said usually) replied always. When we asked a resident would you recommend the home to others they replied oh yes then told us about situation when a visitor had asked how they could get a place at the home. Whilst on 1 of the houses we met 2 Suffolk County Council carers who visit 3 times a week as part of a pilot scheme, to provide extra support for people receiving intermediate care. The scheme allows residents who have been discharge from hospital, but are not quite fit enough to return home, a place to finish their convalescence, whilst being supported to gain confidence in undertaking tasks again, such as making a drink. The staff praised the support they were given by Monmouth Court staff, saying they felt staff work well together, and although a pilot scheme at the moment, they hope it will be extended or become permanent in the future. A thank you letter displayed in the reception stated now that my husbands transitional placement at Monmouth court has come to an end, I should like to express my gratitude to you and your staff feel kindness and care shown to him throughout his stay. Care Homes for Older People Page 13 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can expect to be consulted on how they wish to be look after, treated with respect, and have their nursing needs monitored, and appropriate action taken to address any changes, to ensure their well-being. Evidence: Each resident has a care plan, which gives staff guidance on how the persons medical, physical, and nursing needs are to be met. Staff start putting the care plan together, before the resident is admitted, using information obtained from their pre-assessment. Then once the resident is admitted, staff will continue collecting and recording information in the care plan, to ensure it becomes individualised to the persons needs. Care plans also shows evidence of staff consulting with the resident (and if unable to their relative or friend), to ensure any preferences or wishes the resident has, is included in the care plan. Information held in the care plans is regularly reviewed, and updated as needed, to ensure it meets the residents current needs. We looked at 5 residents care needs in detail, spending time reading their care plan, Care Homes for Older People Page 14 of 39 Evidence: discussing their care needs with staff, and where able to, spending time talking to the resident to hear their views on the level of care they receive. Information held in the care plans showed that staff are supporting people with their mobility, nutrition, continence, medical and nursing needs such as diabetes, and pressure sores. Information held in care plans evidenced that staff liaise with external health professionals, such as General Practitioner, Hospital Consultants, and Speech Therapists, to support residents specialist needs. Where we found residents physical and nursing needs were being well documented, information on supporting 2 residents with their behaviour needs was not so informative. There was more information written about what the residents would not do, refused to change dress to night dress and resistance to care from arrival, rather then looking at why the people may be anxious and resisting care, and adjust the guidance given to staff accordingly. Nursing staff complete a daily record sheet on tasks undertaken, and discussions with the manager and staff, showed that they had a good insight into residents individual needs, and family support group. During our visit whilst talking to residents we noted that they look well presented, however whilst talking to 1 resident, we noticed that their fingers nails were dirty and long. When we pointed this out to staff, we were informed that the activity person normally looks after the nails. This led to discussions around as an activity, some residents enjoy having their nails manicured and varnished, but staff should be monitoring on a daily basis, as part of supporting residents with their personal hygiene. We then looked at the residents concerned care plan, we noticed that they had refused a bath 2 weeks in row, before accepting a bath on the 29 May, then nothing had been written on the bathing sheet, after that date. There was no information on the bathing sheet to show that staff had offered the resident a bath, on other days, apart from their allocated weekly bath day, to see if the resident had changed their mind. The daily record did show that staff had assisted the resident to wash and dress the day we visited. We fed our observations back to the nurse, who said they would look into the situation. When we asked residents surveyed if they receive the medical support they need, all but 3 (who had replied usually), said always. In the compliments file we read a letter sent from a relative saying that they were impressed by how staff knew and understood the people in their care they went on to say in the midst of their busy schedule they would always make time to explain medical matters in terms which a lay person can follow. We observed the lunchtime medication routines on 2 of the houses, and found on both Care Homes for Older People Page 15 of 39 Evidence: houses medication was being given out at the same time, as residents were eating their lunch. When we asked if this was their normal practice, we were told that they would normally be given out before, or after lunch. We also noted on 1 of the houses that the drug trolley was left open, and we