Care Home: Murley House Nursing Home

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What the care home does well Murley House provides purpose built accommodation and the home is situated in a quiet residential area not far from the centre of Taunton. The home is maintained to a safe level and records demonstrate that regular health and safety checks take place. People using the service and those who are thinking about using the service are provided with information about the home and services offered. The home ensure that staffing levels are appropriate to the needs of people using the service. In addition to care and nursing staff, the home employs catering, administrative, maintenance, domestic, laundry and activity staff. We were able to see evidence that the home respond to complaints in line with its complaints procedures. Staff at the home told us there is a good supply of moving and handling equipment and pressure relieving equipment. Procedures are in place to reduce the risk of the spread of infection. What has improved since the last inspection? An acting manager has been in post for almost six months and has taken steps to address some of the requirements of the last inspection. Completed comment cards contained positive comments about the improvements the acting manager had made. Positive comments were also received from staff spoken with during the inspection. We spent time observing staff interactions with people using the service and we found these to be much improved. Staff were heard to communicate with people in a kind and respectful manner and staff took time to explain what was happening before and during the time they were assisting them with a task. Staff morale appeared more positive and this will have a positive outcome for people using the service. We found the meal time experience for people receiving nursing care to be much improved. People were being offered choices and were assisted with meals in a dignified and unhurried manner. Although care planning procedures would still benefit from further improvements, we were able to see evidence that staff were delivering care in line with the plan of care. Staff training has improved since the last inspection and further training is planned. This includes mandatory and specialised training. NVQ training is also being promoted. Steps have been taken to ensure that all staff are appropriately supervised. Staff spoken with confirmed that they had started to receive formal supervision sessions. Quality assurance procedures have improved. Since the last inspection the home have sent questionnaires to people using the service and other appropriate stakeholders to seek their views on the quality of the service provided. An analysis showed responses to be generally positive. Regular meetings are now taking place for staff and relatives. A company representative is completing monthly visits/reports to audit the quality of the care delivered. We were able to see that the home are reviewing care plans so that they promote a more person centred approach to care. This is currently on-going. What the care home could do better: The home have procedures in place to ensure that people are assessed before a placement is offered though they need to ensure that information about peoples mental health needs are fully assessed and considered. They also should ensure that all documentation is signed and dated. There have been some improvements in the home`s care planning procedures although the documentation in use is sometimes repetitive and `bulky`. The home do need to ensure that a plan of care is raised to address all assessed needs. Wound care plans need some improvements to ensure the prescribed treatment, frequency of treatment and date to review the effectiveness of treatment are clearly recorded. Where an individual requires their diet and fluid intake to be monitored, the home needs to ensure that more information is documented so that any concerns can be identified in a timely manner. Staff recruitment procedures are generally safe though the home do need to ensure that any gaps in the applicants employment history are fully explored and documented and that one of the references is obtained from the applicants most recent employer. The home have plans to review the current staff induction form so that it follows the skills for care common induction standards which is positive, the home do need to ensure that induction programme are fully completed for newly appointed staff. We were informed that improvements have been made to the provision of activities though we were unable to see evidence that people receiving nursing care are provided with the same opportunities as those on the residential wing. Documentation seen at this inspection needs to be reviewed so that the outcome for people can be recorded. The garden on Rose wing (residential) needs to be made more accessible and inviting for people. This area was noted to be somewhat neglected. Comments about this were also made by some relatives in completed comment cards. Key inspection report Care homes for older people Name: Address: Murley House Nursing Home Wyvern Road Taunton Somerset TA1 4RA     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: kathy McCluskey     Date: 0 8 0 6 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: Murley House Nursing Home Wyvern Road Taunton Somerset TA1 4RA 01823337674 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): murley.house@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 105 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: A Nurse (RMN) on sub-part 1, RN3 or RNHM, of the current NMC register must be on duty at all times when nursing beds occupied exceed 34. Up to 45 places for Service Users requiring personal care only in the categories OP and DE(E) to be accommodated on Rose Wing. Up to 60 places for Service Users requiring nursing care in the categories DE(E) and MD(E) to be accommodated on Redwood Wing. Date of last inspection 1 0 1 2 2 0 0 9 0 0 0 Over 65 105 105 105 Care Homes for Older People Page 4 of 32 Brief description of the care home Murley House Care Home is purpose built and is situated in a residential development on the outskirts of Taunton. The registered provider is Ashbourne (Eton) Ltd a subsidiary of Southern Cross Ltd. The home does not currently have a registered manager though an acting manager is in post. The home is registered with the Care Quality Commission (CQC) to provide a service for up to 105 people with dementia to include personal and nursing care. Murley House consists of four areas, Redwood is split into three units and provides nursing care for people with dementia. Rose wing provides personal care only for older people, including those who have dementia care needs. There is ample car parking to the front of the home and secure garden areas. The main entrance is kept locked (keypad) at all times for security of the home and the people living there. There is a bell on the front door for visitors to make staff aware they are there. We were informed that current fee levels start at £560 per week for personal care only and are from £695 per week for nursing care. People also meet the cost of personal items such as toiletries, newpapers, hairdressing. Information about the fees and additional charges should be obtained from the home. 