Care Home: Netherton Green Nursing Home

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What the care home does well There was published information about the home, which helped people make choices about where they wish to live. Everyone had an assessment of their needs before they came to live at the home, with the exception of people who were transferred from hospital for short rehabilitation stays on Saltwells. This gave people reassurance the home could meet their needs. The home had a friendly and welcoming atmosphere where some people were encouraged to personalise their rooms to reflect preferences and tastes. There were ample communal areas, including conservatories and a `pub` on Primrose unit. There was good access throughout the building where people were accommodated with a range of aids and adaptations available for dependent people. People were generally well presented and looked well cared for, with clothing, according to their preference. There was an open visiting policy and people were welcomed, so people living at the home were able to maintain important friendships and relationships. Three activities organisers make sure there activities and interesting events, which could be enjoyed with families and friends. The majority of people were supported with their spiritual needs. People told us most staff were kind and helpful. There were comments such as, "staff are lovely"; and "staff are as good as gold but they don`t have a minute". There were meetings involving people living at the home and their relatives so they could have their say about their home. The home had achieved the 5-star award from the local authority`s inspection of food safety and healthy eating. Most people told us they enjoyed the food and they could choose what they liked. What has improved since the last inspection? A new enthusiastic unit manager had been appointed to Saltwells. Improved information was being obtained from the hospital for people transferred to Saltwells so that treatment plans for people`s care and support could be put in place. There were improvements to care records on all units, which meant that people`s health and well being was being planned, provided and monitored more effectively. There were improvements to medication administration, so that people received their medicine in a more timely way.There were improved opportunities for activities and socialisation for some people. Saltwells had been completely redecorated and refurbished, with new furnishings, furniture, commodes and nursing profile beds, improving the environment and infection control. Staff had received training to improve their clinical skills in areas such as wound care and diabetes and improved their awareness to safeguard vulnerable people. The organisation had provided considerable additional management support to monitor the quality of care provided for people using the service. What the care home could do better: There has been management instability at this home since 2006 and the staffing is also inconsistent. Management and staffing arrangements must provide continuity of good quality care at all times to meet every person`s needs. There must be improved communication and co-operation between the care staff and therapists on Saltwells so that people can have the maximum benefit from their stay. Clinical practices and health care records must be further improved, with timely referrals made to health care specialists to make sure each person`s wellbeing is maintained and safeguarded. Some medication practices continued to pose risks. Agency nurses must be more closely supervised and administration practices and records must be improved to protect people from risks of harm. There must be an appropriate response to all concerns or complaints. Appropriate safeguarding training must provided for all staff so that people using the service are safeguarded from risks of harm. The planned total refurbishment we had been told would take place had not been completed. The improvements already identified must be provided in a timely manner, with standards maintained and equipment provided for the comfort and safety of people using the service. Comments from relatives included, "Darby is badly in need of refurbishment. The bedroom furniture and furnishings are worn and shabby and the whole unit needs refurbishing", "there is an unpleasant smell at times". These were recurring themes. The management must be able to demonstrate that there are skilled staff in suitable numbers to meet all the needs of the people living at the home. There were numerous comments in discussions about staffing shortages, such as, "frequently have to wait for attention" and "X has to wait when staff are busy and they do the care as quick as possible". Staff must consistently receive structured supervision, support and training to develop the knowledge and skills to provide good quality care to meet each person`s needs. The quality assurance audits must be sufficiently robust so that failings can be recognised with actions taken to improve the service in a timely manner. Key inspection report Care homes for older people Name: Address: Netherton Green Nursing Home Bowling Green Road Netherton West Midlands DY2 9LY     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: Jean Edwards     Date: 1 1 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 40 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 40 Information about the care home Name of care home: Address: Netherton Green Nursing Home Bowling Green Road Netherton West Midlands DY2 9LY 01384410120 01384413460 taylorgr@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Christine Alexander Type of registration: Number of places registered: care home 120 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 120 The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 60 Physical disability (PD) 30 Old age, not falling within any other category (OP) 60 Date of last inspection Brief description of the care home Netherton Green Nursing Home is a purpose built home consisting of four separate and spacious bungalows set in attractive landscaped grounds. Windmill and Primrose accommodate up to thirty people with dementia, Darby up to thirty frail elderly and Care Homes for Older People Page 4 of 40 Over 65 0 60 0 60 0 30 Brief description of the care home