could not see, from where we were sitting, any member of staff monitoring the trolley, to ensure that nothing was removed. When we asked the nurse concerned, we were told that they didnt normally leave the trolley in that area (in-between the main dining room and sun room), they would have it with them in the dining room, and felt they could see it from where they were. On 1 of the houses we observed 2 nurses not following safe practise when giving a resident their controlled medication. This was due to the first nurse signing to say they had given the drug, and the second signing to say they had witnessed it being given, whilst they were still standing in the medication room. When the first nurse went off to give the resident their medication, we observed the second nurse pop their head out of the door. We checked BUPAs own medication policies and procedures, which correctly states that both staff should go together, to witness the medication being given, then come back and sign the record book. In following these procedures, it works as a double check to ensure the right resident is given the right medication. We asked both staff individually if this was their normal practice and they told us no, and then told us what they should have done. The second nurse commented that on realising they had not followed proper procedures - had checked to ensure the first nurse had gone to the right residents bedroom when they had popped their head out of the room. we fed our findings back to the manager, who confirmed that the staff concerned are fully aware of the procedure, and the situation would be addressed through supervision. On 2 of the houses we visited, we checked a sample of the medication administration records, known as the MAR sheets, which lists the individual medications residents are taking. The majority of the medication is provided by the local pharmacist in blister packs. The packs provide a 28-day supply of individual residents medication, and the see-through packaging enables nurses to see what tablets they are giving, and how many they have left. We checked a sample of 3 residents medication which had not been supplied in blister packs, and found the amount held, agreed with the totals the home said that they had in stock. On the second day of our visit, we observed medication being given out in another house, this time prior to residents having their evening meal, so the taste of their medication would not distract from the taste of their food. A check of bottles of eye drops held, showed that staff are writing the date it was first opened, so they know, due to having a 28-day shelf life when to stop using the drops, and start a fresh Care Homes for Older People Page 16 of 39 Evidence: bottle. Where medication was being stored in a drugs fridge, the temperature was to be checked and recorded daily to ensure it is being stored at the correct temperature. When we looked at the records we noted that out of the 18 days recorded, 8 have been below the required minimum temperature. When we pointed this out to the nurse, they took action by adjusting the dial on the inside of the fridge, and when we checked again, it was back within the required temperature range. The nurse confirmed that they would continue to monitor the situation, to ensure the fridge was working okay, and if not, seek further advice. Whilst walking around the bedroom areas, we heard staff knocking on bedrooms doors, asking if it was alright for them to go in. Residents we spent time with, confirmed that this was staffs normal practice. During lunch time, staff went round putting a disposable paper bib on residents to protect their clothing from spillage. Some staff were heard to ask the resident if they would like 1 - before they put it on, for others it seemed to be an automatic part of the meal time routine, of placing a bib around the residents necks. Good practice was seen when a carer, having noticed that the residents bib had got very messy, straight away offered to replace it with a clean one to protect their clothing. When we asked a resident if they felt staff ensured their privacy and dignity is preserved whilst they received personal care, they told us that staff are well mannered and they have never had any problems. Another resident told us that they felt pestered by a resident who is confused, as they kept coming in and out of their bedroom. Although they were aware that they could close their door, which would prevent this from happening, they didnt want to do this, as they preferred it to be left open. They were also aware that the person was on respite care, so they would be leaving soon. With their permission we fed this back to the manager, who said they would take action to prevent this happening by using sensor mats, to alert staff that the confused resident had left their bedroom, so they can offer assistance/monitor where the resident is going. The homes own quality assurance survey feedback shows that out of the 44 people completing them, when asked how do they rate the respectfulness of staff towards you, the replies were spilt 50/50 between excellent and good. When we asked the relatives surveyed, if they felt the home is able to meet the different diverse needs of the residents, they replied always, with 1 relative commenting they treat and respect everyone as you would expect. When we asked a Care Homes for Older People Page 17 of 39 Evidence: relative who visited daily about the