Care Home: Nelson House

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What the care home does well People felt they had good information on which to base decisions to move into Nelson House. One new person, over 100 years old, had made a positive choice to move into residential care and told us she was happy at the home. Everyone had received a contract with terms and conditions of their residency, which reflected guidance from the Office of Fair Trading and gave people good information about their rights and responsibilities. It was positive that one person had been give the opportunity to discuss the contract with their family before signing it. The registered manager had introduced new care plans, assessments of risks, and improved health care screening for each person. There was attention each person`s care needs and the active involvement of each person and their relatives or representative. There was good progress to show that the health and well being of all persons at the home was properly safeguarded. A number of people told us they regarded Nelson House as their home and they liked being able to choose colour schemes and arrange their bedrooms according to their preference. A person was able to continue to make their own drinks and snacks in their bedroom. Some people also chose to have their meals in their rooms. Members of staff were caring, committed and flexible, and demonstrated they were often willing to work extra shifts, and sometimes in different roles to help out. There was a genuine and warm rapport between staff and people living at the home. Comments included, the staff are very good and helpful. This inspection was conducted with full co-operation of the registered manager, proprietor, staff team and people living at the home. The atmosphere through out the inspection was relaxed and friendly. What has improved since the last inspection? Efforts had continued to improve the way medication was stored, administered and recorded, and the additional areas requiring improvement at this visit, mainly relate to medication records and the need for agreed protocols for the use of calming medication. Very positive progress had been made to the maintenance and decor of the home, such as the redecoration of some of the communal areas and many of the bedrooms, which were bright, cheerful and airy and some with new carpets and curtains. There were two new refrigerators, which provided improved food storage. The frontage to the home had been improved with a tarmac area and new ramp providing better access for people with physical disabilities. A government grant had been used to create a sheltered, sunken patio and raised lawn in the rear garden, which with new garden furniture would provide a pleasant area for people to enjoy in the warm weather. The registered persons had made good efforts to provide a wider range and more opportunities for people to be involved in activities and outings of their choice, supported by sufficient numbers of staff. People had enjoyed varied activities with anactivities co-ordinator in the home, church groups, a visiting theatre, shopping trips and a Christmas meal at a local venue. The home must continue these efforts. Improvements had been made to the homes complaints procedure, with a large print, easy read version and assurances other formats could be produced so that is understandable to the people needing to use it. Staffing levels were more stable and considerable efforts had been made to improve staff training to make sure that all members of staff understand what is expected of them and how they should carry out their duties. People at the home told us staff were attentive to their needs. The registered persons had put in place a formal system of staff supervision meetings for support and development, to equip staff to recognise and effectively meet people`s care needs. There are now some staff meetings to improve communication, though they should be more frequent. What the care home could do better: The registered manager must continue to monitor the way people`s medication is administered at the home, taking action to assess the competency of staff to make sure mistakes in recording are avoided and do not pose risks to peoples health and well being. The registered persons had been revising the menus in consultation with people at the home however these have not yet been fully implemented or assessed by the community dietician for nutritional content. This is required to show that all persons living at the home have sufficiently nutritious diets. The registered persons need to complete the process of putting into place a quality assurance and monitoring system, based on seeking the views of the people living at the home, relatives and other professionals about how well the home is providing positive lifestyles for people living there. There must be more regular residents meetings, with notes of discussions and actions. The registered person must also complete putting in place an annual development plan for the home based on a systematic cycle of planning, monitoring and review. There a small number of areas of health and safety, which need improvement, such as the management of risks associated with bedrails, fire safety and the laundry area. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Nelson House 1-3 Nelson Road Dudley West Midlands DY1 2AG     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: Jean Edwards     Date: 1 6 0 1 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 34 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.csci.