Saltwells is the intermediate care unit for Dudley PCT (Primary Care Trust). Netherton Green Nursing Home is a private home owned by BUPA. All bedrooms are single with toilet and bathroom facilities close by and each unit has a large communal lounge/ dining room, which has smaller partitioned off areas. A kitchenette is situated off the main lounge/dining area, where drinks are prepared, a fridge and microwave are also available. Administration services are situated in a separate central block where the Home Manager responsible for the complex has her office. A central laundry and kitchen are also situated in this block. The home is situated off Bowling Green Road, Netherton. The home has ample car parking and is accessible by public transport. The home had not published information about the range of fees charged. The home should be contacted for up to date information about the range of fees. There are additional costs should as hairdressing and private chiropody, which could be provided within the home on request. Care Homes for Older People Page 5 of 40 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: We, the Care Quality Commission (CQC), undertook a second unannounced key inspection visitin the inspection cycle for 2009 - 2010. This meant that the home had not been given prior notice of the inspection visit. We monitored the compliance with all Key National Minimum Standards at this visit. The team comprised two regulation inspectors, a pharmacist inspector and enforcement inspector. The range of inspection methods to obtain evidence and make judgements included discussions with the home manager, regional manager, quality manager, nurses and staff on duty during the visit. We also talked to people living at the home, and spent time observing people without verbal communication skills. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the Commission. We looked at a number of records and documents. We looked around the premises, looking at communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their Care Homes for Older People Page 6 of 40 permission, where possible. Care Homes for Older People Page 7 of 40 What the care home does well: What has improved since the last inspection? A new enthusiastic unit manager had been appointed to Saltwells. Improved information was being obtained from the hospital for people transferred to Saltwells so that treatment plans for peoples care and support could be put in place. There were improvements to care records on all units, which meant that peoples health and well being was being planned, provided and monitored more effectively. There were improvements to medication administration, so that people received their medicine in a more timely way. Care Homes for Older People Page 8 of 40 There were improved opportunities for activities and socialisation for some people. Saltwells had been completely redecorated and refurbished, with new furnishings, furniture, commodes and nursing profile beds, improving the environment and infection control. Staff had received training to improve their clinical skills in areas such as wound care and diabetes and improved their awareness to safeguard vulnerable people. The organisation had provided considerable additional management support to monitor the quality of care provided for people using the service. What they could do better: There has been management instability at this home since 2006 and the staffing is also inconsistent. Management and staffing arrangements must provide continuity of good quality care at all times to meet every persons needs. There must be improved communication and co-operation between the care staff and therapists on Saltwells so that people can have the maximum benefit from their stay. Clinical practices and health care records must be further improved, with timely referrals made to health care specialists to make sure each persons wellbeing is maintained and safeguarded. Some medication practices continued to pose risks. Agency nurses must be more closely supervised and administration practices and records must be improved to protect people from risks of harm. There must be an appropriate response to all concerns or complaints. Appropriate safeguarding training must provided for all staff so that people using the service are safeguarded from risks of harm. The planned total refurbishment we had been told would take place had not been completed. The improvements already identified must be provided in a timely manner, with standards maintained and equipment provided for the comfort and safety of people using the service. Comments from relatives included, Darby is badly in need of refurbishment. The bedroom furniture and furnishings are worn and shabby and the whole unit needs refurbishing, there is an unpleasant smell at times. These were recurring themes. The management must be able to demonstrate that there are skilled staff in suitable numbers to meet all the needs of the people living at the home. There were numerous comments in discussions about staffing shortages, such as, frequently have to wait for attention and X has to wait when staff are busy and they do the care as quick as possible. Staff must consistently receive structured supervision, support and training to develop the knowledge and skills to provide good quality care to meet each persons needs. The quality assurance audits must be sufficiently robust so that failings can be Care Homes for Older People Page 9 of 40 recognised with actions taken to improve the service in a timely manner. 