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: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced key inspection was conducted over one day (8hrs) by CQC inspectors Kathy McCluskey and Jane Poole. The homes last key inspection conducted in December 2009 resulted in a zero star poor rating. A further random inspection was carried out on 24th February 2010. The home submitted their improvement plan to the Commission as required. The improvement plan details how the home will meet the requirements raised at the key inspection. As part of this key inspection, comment cards were sent to a number of people using the service to seek their views on the quality of the service provided. We received five completed comment cards which had been completed by relatives. The acting manager was available for the majority of this inspection. We were given Care Homes for Older People Page 6 of 32 unrestricted access to the home and records required for this inspection were made available to us. We were able to speak with people using the service and staff working at the home. We were also able to observe staff interactions with people during the day. We were informed that, at the time of this inspection, 53 people were residing at the home of which 37 were receiving nursing care and 16 personal care only (residential). The inspectors would like to thank all those involved for their time and cooperation with the inspection process. The term we used throughout the report refers to we the Commission. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? An acting manager has been in post for almost six months and has taken steps to address some of the requirements of the last inspection. Completed comment cards contained positive comments about the improvements the acting manager had made. Positive comments were also received from staff spoken with during the inspection. We spent time observing staff interactions with people using the service and we found these to be much improved. Staff were heard to communicate with people in a kind and respectful manner and staff took time to explain what was happening before and during the time they were assisting them with a task. Staff morale appeared more positive and this will have a positive outcome for people using the service. We found the meal time experience for people receiving nursing care to be much improved. People were being offered choices and were assisted with meals in a dignified and unhurried manner. Although care planning procedures would still benefit from further improvements, we were able to see evidence that staff were delivering care in line with the plan of care. Staff training has improved since the last inspection and further training is planned. This includes mandatory and specialised training. NVQ training is also being promoted. Steps have been taken to ensure that all staff are appropriately supervised. Staff spoken with confirmed that they had started to receive formal supervision sessions. Quality assurance procedures have improved. Since the last inspection the home have sent questionnaires to people using the service and other appropriate stakeholders to Care Homes for Older People Page 8 of 32 seek their views on the quality of the service provided. An analysis showed responses to be generally positive. Regular meetings are now taking place for staff and relatives. A company representative is completing monthly visits/reports to audit the quality of the care delivered. We were able to see that the home are reviewing care plans so that they promote a more person centred approach to care. This is currently on-going. 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 order line 0870 240 7535. Care Homes for Older People Page 9 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 10 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with information about the home and services offered so that they are able to make an informed decision about using the service. Procedures are in place which ensure people are assessed before a placement is offered though the home need to ensure that mental health needs are fully assessed and considered and that documentation is signed and dated by the person completing the assessment. Evidence: The home have produced a Statement of Purpose and Service Guide which is made available to people using the service and to those who are thinking about using the service. These documents provide information about the home and services offered. We received five completed comment cards from people using the service which had been completed by their relative. Four people confirmed that they had received Care Homes for Older People Page 11 of 32 Evidence: enough information about the home to enable them to make an informed decision about using the service. All confirmed that they had been given a contract which provided information about the fees to be charged and the terms and conditions of occupancy. The home need to make some improvements to its pre-admission procedures so that all needs are considered and assessed. We examined the care files for two people who had been admitted since the last inspection and found that one pre-admission assessment made no reference to the individuals mental health needs. We were therefore unable to establish why the individual had been admitted to a specialised dementia care home. We also found that this assessment had not been signed or dated by the person completing it. Since the last inspection, the home have taken steps to ensure that staff have the specialised skills to meet the needs of people using the service. A training matrix made available to us showed that more staff have completed training in dementia awareness. We were informed that this training will be on-going. During this inspection we noted improvements in staff interactions with people using the service. 