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Nelson House 1-3 Nelson Road Dudley West Midlands DY1 2AG 01384237717 01384237717 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) : Quality Care Home (Midlands) Limited care home 17 Number of places (if applicable): Under 65 Over 65 2 12 4 mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: 0 0 0 One service users accommodated at the home may also be A(E). This will remain until such time that the current service users placment is terminated. Date of last inspection Brief description of the care home Nelson House is a private care home in a residential area within walking distance of Dudley town centre. The premises are adapted from three large traditional terraced properties, extended and adapted to offer the accommodation currently registered for up to 17 older people, including four older people with a physical disability and one older person with dementia. There are thirteen bedrooms and two double bedrooms located on the ground and first floors. The bedrooms have a variety of layouts, with some well-proportioned rooms. The first floor can be accessed via a 5-person passenger lift. The home has two communal lounge / dining areas on the ground floor. The home offers a number of aids and adaptations, these including some adapted Care Homes for Older People Page 4 of 34 Brief description of the care home bathing facilities, portable lifting equipment, and an emergency call system. The home has access to the frontage and side of the building, for people with physical disabilities. There is an enclosed rear garden and limited off road parking at the front of the premises. Care Homes for Older People Page 5 of 34 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: The last key inspection took place on 04 October 2007, and the CSCI undertook a Random Inspection on 22 February 2008. We, the Commission for Social Care Inspection (CSCI) undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. We visited the home between 07:40 am and 16:45 pm. We monitored the compliance with all Key National Minimum Standards at this visit. The range of inspection methods to obtain evidence and make judgements included, discussions with the registered manager, registered provider and staff on duty during the visit. We also talked to people living at the home, and made observations of people without verbal communications. Other information was gathered before this inspection visit Care Homes for Older People Page 6 of 34 including notification of incidents, accidents and events submitted to the CSCI. A number of records and documents were examined. The registered persons submitted the homes Annual Quality Assurance Assessment (AQAA) as requested at the time of the inspection visit. We toured the premises, looking at communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. The home had published the range of fees for the service in the service user guide. These ranged from 357.00 pounds and 362.00 pounds per week. We were told that there were no third party top up fees charged. People are advised to contact the home for up to date information about the fees charged. What the care home does well: What has improved since the last inspection? Efforts had continued to improve the way medication was stored, administered and recorded, and the additional areas requiring improvement at this visit, mainly relate to medication records and the need for agreed protocols for the use of calming medication. Very positive progress had been made to the maintenance and decor of the home, such as the redecoration of some of the communal areas and many of the bedrooms, which were bright, cheerful and airy and some with new carpets and curtains. There were two new refrigerators, which provided improved food storage. The frontage to the home had been improved with a tarmac area and new ramp providing better access for people with physical disabilities. A government grant had been used to create a sheltered, sunken patio and raised lawn in the rear garden, which with new garden furniture would provide a pleasant area for people to enjoy in the warm weather. The registered persons had made good efforts to provide a wider range and more opportunities for people to be involved in activities and outings of their choice, supported by sufficient numbers of staff. People had enjoyed varied activities with an Care Homes for Older People Page 8 of 34 activities co-ordinator in the home, church groups, a visiting theatre, shopping trips and a Christmas meal at a local venue. The home must continue these efforts. Improvements had been made to the homes complaints procedure, with a large print, easy read version and assurances other formats could be produced so that is understandable to the people needing to use it. Staffing levels were more stable and considerable efforts had been made to improve staff training to make sure that all members of staff understand what is expected of them and how they should carry out their duties. People at the home told us staff were attentive to their needs. The registered persons had put in place a formal system of staff supervision meetings for support and development, to equip staff to recognise and effectively meet peoples care needs. There are now some staff meetings to improve communication, though they should be more frequent. 