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 10 of 40 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 40 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is published information about the services the home provides but is not entirely up to date and does not include information about the fees charged. People who wish to live at the home permanently have a comprehensive assessment giving assurance that staff can meet their needs. Intermediate care is generally effective and people generally benefit from the working relationships between the home and other health care professionals. Evidence: There were copies of the homes corporate statement of purpose and service user guide available in reception and there were welcome packs, containing information, in some bedrooms. The Responsible Individual told us that she was in the process of updating the homes statement of purpose and service user guide to reflect the intermediate services provided on Saltwells but she was hampered by a lack of clarity from the Primary Care Trust about timescales and expectations for support from other professionals such as the Tissue Viability Nursing service. The documents had not Care Homes for Older People Page 12 of 40 Evidence: been produced in alternative formats such as large print, easy read or pictorial formats, which would improve access for people with sensory or other disabilities such as dementia but we were told that alternative formats could be produced on request. As reported at previous inspections there was no information about the range of fees charged at this home. This meant that people might not have full information to assist them to make decisions about moving into the home. We were told that people who funded their own care had contracts with terms and conditions of residence. However people who had their care funded through Local Authorities or Primary Care Trusts (PCT) did not have contracts between them and the home. We established that BUPA had a document to be used for this purpose. All persons living at the home should be provided with a contract with terms and conditions of residence, including information about fees, rights and responsibilities, signed and dated by the person or their representative and the organisation. We looked at case files for a sample of people recently admitted to the home and with the exception of Saltwells; each persons needs had been assessed prior to them coming to live at the home. People and their relatives were offered the opportunity to visit the home prior to admission. The 30 beds at Saltwells were block purchased by Dudley PCT. These step-down beds provided people transferring from hospital to receive intermediate care for up to 28 days. The aim of rehabilitation to enable them to be fit to return to their home in the community, often with a package of care. We were told that there was an agreed admission criteria and the contract between the home and hospital was being jointly monitored more rigorously. This meant that the home was receiving pre-admission information in a more timely way and there were less inappropriate transfers. The recently appointed unit manager told us that there was an agreement to limit both the number of transfers to the home each day and the time when transfers could take place, which meant a better experience for people. She told us that the staff could decline transfers where it was felt the home could not meet the persons assessed needs. She gave an example of someone in hospital who was still receiving fluids and medication intravenously, where the home did not agree to the proposed transfer. Physiotherapists and Occupational Therapists were available on Saltwells to assist people from Monday to Friday. A doctor from the hospital also visited people on Saltwells most days. The sample of care records we looked at had improved. The care records were generally more appropriate for short stay intermediate care but they could be further improved. For example with details about what people could do for themselves and with plans for their needs when they go home such as dealing with Care Homes for Older People Page 13 of 40 Evidence: their own medicines, mobility, continence and food and drinks preparation where appropriate. Although there were notes of Occupational Therapists and Physiotherapists treatment plans and daily visits, these were only shared verbally with the homes staff and were not holistically incorporated into person centred plans. At the random inspection carried out on 3 February 2010 we saw that there had been considerable improvements to the environment on Saltwells, with redecoration, all new furnishings, new commodes and 30 new nursing profile beds. At that visit we found that there had been overall improvements in care records and care provided and the unit appeared generally calmer and more organised. These improvements had generally been maintained. However, we discussed concerns about a persons pressure ulcers not being reviewed by a Tissue Viability Nurse for several days after transfer from hospital. There was also a lack of regular descriptions of the pressure ulcer would to enable a system of monitoring of progress or deterioration. There was also a lack of detailed records about the persons mobility and the hoist and sling size required for transfers. This meant that staff, especially agency staff, would not have comprehensive guidance to meet the persons needs. We also saw a hand written recording in a persons file regarding a relatives decision for no resuscitation preference. We discussed with the management the lack of a Deprivation of Liberty assessment and medical opinion in relation to this decision. We spoke to a number of people transferred to Saltwells and their visitors. We received generally positive comments such as, Its clean, staff are friendly, satisfied with the care, Physio, very good explains things and what to expect, meals seem alright and nice place, no complaints, they seem well looked after, staff very helpful and seen a big improvement, shes eating now, staff, they vary, theyre not too bad on the whole. On the other three units there was some evidence that as peoples needs changed or deteriorated their assessments were reviewed, with referrals to appropriate healthcare professionals demonstrating good practice. Care Homes for Older People Page 14 of 40 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 care plans, risk assessments and treatment regimes generally ensure each persons needs are met. The arrangements for the administration of medication do not always ensure that every person at the home receives their medicines as prescribed by their doctor. People are treated with respect and courtesy, with rights to privacy and dignity maintained. Evidence: At the random inspection on 3 February 2010 we saw that care records and care provided was improving, though additional improvements were needed. At this inspection we looked at the care for a sample of people on all four units. We saw that there was usually comprehensive guidance in the QUEST assessment and care planning documentation; and the implementation