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. The home have taken steps to ensure that staff follow the guidance in the plan of care though it needs to ensure that all assessed needs are clearly recorded in the plan of care. Procedures are in place to ensure that peoples health care needs are met though the management of wounds could be improved. Safe procedures are followed for the management and administration of peoples medication. People are treated with respect though consideration needs to be given to the storage of incontinence products in peoples bedrooms. Evidence: We examined seven care plans at this inspection. Two related to recent admissions to the home, one related to an individual with a pressure sore, three related to people with high nutritional needs and included one individual who was being nursed in bed. Care Homes for Older People Page 13 of 32 Evidence: We also looked at the plan of care for one individual who was being funded for one to one care. We were able to see that care plans had been reviewed at least monthly and that the home had sought the input of appropriate health care professionals where concerns had been identified. Care plans contained a range of assessments which included reducing the risk of pressure sores, nutrition, reducing the risk of falls, moving and handling and bed rail safety. One care plan examined did not contain a completed moving and handling assessment. We brought this to the attention of the acting manager at the time of the inspection. We saw that care plans had been raised for people who had been assessed as high risk of malnutrition and that staff were maintaining a record of peoples diet and fluid intake where required. We did find that the homes documentation did not prompt staff to total the amount of fluid taken over a 24 hour period. We were therefore unable to ascertain how concerns would easily be identified or communicated to the nurse in charge. A recommendation has been raised. We also found that the type and amount of food offered was not being recorded in sufficient detail. One example of this was where staff had recorded refused main meal. We have recommended that more detail is recorded as this information would assist the reviewing process and to provide staff with information as to peoples preferences where they are unable to communicate this. It will also assist in demonstrating that people are offered a wholesome and varied menu. We were able to see evidence that the home had sought the advice and input from appropriate health care professionals including the input from dietitians. We were informed by the acting manager that due to on-going concerns with one individual, further action was being taken to ensure that the individual had access to health care professional input which had not been forthcoming. We were informed that there was currently one person at the home who was being treated for a pressure sore. A pressure sore risk assessment and plan of care was in place though it was difficult to ascertain the prescribed treatment, frequency of treatment or date to review the effectiveness of the treatment. This had not been recorded on the initial wound assessment or on the on-going wound assessment. Staff had made regular entries regarding the size and status of the wound which was also supported by photographs, but we were unable to ascertain when the effectiveness of the treatment would be reviewed. We also noted that the wound had been treated since February this year. We looked at a care plan for an individual who was being nursed in bed due to failing Care Homes for Older People Page 14 of 32 Evidence: health. We found all assessments to be up to date and that care was being delivered in accordance with the plan of care. The individual had been seen by a physiotherapist the day before the inspection and we were assured that a care plan would be raised to address the recommendations made. The acting manager needs to ensure that this is followed up. Following a deprivation of liberties assessment, one individual is now funded for one to one care to ensure their mental health needs are met. A care plan was in place but this only provided information about the DOLs assessment and outcome. There were no clear instructions for staff as to the reason for one to one care or of how this should be managed. In the absence of the acting manager, we brought this to the attention of the registered nurse at the time of the inspection. We examined the care plans for two people who had moved to the home since the last inspection. As previously mentioned in this report, we found that one pre-admission assessment had not been signed or dated and that this contained no reference to any mental health needs. We also found that a moving and handling risk assessment had not been completed and that a care plan had not been raised to address their dementia care needs. We examined the homes procedures for the management and administration of peoples medication. The home uses the monitored dosage system (MDS) with preprinted medication administration records (MAR). We found all medicines to be securely stored with no excess stocks. Appropriate records were being maintained for the receipt of medicines into the home and of their destruction. This allows for a clear audit trail. We examined all available MAR charts and found these to be appropriately completed. Policies are in place for the use of homely remedies and as required medication. On the nursing units, medicines are administered by the registered nurse on duty. Senior care staff are responsible for the administration of medicines on the residential unit. A staff training matrix made available to us told us that staff have received training in the safe handling of medicines in March and April of this year. At this inspection improvements were noted in staff interactions with people. We heard staff communicating with people in a kind and respectful manner. Staff took time to explain