care their next of kin receives, their comments included staff are very nice - cant find any faults - happy with the care. A resident staying on short term respite care, when we asked their views , they told us that they are very happy with them, and liked the house they were staying on. Care plans contain varied information on residents end of life care arrangements, depending if the resident wanted to discuss this subject with staff. For example in 1 care plan staff had written didnt want to discuss, where another care plan gave detailed information on the residents wishes. Whilst talking to a resident, we found that they brought up the subject themselves, telling us it frightens you a little bit as 4 people have died, who they have known since they moved into the home. Further discussion identified that seeing how people are cared for, they felt comfortable that if they became very ill, that staff would give them the care and attention they needed. The AQAA informs us that over the last 12 months staff have built up good links with Hospice, Hospice at home , McMillan, Marie Curie and other community support services, to ensure good end of life care for residents. When a resident is identified as requiring palliative care, staff complete a extra section (Liverpool Care Pathway) of the residents care plan, which details how the staff will support the resident during this stage (taking into account their wishes), including support from other health professionals involved in their care. Care Homes for Older People Page 18 of 39 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. Residents are offered a range of nutritious meals to meet their individual tastes and dietary requirements. Visiting is flexible around the residents wishes, and the home has an activities programme in place, which residents can choose to take part in if they wish. Evidence: When we arrived on the first day of our visit, we met a resident who was celebrating their 99th birthday, and was enjoying the special attention from staff. In the same house we also saw activities going on with 4 residents taking part in a game of skittles. Residents surveyed when asked if there are activities arranged by the home that they can take part in, their replies were split between always or usually. Comments included would like to have more consistent activities and love my game of bingo. The feedback in the homes own quality assurance survey (2008) when asked how would you rate the social and recreational activities and events at the care home overall, 18 replied excellent, 73 said good, and 9 felt neither good nor poor. Comments included more stimulation - different games and more to do - need to be Care Homes for Older People Page 19 of 39 Evidence: more stimulated. On each house there is an activity folder, completed by the Activities Co-ordinator to show what they have undertaken on the house, as a group and also time spent with individual residents. We looked at the activities file on 1 house which showed a sheet completed for October and another in November with no further entries. Another house had completed sheets for June, which gave information on the activities going on Manicures, Snakes and Ladders, Quizzes, Sukdou, Match the Cards and Dominoes. We asked staff how often activities are undertaken and informed every morning 10 1.30, and also for those residents who do not wish to join in, individual activities are also arranged, taking into account their interests and abilities. Staff told us that a trip to Abby gardens had been arranged for July. On the notice board was the hairdresser price list, and information that a mobile trolley shop visits every 5 to 6 weeks, selling a range of items including toiletries and clothing. A resident told us that they had purchased a new tea-shirt from the shop, and had no problems changing it, when they found it did not fit. Monmouth Ct produces their own newsletter, to keep residents and visitors updated on what is happening at the home. The newsletter we read (Winter 2008/Spring 2009), gave information on what had happened over Christmas and that they were looking to try something new for 2009, to raise funds residents and was thinking about planning a race night. There was also information on the Ipswich Mayor and Mayoress officially opening the new extensions in October 2008, and information updating people on staff promotions and transfers within the home, as well as new staff who have just joined them. On the first morning when we arrived, a member of staff was heard to knock on a door, popping their head in saying morning - do you want to get up. Then asking would you like breakfast in your chair - no thats okay, as the resident informed them where they would prefer to have their breakfast. We asked a resident if they are free to choose when they get up and go to bed, they told us yes and that they like to get up at 6.30 in the morning as they have always been used to getting up early during their working life, and go to bed at a decent time 9 pm . We found their name on the early risers board in the office, which alerts night staff, as to who prefers to get up earlier. Another resident told us that while staff are undertaking their care that morning, an extra member of staff had come into assess their work. We asked if the person assessing had asked their permission first and they replied yes. residents confirmed that they can receive their visits when they wanted