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 34 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 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a comprehensive and easy to read statement of purpose and service use guide, which are made available to people living at the home, potential new residents and families. This means that people have good information to help them make choices about the home. The registered manager ensures that there are continued reassessments of the residents needs. Evidence: The information contained in the homes AQAA about what it did well stated, we have devised a new brochure, all service users have a contract. New pre-assessment documents have been devised to ensure a detailed pre assessment. Trial visits are encouraged. The provider ensured that they are available to show people round, even giving them her personal contact number in case they need to asked any further questions. We have formed good relationships with local social workers and they are happy to recommend us. There are new detailed care plans in place. We do not offer Care Homes for Older People Page 11 of 34 Evidence: intermediate care, standard 6. We looked at copy of the homes statement of purpose and service user guide, which had been updated in May 2008. The documents, on display in reception, contained comprehensive information and were in easy read formats. We saw that each person living at the home had been given their own copy. The registered provider had included information about the range of fees in the statement of purpose and service user guide. This was very positive and gives people comprehensive information about the service to help them make decisions about the choice of home. From the information provided at the home we noted that the majority of residents were funded through the Local Authorities. We looked at the care records for two people admitted to the home since the Random Inspection in February 2008. We saw evidence that they had contracts and terms and conditions, which had been updated and included information about individual fees. We were told that everyone living at the home had been given contracts with up to date terms and conditions and information about their individual fees. Care Homes for Older People Page 12 of 34 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. There are care plans, risk assessments and monitoring arrangements, which provide staff with information and guidance to meet each persons needs. There is multi disciplinary working taking place on a regular basis, which results in the health needs of people living at the home being well met. There are sufficient arrangements for the administration of medication, which means that generally peoples health and well being is maintained and they have safeguards from the potential to place them at risk. Evidence: The homes AQAA cited following as what they did well, each service user has a detailed care plan. Service users have regular access to health professionals including optician, dentist, and dietician. The home has no history of any person suffering from pressure sores over the past year. The staff are trained. The medication system has improved, storage has improved and we now have a new controlled drugs cabinet and medication fridge. We promote privacy and dignity especially when providing personal Care Homes for Older People Page 13 of 34 Evidence: care. Medical visits are always carried out in the persons own bedroom. We have had no deaths in the home over the past 12 months. Staff have been very supportive to the representatives of those people that have passed away in hospital. We looked at a sample of residents case files containing care plans, risk assessments and held discussions with residents and staff about how people were supported and given assistance to meet their daily needs. We noted that residents or their relatives and representatives, had signed the plans to indicate their agreement. The registered manager had introduced new care plans, health screening tools and risk assessments. The sample of care records were very well organised and provided easy to understand information. The risk assessments and care plans considered all areas of the persons life including health, specialist treatments, personal and social care needs. The information provided by the social care assessment and the homes pre assessment was accurately transferred to each persons care plan to maintain their strengths and meet their needs. We also saw evidence of short term care plans for additional guidance to manage and meet the needs for time limited conditions, such as chest infections or localised infections. It was very positive that the registered persons had introduced new improved personal profiles for each person recording important facts about them such as, where they were born, their family, friends and contacts, their previous work and experiences, their spiritual needs, their favourite things, and likes and dislikes. One person required oxygen for chronic obstructive airways disease. The home had an oxygen risk assessment, and evidence staff were trained to change oxygen as needed, which was very positive. The home had also considered this persons psychological and emotional needs and had put in place a risk assessment for the open bedroom door, and had taken positive action to put a door guard put in place. There was also a risk assessment for the first floor bedroom window restricted to be eased further open to allow a better airflow, which was important for this person with severe breathing difficulties, for psychological as well as physical comfort. There was evidence that the home was developing the staff team to have skills and ability to support and encourage people to be as actively involved as possible in the ongoing development of their plan. The home also had a key worker system, which should enable staff to establish special relationships and work on a one to