what was going to happen before assisting an individual with a task. Staff morale appeared improved and people appeared to respond positively to staff. This is a positive improvement. We did note that in some bedrooms, continence products had not been stored out of sight. Staff should consider that this may have an impact on individuals dignity. Care Homes for Older People Page 15 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. Some people told us of improvements in the provision of activities at the home though this could not be fully evidenced for people receiving nursing care. Visitors are welcome in line with peoples preferences and the home have created a family room for people to use. The mealtime experience for people receiving nursing care has improved. Evidence: At the last key inspection concerns were raised regarding the provision of activities for people receiving nursing care. The homes completed improvement plan told us that a new activities programme was being developed and that the allocation of activity workers had been reviewed. During the inspection the acting manager told us that a revised programme of activities had been developed and that activity staff had been allocated to each unit on a daily basis. We were also informed that people were now being offered trips outside of the home and that external entertainers and schools were visiting the home on a regular basis. During the inspection we spent time on each unit in the home at different times during Care Homes for Older People Page 16 of 32 Evidence: the day. We were informed that one of the activity workers was currently on leave. On Rose Unit, which is for people receiving personal care only, we observed people joining in with a game of giant snakes and ladders followed by poetry reading by one of the activity workers. Just before lunch, one person was seen to lay the tables with a member of staff. We did not observe any input from activity staff on the nursing units though on one of the units, a staff member was seen to be involving one individual with a ball game. Staff told us that they felt that the opportunity for activities had improved and that they were encouraged to spend quality time with people. Not all care plans examined on the nursing units contained evidence that people were offered regular activities and an up to date weekly activity planner was not available. We were told that this was because one of the activity staff was on leave and that this weeks planner was being worked on. Life historys had not been fully competed in some care plans. We found documentation in care plans for activities which the individual had been offered though we were unable to ascertain the outcome for people as the documentation just requires staff to record a code for the type of activity. The home should consider reviewing the current documentation so that outcomes for people can be recorded and monitored. Although we were informed of improvements, we were unable to see evidence that the home had fully met the requirement raised at the last inspection. One relative commented that the home could further improve by providing more activities such as going out for short trips and walks and by providing more one to one time. Three people with relatives living on Rose wing stated that they would like to see the garden safe, accessible and well maintained. Visitors to the home are welcome in line with the wishes of the individual. The home has recently created a family room, which can be used by visitors and their relative as they wish. In line with fire regulations and to ensure the safety of people using the service, all visitors are required to sign the visitors book on arrival and when leaving the home. Following concerns raised at the previous inspections, we were able to observe lunch being served on the nursing wing and improvements were noted. We were able to observe staff offering people a choice of meal and as required, staff were observed assisting people to eat in a dignified and unhurried manner. On the downstairs Redwood unit, we did see that tables had been laid for lunch by 1115hrs and that lunch was not served until 1300hrs. Although tables looked attractive, this practice should be reviewed as this may be confusing for people with dementia. The home should also consider, as appropriate, encouraging people to assist in the laying of tables for lunch on the nursing units. We did observe this practice on the residential Care Homes for Older People Page 17 of 32 Evidence: unit (Rose). The days menu was displayed though this was not in a format which would be easily accessible to people using the service. We asked some people on the nursing unit what was for lunch, they were unable to tell us. The acting manager did inform us that she was currently working on a pictorial menu. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that complaints are taken seriously and are investigated in line with its procedures. Procedures are in place to reduce the risk of harm or abuse to people using the service. Evidence: The home displays an appropriate complaints procedure and we were able to see evidence that complaints are investigated and responded to in line with its procedures. Two concerns have been raised with the Commission since the last key inspection. These appropriately investigated and actioned by the home. We examined the homes complaints records which indicated that two further complaints had been investigated by the home. We were able to see evidence that these had been responded to in accordance with the homes procedures and that the complainants had been satisfied with the outcome. The home have policies and procedures in place for staff relating to recognising and reporting abuse and whistle blowing. Information is also displayed on the notice board in the reception area of the home. A training matrix made available to us shows that all staff have now received up to date training in recognising abuse and the protection Care Homes for Older People Page 19 of 32 Evidence: of vulnerable adults. The home assist some people to manage small amounts of pocket money. Appropriate records and receipts are maintained for all transactions. Auditing procedures are in place. Care Homes for Older People Page 20 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. Some improvements have been made in some areas of the home to provide a