to, and that they are always made to feel welcome. Care Homes for Older People Page 20 of 39 Evidence: Residents asked (surveys) if they like the meals at the home, 14 replied always, 8 usually and 1 sometimes. Comments included chef will cook me anything I want, the food is very good, always makes an alternative if I dislike what is on the menu and the food is always excellent. During our visit when we asked a resident their views on the food provided, they told replied that they receive 3 meals a day and that they have a good dinner. They told us that someone comes around with the choices for the next day, during the afternoon and fill paper in. We found completed menus on the houses, which also showed the alternative meal choices, and specialist diets offered to residents. The AQAA informs us that the menu master helps ensure every menu within the home is customer led and nutritionally balanced. The lunch time choices on 1 of the days was Cottage pie or Macaroni Cheese, creamed mash/potatoes, cabbage and peas. Followed by Stewed Apples or Bakewell Tart and Custard. The resident also told us that the manager and chef comes every day to see if meals are alright. We witnessed during both lunch times, the Manager and Chef visiting the houses, and asking residents their views on the meal. Observing the lunch time routines on 2 different houses, showed that they both varied, we found the routines on the second house more relaxed, with a more social atmosphere with relatives sitting eating with the residents, joining in and instigating conversations. We were also told by a resident that they get plenty of drinks during the day, especially as they like to drink plenty of water, at which point a member of staff came in and changed their water jug. When they left, the resident informed us that they do that every day. We asked if they felt the meals times are rushed and they said no saying staff serve the meal up. The AQAA tells us that their Nite Bite menu allows our residents to choose what to eat when they feel like it, proving healthy choices at any time through the night. The menu is available between 6.30 pm and 6.30 am, is displayed on each of the houses, and includes snacks such as beans or spaghetti on toast, selection of sandwiches, soup, cakes and biscuits. When we asked a resident if they had ordered anything off the menu, they said they felt they were eating enough as it was. The home has started their own vegetable garden (which we were shown photographs of), and residents had been able to sample a range of their produce, including strawberries, lettuce and beetroot. Care Homes for Older People Page 21 of 39 Care Homes for Older People Page 22 of 39 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 relatives feel staff will listen to any concerns they may have, and then take appropriate action to address them. Staff are aware of their responsibilities in reporting any concerns they may have over a residents welfare , to safeguard the interests of the people they are looking after. Evidence: The AQAA tells us that the complaints policy is prominently displayed in the home, it is also contained in the Service User Guide and Statement of Purpose. Survey feedback from residents and relatives, showed that they are aware of the homes complaint policy, and know who to speak to if they are unhappy with any aspects of their care. Discussions with relatives during the inspection identified where they have raised concerns, they felt the home had listen to what they had to say, and taken action to put the situation right. We asked a resident if they would feel comfortable to tell staff if they were not happy with the care they were receiving, and they said they would. They gave as an example where they felt a new member of staff was moving them a bit quickly. They said they had dealt with the situation by saying to the carer Im not a bit of meat on the butchers slab, I am a person please be careful. They said this resulted in apologies straight away from the person concerned, and there was never a repeat of the situation. Care Homes for Older People Page 23 of 39 Evidence: The AQAA informed us that at the time of completing (14/05/2009) they had received 8 complaints, 75 of which had been resolved within 28 days (discussion during the inspection identified any delays had been due to collecting further information). We looked at the records kept by the home, which gave detailed information on the complaints received, and what action the staff had taken to address them. All complaints received had been acknowledged by the manager quickly, for example 1 received on the 14/4/09, the manager had sent a letter on the 17/4/09 acknowledging their concerns. Where a complaint had been upheld, there was information on what action had been taken by the manager to ensure the situation did not happen again. There was also an anonymous complaint which was sent directly to the BUPA main office. Unfortunately the person complaining had given very limited information such as quality of care is appalling. There was no information to back up why they felt this, and if their concerns were about staff practice on a particular house. The manager said, as they take all complaints seriously, in this case, they could only make each of the houses senior staff aware of the general concerns raised, and continue monitoring practice on the houses. The AQAA also informed us that 2 safeguarding referrals had been