one basis to meet each persons individual needs. We heard from some staff, who felt there were considerable improvements to the way people were supported and cared for. We noted that care plans were reviewed regularly, every month by the registered manager. We looked at the review notes for a new person, which included comments from the Care Homes for Older People Page 14 of 34 Evidence: relative, very happy with care X is receiving. The home had received very positive comments from the district nurses providing care of a leg ulcer about improvements for a person who was 100 years old, since admission to this home. This person had chosen to enter into residential care, she had phoned and told her family at the age of 99 years and 350 days she wanted to move into residential care. Her GP had organised a respite stay at another home, prior to her making a positive choice to move into Nelson House. We looked at the homes medication system and practices, which were generally well managed and monitored. The registered manager also showed us medication competency assessments for staff she planned to introduce. There was a list of staff signatures and staff initials, which identified members of the senior care staff who had completed an accredited medication training course to administer medication. An updated medication procedure was available, which was specific to the medication management at this home. This means that people who use the service are safeguarded by a working medication policy and are given medication by staff who have received training on medication management. There was a household, homely remedy list available for the treatment of minor ailments such as a headaches or coughs. From care records sampled we saw that each person had their own homely remedy list to suit their particular healthcare needs. The registered manager had written to each persons GP, to ensure this had also been checked and agreed by a healthcare professional to ensure the safety of the people who use the service. We were told that there were regular medication audits but not all dates of opening of medication in boxed containers were recorded, and though any balances of medication were recorded and carried forward onto a new medicine record chart, which was good practice this made random audits more difficult. The random checks we undertook were generally accurate. Though a random audit of Warfarin was unclear because a variable dosage had not been recorded on the persons MAR sheet. There were also a small number of gaps on MAR sheets, where there was no signature or code for nonadministration, which did not evidence that medication had been administered as prescribed. Additionally not all hand written entries on the MAR sheets had be signed and witnessed by two trained and competent staff, which would be a safeguard against the risk of errors. We noted that there were improvements to the storage of medication, which was secure and locked away safely. The home had obtained a new controlled drugs Care Homes for Older People Page 15 of 34 Evidence: cabinet, which complied with legal requirements. A new drugs fridge had also been provided, with evidence that minimum and maximum temperatures were recorded daily to ensure that medication was stored at the correct temperature. There were some people who were prescribed medication to be given PRN, as and when required. Examples were pain relief and one person was prescribed medication to calm and control their agitated behaviour when required. The registered manager acknowledged that there was not a detailed individual protocol and care plan with detailed written information to inform staff under what circumstances this medicine should be administered. The medicine records showed that staff had administered the medication on certain dates. The detailed records are required to show that follow good practice to ensure that the health and welfare of people are safeguarded. We saw that some people were taking responsibility for the administration of their inhalers, which was positive and promoted their independence. However the registered persons must put in place risk assessments and agree monitoring arrangements with each person so that they receive their medication to maintain their health and well being. The receipt and disposal of medication from the pharmacy was documented which meant that the service ensured that levels of medication were kept at a safe level. We saw that staff treated people respectfully, maintaining their privacy and dignity. People were addressed by their preferred name and staff talked to people in a way they understood. Care Homes for Older People Page 16 of 34 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. There is progress to make planned and spontaneous activities available on a regular basis so that people have opportunities to take part in socially stimulating interests. The majority of people are supported to maintain good contact with family and friends. The home proactively seeks independent advocacy for people, without the close support of relatives or other representatives. Though people are offered a nutritious diet, which generally meets their tastes and choices, the menus have not yet been fully developed and assessed by a dietician to show that the dietary needs of each person are always catered for with a balanced, nutritional and varied selection of food. Evidence: We observed that all of the people living at the home looked well groomed, with appropriate clothing for the time of year, some female residents wearing jewellery of their choice. People also had their glasses and hearing