and the clinical practice had generally improved across the units. Care Homes for Older People Page 15 of 40 Evidence: We saw people on Darby with care plans in place for management of the pressure ulcers, which had improved. The care plans reflected the care instructions from the Tissue Viability Nurses. There were regular reviews and good audit trails of the care given, including photographs, which showed the improvements. We looked at the pressure relieving mattress on Darby and Windmill and noted that a person with a pressure ulcer on their heel had heel protectors and there were new auto logic pressure releiving mattresses in place. These mattresses self regulate so staff did not need to record and monitor the correct setting in relation to the weight of the person. We looked at turn charts and these had generally improved, though not all charts demonstrated changes of position in accordance with instruction in risk assessments and care plans. Though when talking to staff on Windmill they were all aware of when people needed to be turned and position changed. We looked at the care of a person who was a new admission to the home since last inspection. The QUEST documentation was completed, and it was possible to see that care staff had taken time to sit with the person to find out likes and dislikes. The persons relative had complained to the nurse in charge that the person was not wearing her glasses; staff explained she repeatedly took them off she doesnt like wearing them, she broke the last pair in half but we do keep trying. Her relative bought a cord for the glasses but she also took this off and refused to wear it. Despite this the staff had not given up and they had obtained new glasses and were encouraging the person to wear them. The persons risk assessments including Waterlow, falls, moving and handling, MUST (Malnutrition Universal Screening Tool) and mental capacity assessment were all completed. We identified a number of further improvements, which should be made. For example the assessment records for a person admitted to Saltwells had a number of discrepancies, where assessment scores did not correspond to other information. There were also examples were the Comments/Prompts section was blank so it was not possible to justify the score. The person required attention for foot care but there were no entries in the file to confirm that a chiropodist had been requested to visit. There was a wound care assessment for the persons right heel with a grade 4 heel ulcer, which was 100 percent necrotic. The assessment record showed the box for a tissue viability nurse referral had been ticked but there were no recordings to confirm that the referral had been made until 10 March 2010, though the person had been transferred to Saltwells with the pressure ulcer on 26 February 2010. We looked at a sample of mattress pressure charts on Saltwells and noted that there were no pressure settings recorded although the charts were filled in each day. In one persons room the pressure relieving mattress chart had not been completed to inform staff Care Homes for Older People Page 16 of 40 Evidence: about the persons body weight and the recommended pressure setting for the pressure relieving mattress. We looked at the care of a person on Darby with a PEG feeding regime, who was nil by mouth. The person did not have an oral care plan or mouth care charts and there was no oral care equipment in the bedroom. The unit manager and staff assured us that mouth swabs, kept in the treatment room were used at frequent intervals. The person had some her own teeth and it was not clear how these were cleaned. As agency staff were used the lack of clear guidance and records of care provided meant that the persons needs may not be met consistently. There was a care plan and records for the nutrition regime via the PEG tube but it lacked the instruction to clean and rotate the tube 360 degrees each 24 hours. We looked at the PEG site, which was clean and dry. The records of administration were also incomplete from 08 to 10 March 2010 when the Nutrison feed had not been entered. The unit manager told us this was because agency nurses had not completed the food and fluid charts correctly. We saw from the MAR records that the person had received the feed as prescribed. We noted that the person had been seen on several occassions by the doctor due to vomited. The recorded advice from the doctor was to make sure the person was supported at 45 degrees, whilst the feed and water were in progress. We saw that the person was not positioned as the doctor had advised and the unit manager informed us it was difficult to ensure staff understood and followed the instructions at all times. The pharmacist inspector visited the home to check the management and control of medicines within the service. We looked at medication storage on all four units, some care records and medication administration records. We saw that all medication was stored securely and neatly which means that medication is safe and therefore the people who live in the service are protected from harm. The controlled drug cabinets on three of the units did not meet the specific requirements of the Misuse of Drugs Act 1971, the Misuse of Drugs (Safe Custody) Regulations 1973. We discussed these findings with the management who agreed to change the storage cabinets to meet the legal requirements. We looked at the Medication Administration Record (MAR) charts on each of the four units and overall found that they were well documented with a signature for administration or a reason was recorded if medication was not given. We saw that the times of administering medicines were clearly highlighted on the MAR charts. This ensured that staff knew when to give medicines. On one unit we saw that one person Care Homes for Older People Page 17 of 40 Evidence: had not been given their prescribed medicine according to the written directions of a doctor. The medicine was to be given for anxiety twice a day when required, however the MAR charts were signed regularly four times a day. We spoke to an agency nurse who could not tell us why it was being given four times a day. We saw a protocol dated November 2009, which stated the medicine could be given four times a day when required but it had not been reviewed. We spoke with the unit manager