made, which were investigated by the vulnerable adult team, and were not upheld. Discussions with the manager confirmed their knowledge of the Suffolk Safeguarding procedures, and actions they must take to safeguard the people they look after. Training records seen, showed that staff are receiving Protection of Vulnerable Adults (POVA) training to ensure they know what action to take if they suspect, or witness, an incident which affects the safety or wellbeing of the residents at the home. This was further evidenced in the staff survey feedback, with all staff replying yes when asked do they know what action to take if a person raises any concerns. Comments included always report it, if I feel I couldnt go to the nurse on the unit I would speak to (name of person) or Matron and I would listen to their concern and may be able to reassure them myself. Whether or not I was able to, either would pass the matter to my immediate supervisor and also by ticking matrons daily communication (see Management and Administration section of this report) sheet. Residents surveyed, when asked if staff listen and act on what they say, all had replied Yes. Staff also confirmed in their surveys, that the management had taken up references and undertaken Criminal Bureau Record (CRB) checks before they started work at the home. In undertaking this, the home is checking to make sure the new member of staff is suitable to work with vulnerable people. Care Homes for Older People Page 24 of 39 Care Homes for Older People Page 25 of 39 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. The home offers a homely, clean, safe environment,which meets the personal , and mobility needs of the current residents, whilst promoting independence. Evidence: Since we last did our key inspection, major building works has been going on, with an extension being built onto each of the 4 houses, increasing the number of bedrooms from 120 to 153. The 33 new bedrooms offer en-suite facilities, and are furnished and decorated to a high standard. The new extensions have also increased communal space, to reflect the increase in numbers. Many of the beds are yet to be occupied; however, we found good use being made on 1 of the houses, with the new space being used as a rehabilitation area for resident admitted for intermediate care. The area enables staff to support residents to maintain/assess their domestic skills, such as making a drink, prior to being discharged home. In the entrance way to each of the houses we found a Fire emergency folder and fire log book which included a fire risk assessment, information on residents mobility, in case the home needed to be evacuated. There is also information to show when staff fire training is happening, and equipment and alarm systems being checked to ensure they are kept in safe working order. We notice when visiting a resident in their bedroom, that their door back was held back with a novelty door stop. We asked if the Care Homes for Older People Page 26 of 39 Evidence: door closed okay when the fire bells went off, they told us the door starts to close and it slides out of the way. Whilst walking around the houses we met the 2 maintenance persons who visit all the houses each day to check the maintenance books, where staff record any problems that have occurred. Staff confirmed that it is normal practice, telling us that each morning they come, check and sort out any problems there may be. Senior staff on each of the houses who complete the Matrons Daily Report, also write any maintenance issues raising concerns, so they are also aware and can follow it up to ensure it has been sorted. We mentioned to the manager, that whilst observing the lunch time routines on 1 of the houses, we saw that there were not enough stools/chairs for staff to sit on, whilst they were assisting residents with their meal. The manager told us that they are due for refurbishment this year which reflects the information given in the AQAA (under plan for improvement in the next 12 months), refurbishment of the whole site within next six months. The manager confirmed that they had not been given any set dates. The homes own quality assurance survey showed when they ask residents about they could improve, the majority of comments were around the environment could do with decorating - looking a bit tatty in places. This reflected our finds, with areas showing signs of wear and tear. In the bathroom/shower rooms we visited, there was evidence that staff were checking the hot water temperature prior to residents using the facilities, to ensure that the water was not too hot to cause any discomfort. Staff told us that there are sufficient specialist mattresses to put on the beds, to ensure the comfort of residents and prevention of pressure sore developing. The well kept gardens gives plenty of colour, and places for residents to sit out, and showed no signs of the recent building work. We asked a resident if the building work had caused any disruption to their life, and they replied not really, a bit noisy, but okay, they also assured us that any building work was started at a reasonable time in the morning. We found the sluices we looked at, to be clean, tidy and odour free. However, we did notice on 1 house, that the clean commode pots were left drying on a wooden, slated shelf, rather then using an airier, which would allow the air to circulate and dry the pots, which is more hygienic. We asked a resident about