more homely atmosphere. A redecoration programme is in place. Further improvements are needed to signage and points of reference around the home to promote a more enabling environment for people. The home has a sufficient supply of specialised equipment to meet peoples mobility and pressure care requirements. Malodours were noted in some areas though the home appeared clean. Procedures are in place to reduce the risk of the spread of infection. Evidence: During this inspection we viewed all communal areas and some bedrooms. Changes had been made on part of the ground floor nursing unit (Redwood), formally known as the Cornerhouse unit. Numbers on the unit have been reduced following the reassessment of people living there. The dining room and lounge have been moved to other area in the unit and these now promote more of a homely feel. We were informed that there were plans to decorate corridors in this area and to remove the boarding to the door leading from the reception area of the home. A family room has Care Homes for Older People Page 21 of 32 Evidence: been created and their are plans to create a staff training room. Improvements have been made to the courtyard garden. Seating is available and shrubs and vegetables have been planted. This area now looks more inviting for people. The garden on Rose wing looks unkempt and overgrown. Comments about this garden were also raised in some completed comment cards. Staff told us that they had a good supply of moving and handling equipment including hoists, slide sheets and belts. They also told us that there were sufficient supplies of pressure relieving equipment. At the previous inspections we required that the home provided appropriate signage around the home to assist people to orientate themselves. We also noted that some areas of the home appeared sparse and that there were no points of interest. At this inspection the acting manager informed us that she was in the process of sourcing appropriate signage. We found appropriate signage had been placed on bathrooms and toilets but there was nothing to assist people in recognising their own bedroom. Some new pictures have been purchased but further improvements could be made to provide people with dementia with focal points or tactile objects. Although malodours were apparent in some areas, the home appeared clean. We were able to see that staff had access to appropriate hand washing facilities and protective clothing. The laundry facilities were not examined at this inspection. Care Homes for Older People Page 22 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. The home have taken steps to ensure that staffing levels are appropriate to the needs of people using the service. Staff recruitment procedures are generally good though further improvements are needed to ensure that people are protected from the risk of harm or abuse. The home have taken steps to ensure that staff have the skills and training needed to meet the specailist needs of people using the service. Evidence: We were informed that at the time of this inspection, 53 people were residing at the home of which 37 were receiving nursing care and 16 personal care only. The acting manager informed us that staffing levels have been increased since the last inspection and that the use of agency staff has decreased. Nursing care is provided over two floors, each floor having their own communal facilities, bathrooms and bedrooms. We were informed for the 20 people on the ground floor, staffing levels during the day consisted of a registered nurse and 6 carers. This includes the care for the individual receiving one to one care. A registered nurse and 4 carers provide care for the 16 people currently residing on the first floor. We were informed that during the night a registered nurse and 4 care staff are on Care Homes for Older People Page 23 of 32 Evidence: duty. On the residential unit (Rose Wing) where 16 people currently live, cover is provided by a team leader/senior carer and 2 care staff. During the night a senior carer and a carer are on duty. The acting manager informed us that since the last inspection, she has reviewed the skill mix of staff to ensure that appropriately skilled and experience staff are on duty on each shift. When we spoke with staff during this inspection, no concerns were raised about meeting peoples assessed needs. Staff morale appeared much improved and staff were positive about the training and support they now received. As previously mentioned in this report, we received completed comment cards from 5 people using the service which had been completed by relatives on their behalf. In response to the question are the staff available when you need them, 4 responded always and 1 usually. They also told us, the staff are very friendly and caring, the care of the staff is fantastic though very stretched, full marks to all the staff. The acting manager has been pro-active in promoting NVQ training for staff. A staff training matrix told us that of the 34 care staff employed, 12 have achieved a minimum of an NVQ level 2 in care (34 ) and 12 are currently working towards this award. The acting manager informed us that 18 carers have recently been signed up to undertake this award. We examined the homes procedures for staff recruitment. We requested and examined files for the two most recently employed staff. Completed application forms were in place though gaps in employment history were noted in both and there was no documented evidence that the reasons had been explored/discussed. One provided employment history up to 2008 and the other had an unexplained gap between September 2005 and February 2006. In one of the files, two references were available although there was no evidence that a reference had been obtained from the employees most recent employer. The reference obtained did not relate to the information provided by the employee on the application form. Both contained evidence that the applicants had not commenced employment until the receipt of a full CRB and ISA check. A staff training matrix showed us that since the last inspection steps have been taken to ensure that staff are provided with the training to enable them to meet the Care Homes for Older People Page 24 of 32 Evidence: specialised needs of people using the service. The training matrix stated that since the last inspection, 44 staff, including care staff, ancillary