aids according to their needs. We saw that the routines of the home were flexible and people were assisted to get up Care Homes for Older People Page 17 of 34 Evidence: and eat their meals at a time they preferred. This was especially evident at breakfast, which took place from around 07:30 am for early risers to about 10:00am for people who had breakfast at a leisurely pace. We noted evidence in the sample of care records examined their preferred times of rising, retiring, bathing and preferred gender of staff to assist with personal care were clearly recorded. This was confirmed in discussions with people when they told us about their experiences of the home. The registered manager and registered provider, who acted in a support capacity at the home, had increased the level and variety of activities and to improve access to social stimulation since the last inspection. There was evidence that some people preferred to spend time in their own bedrooms and generally chose not to be involved in group activities. Although the home did not have an activities co-ordinator, the registered persons had arranged for someone to visit the home for one hour each week to provide activity sessions. In addition the care staff continued to provide a range of activities throughout the week. We saw that there were activity planners and individual records completed for each person. These also recorded refusals and some evaluations. A sample of activities on offer were ball games, books, the hairdresser on Tuesdays, music sessions, the church group, Art and Crafts, and sing a longs. There was a notice board in the corridor advertising events, such as the theatre company, Frantic, a one person show, due to take place on Thursday 20 January 2009, with another presentation booked for June 2009. Another event included a planned clothes show to enable people to choose their own clothing at the home. We were told that people also enjoyed activities from outside sources, such as fitness sessions and the Dudley Christian Fellowship, which continued with visits to the home every two weeks. The majority of people had access to the local community using a range of transport such as the Ring and Ride service, taxis and public transport. We saw one of the newer people at the home going out unaccompanied, on a risk assessed basis, which was very positive. At the random inspection on 19/2/08 we noted areas of good practice such as, the three residents had been taken out for the shopping trip to the Merry Hill shopping centre. We saw that 11 residents had gone out to The Lodge for a Christmas meal, which people said they enjoyed. The home, as identified at previous inspections, had open visiting arrangements, with a written visiting policy displayed in the home and included in the service user guide. There was a signing in book, where all visitors to the home were requested to Care Homes for Older People Page 18 of 34 Evidence: complete their details for security purposes. Though the home does not have separate visiting facilities, people were aware that they could entertain family and friends in their own room if they wished. During the tour of the home we saw that people were able to personalise their bedrooms with treasured possessions. Many people also had modern had flat screen TVs in their bedrooms and one person with very limited mobility had Sky TV installed to watch all the sports programmes he was passionate about. The inventories on a sample of peoples case files was up to date, signed and dated by staff and the resident or their representative. We were told that forms had been completed to enrol everyone on the electoral register so that anyone who wished to have a postal vote could exercise their right vote in any forth coming elections. We also noted that information relating to advocacy services was proactively displayed. There were 2 cooks at the home, one person working 7:30am to 2:30pm each weekday and another person working Saturday and Sunday. The weekday cook also had contract as senior carer and she was knowledgeable about each persons care and dietary needs. The cook, who had an up to date food hygiene training certificate, told us that the new menu had not been finalised. The registered manager acknowledged that the community dietician had not yet assessed the revised menus for nutritional content, as we advised at previous inspections. We noted that each persons food likes and dislikes recorded were recorded. We also discussed that though it was positive that staff were knowledgeable about peoples preferences and choices, assumptions should not be made about what they would like to eat at mealtimes. For example breakfast cereals, cornflakes or weetabix were put ready in peoples dishes. We saw that people had fish teaks, potato wedges and selection of vegetables or jacket potatoes, fillings and side salad for lunch. Pudding was peach crumble and custard or ice cream. There were selections of sandwiches for the evening meal and supper. We asked a sample of people about the food, including people who sat together at a table, they all told us they liked the food. We noted that there were supplies of fresh fruit, hot and cold drinks were readily available on request from staff. One person was able to make snacks and drinks in their own room. Staff gave support to make sure that products, such as milk were fresh. Care Homes for Older People Page 19 of 34 Evidence: We spoke to staff who were aware of the needs of those people finding it difficult to eat and we noted that they offered sensitive assistance with feeding. They were aware of the importance of feeding at the persons