the laundry facilities and they told us staff are good at Care Homes for Older People Page 27 of 39 Evidence: ironing. We asked if they had ever ended up with other peoples clothes and they said yes but only once, and they gave it straight back. We asked a resident who through their own choice, wishes to spend all their time in their bedroom, if the room is kept clean and fresh they replied oh yes staff will come in early to pull chair out before I am in it, my room is cleaned up every day. They went on to tell us how impressed they were when after a some fluid had been spilt on the floor, this had been fed back to the housekeeping staff, who within a short time came and cleaned the area of carpet. This reflected the feedback we received from the residents surveyed, with 20 replying always and 3 usually when asked if the home is kept clean and fresh. Comments included housekeepers are very friendly, The home is always lovely and clean and Housekeepers does a lovely job. We asked a housekeeper if they are given sufficient equipment and training for their role which they said they did and explain the procedure for clearing up bodily fluids, which we were informed that the carers deal with it first ,t hen they go in and use the carpet cleaner. They felt by tackling it straight away it prevented any unpleasant odours developing. Care Homes for Older People Page 28 of 39 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. Staff have been cleared to work with vulnerable people, and receive training and support to ensure they have the skills and knowledge to provide a good level of care. Evidence: Following our last inspection we recommended that the home should review their staffing levels to ensure they reflect the varying needs of residents, throughout the 24-hour period. The sample rotas we looked at during this inspection on 1 of the houses, showed that the staffing levels are still set, reflecting occupancy and not dependency levels. We asked the unit manager if the current staffing levels are sufficient to meet residents needs. They felt it was at the current time, taking into account that not all their rooms are occupied. However, the unit manager did feel confidant, that if the need arose, they would be given extra staff to support residents individual needs. They then gave us a good example where a resident, who was on respite care, who soon after coming in identified that they would need extra support, due to the persons behavioural problems. They told us that when they fed the situation back to the manager, it was arranged for an extra member of staff to support the resident day and night until they were discharged. Care Homes for Older People Page 29 of 39 Evidence: We also asked nursing staff on 2 other houses if they felt the staffing levels are sufficient, and were informed they were okay. A nurse told us, having moved from a hospital to a care home setting, they felt that they now had got time to talk to the people they cared for. This reflected the feedback from the staff surveyed who replied either always or usually when asked if they feel there are enough staff to meet the individual needs of the people they care for. Comments included seem to have a lot more staff now, more staff are now working here, normally and Charge Nurses and site carers always make sure that any sickness is being covered especially now that we are full of staff. Residents surveyed in response to be asked are the staff available when you need them, out of the 22 responding to this question, 12 replied usually and 10 always, with 1 resident commenting they work very hard. The homes own quality assurance survey showed an improvement on their 2007 survey feedback, when being asked to rate the promptness of staff attending to your needs, 30 rated it as excellent, 68 as good, and 2 saying it was neither good nor poor. A relative surveyed, in reply to being asked how do you think the care home can improve, said sometimes they seem to be short on staff. However, they also confirmed that their next-of-kin is always given the care they expect, which reflected the feedback we received from the 2 other relatives surveyed. We asked 3 residents (on different houses) if when they rang their call bell if they ever needed to wait, replies included no not really, yes if short staffed and yes - if shortage of staff - left waiting. A resident felt that staff dont do it (delay answering the call bell) on purpose and once staff do come - care is good. Further discussion with the residents who said that they are sometimes left waiting, was more due to staff always looking for hoists and stand Aids, 1/2 hour is a long time to wait for a wee. This reflected the 2 comments make in the same section on the homes own surveys quicker to be taken to the toilet and more staff. We fed the comments re lack of hoists back to the manager who said they would look into the situation, as they felt there is sufficient equipment on all the houses. All the residents we spoke with, were very positive about the staff, comments included get on alright with staff, staff friendly - very happy with them, and lovely wouldnt be anywhere else. The AQAA informs us that all mandatory training is up to date, and told us that they have a good level of staff retention, as turn over of staff has slowed (40 care staff/nurses have left in the last 12 months), however they also saw this as an area they could improve on. They informed us that there