who agreed that the information was not clear. During the inspection we were informed by the unit manager that the doctor had been contacted and was going to review the persons medicine requirements. Overall there was a significant improvement seen in the quality and documentation of the medicine records on all units, which ensured that the health and welfare of people was safeguarded. When MAR charts were changed or a new medicine started two members of staff checked the records for accuracy and detailed the reason for the change directly onto the MAR chart. This helped to ensure that accurate medicine records were available for people living in the home. We undertook audits and checks on peoples medication and found that they were correct and up to date. This meant that there were arrangements in place to ensure that medication was administered as directed by the prescriber to the person it was prescribed, labelled and supplied for. We found that other medication records were generally up to date. For example, we saw current records for the receipt and disposal of medication. The date of opening of boxes and bottles of medicines were usually recorded and balances of medication were carried forward from old records to new records. These records helped to ensure there was a clear audit trail of medication, which showed that people who live in the service were being given medication as prescribed by a medical practitioner. Medicines which were returned to people when they go home were not always clearly recorded. This was seen in particular on the intermediate care unit Saltwells. We saw records which stated that medicines had been given to the person to take home, however there was no recorded information about the medicine or quantities returned. This meant that there was not a complete audit trail of medicines leaving the service. We discussed this with the manager who agreed that a system should be available for staff to record and document what medicines were leaving the service and sent home with a resident. Overall we saw better documentation, records and checks made on peoples medicines, which ensured that the health and welfare of people who live in the service was safeguarded. We informed the management that the requirements for medication from the previous inspection had been met. We issued new requirements at this visit. Care Homes for Older People Page 18 of 40 Evidence: The staff we spoke to during the inspection were generally knowledgeable about each persons needs and we saw that they were respectful, caring and helpful. Care Homes for Older People Page 19 of 40 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. People living at this home have some opportunities to take part in activities. People are encouraged to maintain contact with their friends and families and visitors are welcomed. Most meals are appetising, although there may not always be sufficient staff to give people who need assistance the support they require to maintain good levels of nutrition and hydration, which may pose risks to maintenance of their health and well being. Evidence: We noted that progress was being made to find out about each persons preferred daily routine such as the time they get up or go to bed, whether they wished to have a bath or shower and at a time of their choice. However there was little evidence that this process had been incorporated into the daily regimes or was reflected as personal choices and flexible routines. This was mainly because though the number of nurses on duty during the day had been increased, the number of care staff had been reduced from six to five and the morning shifts. This meant that in the mornings there were two teams of two carers to provide care for people, so that they ready for breakfast, whilst one carer served, assisted with the meal and cleared away used dishes. We were told that the majority of people needed two staff for assistance for personal needs. On each unit this was a hectic time. We stressed the need for peoples Care Homes for Older People Page 20 of 40 Evidence: wishes and preferences to be recorded, respected and incorporated into person centred daily routines. We spoke to activities organisers who told us that the way activities were provided had been recently changed by the acting manager. Instead of an activity organiser based on Darby, Windmill and Primrose, the three activities organisers worked together each week day, visiting each unit in turn, including Saltwells. Each of the four units receive 2 activity sessions each week, with two surplus sessions, divided between the units. This meant that there may be three days, plus weekends, where units may have limited activity provision. The management told us that there would be some individual activities on each unit most days. Whilst there were pros and cons it that was unclear whether there was wide ranging consultation with people living at the home, relatives and staff, for this decision. The map of life and activity records to show any activities, planned or spontaneous or participation or refusals were completed by the activities organisers. We were told that there were some outings being planned for the warmer weather. We saw some evidence of church services held at the home and we were told that people could receive visits from their minister, so that they could continue to practice their faith. We saw that some people had been encouraged to personalise their bedrooms, but this varied considerably from unit to unit. There were inventories of personal possessions in care records but they were not all fully completed, signed, witnessed and kept up to date. The home had a four weekly menu, regularly updated and offering a choice at each meal. The home had achieved a Five Stars Award for food safety and healthy eating at the last Environmental Health inspection on 4 October 2009. There was a night bite menu. These were meals and snacks available throughout the night, which could be pre-ordered for people who do not sleep well, especially on the dementia units. At the previous key inspection this initiative was being well used but when we asked how many people were having night bite meals, we were told none were being ordered. We spoke to the cook who was knowledgeable about nutrition. She was not actively involved in residents meetings but had