pace, so that they were not hurried. Care Homes for Older People Page 20 of 34 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. People are assured that complaints are listened to, and action is taken to look into them and there are investigations, outcomes and lessons learned. People are encouraged to exercise their rights to make democratic choices. The home has policies, procedures, guidance and staff training to provide people living at the home with safeguards from risks of harm or abuse. Evidence: We saw homes complaints procedure displayed in the reception area and contained in the service user guide and each persons individual contracts. The homes complaints log had details of the one recorded complaint, identified in the homes AQAA, received in the last 12 months. This complaint was investigated within the 28 day timescale and was not upheld. People spoken to during the inspection confirmed they knew how to raise concerns or make a complaint, should it become necessary, which was positive. We were able to verify the information provided by the home in the AQAA that all staff had attended training provided by Dudley DACHS. Training certificates were available on the sample of staff files examined. The registered manager told us that some staff would soon be due for refresher training, which was identified in the homes training and development plan. The home had the up-to-date copy of the Dudley multi agency, Safeguard and Protect Care Homes for Older People Page 21 of 34 Evidence: procedure for safeguarding vulnerable people. The registered manager had obtained staff signatures to demonstrate their awareness of the policy and procedure. It was positive that staff spoken to could describe how they would respond to a complaint or suspicions or allegations of potential harm or abuse. The registered manager had pro-actively reported concerns about two residents welfare to the lead agency and notified the CSCI in compliance with Regulation 37 of the Care Homes Regulations. Strategy meetings had been held and the registered persons demonstrated very positive co operation to take any recommended actions to safeguard people, especially where the risk was of potential self harming behaviour from the person being cared for. Care Homes for Older People Page 22 of 34 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. There is evidence of forward planning for positive changes to the design, decor and furnishings. The standards of cleanliness and infection control have means that people can live in comfortable pleasant environment. Evidence: Nelson House was a series of adapted and extended traditional town houses. There were interesting shaped and sized rooms. There were some of the corridors, which were narrow and thought would need to be given to options if the registered persons chose to accept admissions of persons who were dependent on wheelchairs for their mobility. We took a tour around the premises there was evidence that the home continued to be improved to high standards with an ongoing maintenance programme. We noted that space in the communal areas had been maximised, with the creation of two lounge and dining areas. The dining tables and chairs provided meant that everyone could be comfortably accommodated at mealtimes, should they all wish to eat their meals at the tables. The home had one bathroom on each floor. It was very positive that the ground floor Care Homes for Older People Page 23 of 34 Evidence: bathroom, which had not been suitable for people with physical disabilities, was almost completely refitted as a walk in shower room. This meant that people could have a choice of bathing facilities, of either an accessible shower or the option of the first floor assisted bath for their comfort and safety. During the tour of the premises the majority of bedrooms have been viewed, with each persons permission. There was evidence that people were encouraged individualise their bedrooms and to have personal possessions and limited furniture arranged to their own preference. Two people were able to make drinks and snacks in their bedrooms. One person who stayed mainly in their bedroom told us they had disturbed nights due to the person in a nearby bedroom, banging on their bedside table for attention. This person had chosen not to use the nurse call system to call for attention. The person being disturbed told us they retired to bed at 7:45 p.m. to get a few hours sleep before being disturbed. The registered manager told us that the person who was making the noise was unable to use nurse call system. We discussed alternative options with the registered persons, such as a pendant alarm or more regular checks, to try to resolve the problem. We noted that another person who was being cared for in bed with bedrails in use had a risk assessment in place but the home made bedrail bumpers were not adequate and one bedrail was not secure. Additionally in a shared bedroom there were beds with bedrails in place, which were not entirely safe, one was not fitted correctly and there were no appropriate bedrail bumpers. We issued a requirement for the registered persons to obtain the written manufactures and guidance for the safe use of bedrails and put in place a management system of safety checks and appropriate bedrail bumpers to safeguard residents from risks of injury or harm. The decor of the home is generally much improved with the proprietors spouse undertaking the minor repairs and most of the redecoration and maintenance. Some of the improvements made since the last inspection included, several redecorated attractive bedrooms, and utilising a