is very minimal use of Care Homes for Older People Page 30 of 39 Evidence: temporary/agency staff, which helps ensure a consistent approach to care. Staff surveyed also told us that they are receiving training which is relevant to their role, helps them understand and meet the individual needs of the residents, and keeps them up to date with new ways of working. Training records showed staff are attending regular training sessions to support them in their role, which includes dementia care awareness, moving people safely, preventing the spread of infections and handling food safely. Information given in the AQAA shows that out of their 56 permanent care workers, 13 hold a National Vocational Qualification (NVQ) at level 2 or above. Therefore, the home will need more staff to undertake the training, to be able to achieve having 50 of their staff qualified to this level. The AQAA gave no information on how they will be achieving this. However, discussion during the inspection with the Manager and staff, identified that they now have a dedicated training co-ordinator, who will monitor new staff through their induction training, then will be supporting them to apply, and obtain their NVQ. We spoke to a new member of staff who had completed their induction training, and had started their NVQ training 3-4 weeks ago. Staff surveyed when asked if their induction covered everything they needed to know to do their job when they first started, 4 replied mostly and 9 very well. Comments included watched lots of videos, had manual handling training, and fire, and first aid, then a week of shadowing an experienced carer. Time spent with a housekeeper, also identified that they had received training in handling cleaning equipment and materials safely. When we asked a nurse if they felt they receive the training and support to help with their professional development, they confirmed they did, and showed us some of the training sessions advertised on the notice board ,which they can apply for. We also spoke to 2 newly qualified Nurses about the homes preceptorship and orientation training, which supports newly qualified nurses, whilst they build up experience and confidence in their new role. Feedback was very positive, with staff feeling that the support given is fantastic, as they feel they are being given the responsibility of overseeing a shift, whilst knowing that there is always a more senior nurse on site, to contact at any time, to discuss any professional/practice issues. Relatives asked if they felt staff have the right skills and experience to look after people properly, taking into account their different cultural needs, replied always or usually. Comments included as far as we are concerned and they have a lot of new staff and they are often trained while they are working and mum has often spoken of helping new carers. Care Homes for Older People Page 31 of 39 Evidence: We looked at 2 recently recruited staffs recruitment paperwork, which showed that the home is following safe recruitment procedures, undertaken prior to staff starting work at the home. This included making sure that they physically and mentally fit to undertake the job, and being given a job description, so they know what is expected of them in their role. Care Homes for Older People Page 32 of 39 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. Staff are committed to working as part of a team, to ensure they are working in the best interests of the people they care care for. Evidence: Throughout the inspection the Registered Manager Claudette Lyons demonstrated her enthusiasm and commitment, to ensure staff are working in the best interests of the people they care for. Discussions with the manager and records seen, shows they are keeping their own professional and regulatory knowledge updated to ensure the home is keeping up to date with current practise. They have also continued to build links with other care professionals and organisations in the community, as part of accessing services to the benefit of the residents, for example as being part of a local palliative team forum. In such a large home (153 beds), spread over 4 houses, each of which has a unit manager, who are in-charge of the day-to-day running, Mrs Lyons is aware of the Care Homes for Older People Page 33 of 39 Evidence: importance of ensuring that she is kept up to date, with all aspects that could affect the residents and staff welfare by having good communications systems in place. We saw 2 of these systems in use during our inspection with their daily visits with the Chef, to each of the houses, to hear what the residents thought about their meal. The second, being the Matrons daily diary where senior staff from each of the houses complete each day, providing the manager with up to date information on any aspects, affecting the welfare and safety of the residents on that house. The manager has also developed a site cover rota which ensures that nursing staff, especially those new to the role, always know that a more experienced person is on hand to provide management and professional support. We identified a shortfall in the management of the home (see Choice of Home section of this report), when it became evident that the manager had admitted a resident whose primary needs are dementia, which falls outside their category of registration. The manager admitted they had been swayed by the family situation. The manager acknowledged there was some