staff and registered nurses have completed training in dementia awareness. Newly appointed staff undertake an in-house induction programme when they commence employment. The acting manager informed us that she is currently in the process of seeking advice from Care Focus so that an induction programme, which follows the Skills for Care common induction standards, can be developed. When we looked at staff recruitment files, the in-house induction programme had not been fully completed for one staff member who commenced employment at the beginning of April 2010. All mandatory training appeared to be up to date. Care Homes for Older People Page 25 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although the home does not have a registered manager, steps have been taken to improve the overall management of the home. Quality assurance procedures have improved and the views of appropriate stakeholders are sought. The home have taken steps to ensure that staff are appropriately supervised. Procedures are in place to ensure the health and safety of persons at the home. Evidence: The home do not currently have a registered manager though an acting manager has been in post since January of this year. We have been informed that the acting manager is in the process of making an application with the Commission to be registered manager. Care Homes for Older People Page 26 of 32 Evidence: We received positive comments about the acting manager and of the improvements/changes made from staff spoken with during the inspection. Positive comments were also raised in completed comment cards received. Regular meetings now take place for staff and meetings have also been introduced for relatives. Quality assurance procedures have improved. There was evidence that appropriate Regulation 26 visits are now being conducted by a company representative with reports being maintained at the home. Questionnaires were sent out to relatives and health care professionals to seek their views on the quality of the service provided earlier this year. We were provided with an analysis of the returned comment cards and responses to questions were overall positive. We were informed that no completed questionnaires were received from health care professionals. We were able to see evidence that the acting manager had developed a staff supervision planner to ensure that all staff receive a formal supervision at least six times a year. staff spoken with confirmed that they had received supervision sessions this year. We found documented evidence of supervision sessions in the staff files examined. As previously mentioned in this report, we were able to see that appropriate procedures are in place and followed for people who are supported by the home to manage small amounts of pocket money. Health and safety records were found to be up to date as was mandatory training for staff. Care Homes for Older People Page 27 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 12 16 (m)(n) The registered person 31/12/2009 must ensure that there is a programme of activities which is able to include people with all interests and abilities. To ensure that everyone receives social stimulation and is able to take an active part in daily life. 2 19 23 (2)(a) The registered person 31/03/2010 must ensure that there is adequate signage and points of reference around the home. Previous timescale of 31/03/2010 not yet up. To enable people to move easily around the home and maintain independence. Care Homes for Older People Page 28 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 15 (1) The registered person must ensure that an appropriate plan of care is raised for the individual receiving one to one care. This is to ensure that the individuals assessed needs can be met by staff in a consistent manner. 21/06/2010 2 8 12 The registered person must ensure that wound management plans contain clear information about the prescribed treatment, frequency of treatment and date to review the effectiveness of the treatment. This is to ensure the health and welfare of people and to ensure they receive appropriate treatment 21/06/2010 3 12 16 (m)(n) The registered person must ensure that there is a programme of 09/07/2010 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 activities which is able to include people with all interests and abilities. Previous timescale of 31/03/2010 not fully met. To ensure that everyone receives social stimulation and is able to take an active part in daily life. 4 19 23 (2)(a) The registered person 30/07/2010 must ensure that there is adequate signage and points of reference around the home appropriate to people with dementia. Previous timescale of 31/03/2010 not fully met. To enable people to move easily around the home and maintain independence. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 3 The home should ensure that mental health/dementia care needs are fully assessed and considered during preadmission assessments and that documentation is signed and dated by the person completing the assessment. Where people require their diet and fluid to be monitored, the home should ensure that documentation prompts staff to total the amount of fluid taken over a 24 hour period. Staff should also ensure that more detail is recorded as to Page 30 of 32 2 8 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 the amount and type of diet offered. 3 4 10 12 Staff should consider the impact on peoples dignity when storing continence products in their bedrooms. The home should review the current documentation used to record peoples involvement in social activities so that the outcome for people can be documented. The home should ensure that menus are produced in an appropriate and easily accessible format for people using the service. This was recommended at the last two inspections. The home need to ensure that a professional reference is sought from an applicants most recent employer. The home should ensure that any gaps in an applicants employment history is fully explored and the reasons documented. The home should ensure that the in-house staff induction programme is fully completed by newly appointed staff and that a revised induction programme is developed which follows the Skills for Care common induction standards. 5 15 6 7 29 29 8 30 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. 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