government grant for care homes, there were improvements to the rear garden area with a new patio area, garden tables and chairs created in a sunken garden area with an attractive raised lawn. There was also a new ramp and Tarmac drive at the front entrance to the home, considerably improved the aspect and ascetic look of the frontage. The kitchen had been improved, it was well organised, with generally well maintained equipment, and a variety of food stocks generally stored and prepared in compliance with food safety. We recommended that a small number of food items stored in the refrigerator either Care Homes for Older People Page 24 of 34 Evidence: without the date of opening or past its use by date after being opened should be discarded and that in future high risk foods should be labelled both the date of opening and the use by date. They were also small number of dried goods such as flour and rice, which were not stored in sealed containers. The registered persons had provided new refrigerators, which improved standards of food safety for people living at the home. The small laundry was located in an outbuilding, which was equipped with a commercial washer and tumble dryers. The laundry service was generally well organised and though there were no designated laundry staff, the housekeeper and care staff showed good standards of infection control. There was a laundry procedure and measures in place for supplies of disposable gloves and aprons to be readily available in the laundry at all times. Although the manager had sought advice about revising the laundry procedure, the previous good practice recommendation to seek advice from the Health Protection Agency and Local Authority Environmental Services regarding the homes laundry facilities had not yet been actioned. Throughout the home good standards of cleanliness continued to be maintained and there were no discernable malodours during this visit. Care Homes for Older People Page 25 of 34 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. Staffing levels are more stable and as a result people living at the home now receive more consistent care. There are robust recruitment practices with appropriate vetting and checks completed, providing good safeguards for people living at the home. Evidence: The homes AQAA cited the following as evidence of what they do well, staff numbers calculated in accordance with guidance recommended by Department of Health. The dear to recruitment policy ensuring staff are only appointed once they received a CRB clearance and references. Only recruit quality and trained staff. We noted that there were 17 people with diverse needs living at home. We undertook an assessment of the staffing rotas, which demonstrated that the improvement shown at the Random Inspection on 22 February 2008 had been maintained, with numbers and stability of staff. There was improved evidence that the registered manager was regularly identifying the dependencies and occupancy levels of people living at the home and regularly reviewing and appropriately adjusting staffing levels. The AQAA submitted by the home indicated that 9 staff had left the homes employ in the past 12 months, including one full time and eight part time staff. Five new senior care assistants had been appointed for day and night shifts, which was positive. Care Homes for Older People Page 26 of 34 Evidence: The improvements to staff recruitment identified at the random inspection on 22 February 2008 had be continued. At the Random Inspection we looked at a sample of staff recruitment and training records for three new members of staff. A senior member of staff had well documented evidence of registered nurse training, with additional qualifications undertaken in India. She has also undertaken ASET accredited medication training in September 2007, whilst in employment at Nelson House. The staff files were well organised and there were only minor omissions such as a missing photograph and missing job description. These had been rectified at this inspection visit. We looked at the personnel records of two recently recruited senior members of staff, which were very well organised with evidence of robust recruitment processes. These included completed application forms, employment histories, POVA and CRB clearances, satisfactory references and evidence of qualifications. The full details relating to a UK work permit were not clear and we commended that the registered persons put additional measures in place to monitor expiry dates and any restrictions in working conditions. The AQAA submitted by the home indicated that 7 of 16 care staff had achieved an NVQ level 2 or 3 care award, with 5 new candidates registered to undertake NVQ level 2. This was a decreased ratio of staff 31 per cent with an NVQ Award, mainly due to the staff turnover. However we saw evidence of a strong commitment to on going staff training and development. During discussions staff demonstrated that they were aware of the aims, policies and procedures of the home. We saw evidence that staff had a warm rapport with people living at the home and were generally knowledgeable about their needs and preferences. Care Homes for Older People Page 27 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management arrangements provide effective leadership for improved quality outcomes for people living at the home. Evidence: The registered manager, Leah Unitt was an experienced registered manager, with the NVQ4 care management and Registered Managers Award RMA completed at Bourneville College. She demonstrated a commitment to her own professional training and development and