areas of concerns about providing care for this person, and these issues were evident in the care plan. They told us they would further review the persons care plan, to ensure it is more comprehensive on supporting the residents dementia needs, and would be looking to vary their registration to cover the resident they have taken. We observed the resident interacting well during lunch time with the other residents and relatives sitting at the table, and no other concerns came to light during the course of the inspection. Residents, visitors and staff we spoke with, were all aware who the manager is, and said they see them regularly. They also praised the unit managers, who have their individual styles of management. Residents felt comfortable with the staff, with 1 resident referring to them as like being part of their family. The home keeps their thank yous for visitors to read, which included a letter from a relative praising a unit manager, and their team of professionals, referring to the strong ethos of kindness, tolerance and great good humour, saying they will remember the house as a place of warmth in every sense of the word. We were given a copy of the homes resident customer satisfaction survey 2008, which is carried out by an outside agency, who looks at how well Monmouth court is doing as a stand alone home, and as part of the BUPA organisation . It showed that out of the 60 surveys (50 ) of their residents (or where applicable their advocate) sent out in 2008, 44 (73 ) were returned. When asked how they would rate the quality of service for this care home, 30 replied excellent, 67 very good and 2 Care Homes for Older People Page 34 of 39 Evidence: quite good. Comments included staff - all very polite and kind. They are like my own family and matron and her staff all do a brilliant job. The survey also asked people what would be the one improvement that you would make to the home that would improve your stay here?, out of the 25 comments, 17 related to improving the environment re-do my room as we have had some lovely new rooms done and my TV picture is rubbish new rooms have flat screens from Bupa. There was 2 comments about staffing, 3 about activities and 3 who felt there wasnt any improvements they would make cannot find fault, and couldnt improve. The manager said that the feedback enables them to monitor how they are getting on, and take action to address any areas which they can improve on, for example addressing some of the comments about the environment through their planned refurbishment. The AQAA provides us with further information on how the standard of care is monitored the home is supported by a national team of Quality and Compliance Offices whose role includes supporting quality issues within the home, auditing and providing guidance on policies, procedures and practice. We saw a copy of our last inspection report in the reception area and also on each of the houses, so people are able to read our findings from our last inspection. We were also informed that a newspaper journalist might be writing a piece on the home, which will also give them feedback on what it is like living at the home. The AQAA gives us a list of their policies/procedures/codes of practice, which gives staff guidance to undertaking their role safely, to ensure the welfare of the people they look after. We noticed that the documents had not been reviewed since December 2006. However, the AQAA tells us that Bupa Care Homes has a comprehensive suite of policy and procedure manuals that are regularly reviewed by experts and updated when required. In stating this, the home is confirming that since 2006, there has been no changes in the law, or staff guidance to require the need to update any of their policies/guidance. Feedback from staff surveys, discussions during the inspection, and training records seen, evidenced that staff are receiving regular training to update their skills and knowledge, to ensure the safety and welfare of the people they look after. There is a list of staff trained in First Aid displayed in the houses we visited. On both days of our visits there was a fire evacuation training being undertaken for the staff. Discussion with the homes Administrator identified that they still have the same invoicing and accounting systems that we looked at, and were satisfied with, during our last visit. There has also been no changes in the way residents can be invoiced for Care Homes for Older People Page 35 of 39 Evidence: goods and services if they prefer not to keep their money on them. However, if a resident requires cash the administrator keeps a small float so the resident can have money in their hand when needed. To further safeguard the interest of residents finances, any work undertaken by the visiting hairdresser and chiropodist is countersigned by a nurse on that house, to confirm that the resident has received that service. Which we saw happening during our visit. Care Homes for Older People Page 36 of 39 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 37 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 The home must only admit people that they are registered to care for. As they have been assessed as being able to provide that level of care. 21/09/2009 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 Care Homes for Older People Page 38 of 39 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. 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