had implemented the staff supervision system to support the development of the staff team. We looked at the homes quality assurance system, which the registered manager told us was still at an early stage of development. There was evidence at the home of a maintenance, renewal and repairs programme but this had not as yet been committed to a written plan. We were also shown some ideas the registered persons had for the homes annual development plan, also at an early stage. The registered provider and Care Homes for Older People Page 28 of 34 Evidence: registered manager were able to describe some planned targets to develop and improve the home. We recommended using a process of measuring the homes achievements, setting achievable, measurable, time bound goals, which could be annually evaluated and reviewed. The quality assurance system should also include views from people living at the home, relatives, visitors and stakeholders in the community, and in which staff feel involved. We were told that surveys had been issued two weeks prior to this inspection visit. We noted that though the registered provider was at the home almost daily and frequently worked as care support in the home, there were also written reports provided to the home with Regulation 26 reports about the conduct of the home, which demonstrated good practice. We looked at a random sample of the temporary safekeeping accounts held at the home on behalf of some people living there. We saw that monies and valuables were held securely and we noted that cash balances were accurate, records for the transactions show all entries had two signatures. We looked at a sample of mandatory staff training records, fire safety and maintenance service records, which were generally satisfactory. We noted that there were a small number of gaps in mandatory training, mainly for new staff, which needed to be provided for all staff commensurate with their role. The home had an oxygen cylinder and oxygen concentrator in a persons bedroom, with appropriate warning notices on the door, this needed to be added to the fire risk assessment, and we recommended that the West Midlands Fire service was made aware that oxygen was in use and stored on the premises. We looked at the accident records for the past 12 months. There were 22 recorded accidents relating to people living at the home. We saw evidence that the registered manager had undertaken regular documented accident analysis, and additionally analysed falls. This demonstrated good practice to highlight any trends and minimise risks to safeguard people living the home from harm. Care Homes for Older People Page 29 of 34 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 30 of 34 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 9 13 To ensure individual protocols are implemented for any medication administered as variable or PRN, as needed doses. This is to safeguard each persons health and well being. 02/03/2009 2 9 13 The registered persons must 02/03/2009 ensure that all medicine administration records are fully completed with signatures or appropriate codes for non administration, to demonstrate what medicines has been administered. This is to safeguard each persons health and well being. 3 9 13 To implement written risk assessments for all self administered medicines, including inhalers and topical applications such as creams. 02/03/2009 Care Homes for Older People Page 31 of 34 This is to safeguard each persons health and well being. 4 38 13 The registered persons must 02/03/2009 obtain the written manufactures and guidance for the safe use of bedrails and put in place a management system of expanded risk assessments safety checks and appropriate bedrail bumpers. This is to safeguard residents from risks of injury or harm. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 9 That the registered manager commences the planned staff medication competency reviews and takes appropriate action to improve performance where issues are identified. That all original containers of medication show the date and time commenced so that accurate audits of medication can be undertaken. That all handwritten entries on MAR sheets are signed and witnessed by two trained, competent staff. That advice be sought from the GP regarding the timing of medication for someone not receiving some of their medication, such as Digoxin, which was recorded as F, asleep at the recommended administration time. That action is progressed to complete the new menus, including alternative formats, and they should be assessed by the community dietician to show that people are provided adequate nutrition and any special dietary needs. That advice be sought from the health protection agency and environmental services regarding the laundry facilities Page 32 of 34 2 9 3 4 9 9 5 15 6 26 Care Homes for Older People and a plan and timescale should be provided for improvements to meet the DoH guidance. 7 29 That information is recorded on personnel files to show any conditions of working identified on UK work permits, including the expiry dates so that these can be easily monitored to provide assurances of compliance. That all West Midland Fire Service recommendations are actioned as soon as practicably possible. That additional Fire Drills are conducted to include recently recruited members of staff. That the storage and use of oxygen in the home is included on the homes Fire Risk assessment and notified to the West Midland Fire Service. 8 9 10 38 38 38 Care Homes for Older People Page 33 of 34 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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