consulted people about the summer menu to be introduced and regularly received feedback about foods offered, and altered the menu, removing foods, which were not popular. We were told that the menus had not been assessed for their nutritional content, for example, ensuring five fruit and vegetables were offered each day and the cook was not aware of dieticians advice for individual people with pressure ulcers to promote healing. We recommended that Care Homes for Older People Page 21 of 40 Evidence: there should be closer liaison between the catering staff, nursing / care staff and community dieticians. On one unit we saw staff giving out drinks and asking people what they wanted for breakfast and lunch. However on another unit only four people came to the tables to eat their breakfast other people remained in their chairs and ate breakfast off the cantilever tables in front of them. The dining tables were not laid, breakfasts were bought to people along with cutlery, and there were no condiments on the table or offered. One person was asked what she wanted for breakfast, she said just toast please, but the carer bought her a full English breakfast. She also declined a cup of tea but the carer bought her a mug of tea and put it in front of her. On this unit we noted that the carers put a bib on everyone and there was not much interaction between people during this time, with most people waiting for help as there was only one carer to serve, clear and feed all at the same time, so people had to wait. On one unit people complained about the level of noise at mealtimes. We tasted the food for breakfast to make sure that it was still warm and edible, and found it tasty. We saw that each person could have a cooked breakfast if they wanted one. However we were told by staff on Darby that often insufficient supplies were sent from the main kitchen, though this may be a communication issue, which should be resolved. We observed people on Primrose making jam sandwiches and cups of tea as part of their tea party morning. We spoke with the unit manager who told us that following her training as dementia champion she had undertaken observations of the unit including the interactions and as result has made some changes to the routines on the unit. These were small changes at the moment, such as encouraging the domestic help to start washing up later to reduce the noise when people were eating. One carer sat and had a meal with the people encouraging them to eat and talk with one another. Our observations at lunch time showed although it was a little bit disorganised there was definitely efforts being made by staff to engage people. There were generally positive comments from people on Saltwells about the meals. Care Homes for Older People Page 22 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can generally have confidence their concerns or complaints will be listened to though not all complaints are thoroughly investigated and resolved. The management practices generally protect people living at the home from risks of harm or abuse. Evidence: The home had a corporate complaints procedure, prominently displayed on each unit and in the administration block. People spoken to generally told us that if they had any concerns they would discuss them with the Unit Manager or the Home Manager. At the random inspection on 3 February 2010 we reviewed the complaints log. There had been one complaint recorded from Saltwells, which had been recorded appropriately. There was evidence that the complaint had been followed up thoroughly and actions had taken place as a result. Additionally, there had been three concerns raised on Darby and two on Windmill. All recorded concerns raised had been followed up. However we saw a record of a relatives complaint raised in a persons care records on Saltwells. This had not been recorded in the homes complaints log, which meant there was no record of an investigation and monitoring to ensure the issues were resolved to the complainants satisfaction. At the random inspection we were told the complaint would be recorded in the homes complaints log. At this inspection we noted that this had not been done, which meant there was no evidence the complaint had been followed up or that the complainant was satisfied. We had spoken to the relative who had told us about a number of concerns, in addition to those recorded in Care Homes for Older People Page 23 of 40 Evidence: the persons notes. Therefore, with consent, we gave the complaintants details to the responsible individual, so that an appropriate investigation could be carried out, with a formal response. We also received a number of comments from relatives on Darby at the random inspection and at this inspection about their dissatisfaction with the condition of the unit and staffing shortages and high use of agency staff. They told us they had raised their concerns with BUPA management but did not feel anything had changed and were deeply disappointed and disheartened by lack of action. An up to date training matrix was in place. The manager told us that there was training with an internal programme, which consisted of staff watching a DVD, followed by a short presentation by the Quality Manager. The training matrix showed that safeguarding training had taken place on 29 January 2010 and subsequently additional places for senior staff had been booked on safeguarding training provided by the Local Authority. The matrix showed that 26 out of 71 (37 percent) care support workers and 13 out of 23 (57 percent) nurses had received safeguarding training within the last twelve months. A nurse we spoke to told us she had enjoyed the external training and had found it stimulating and thought provoking. We stressed that all staff must receive appropriate safeguarding training so that risks to vulnerable people living at the home are minimised. The organisation had recruitment policies and procedures and the sample of staff recruitment records looked at showed that these had been followed appropriately. This meant that there were sufficient safeguards to show that people were safe to work with vulnerable people. Care Homes for Older People Page 24 of 40 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a warm, generally safe environment for people living there but the lack of ongoing maintenance detracts from peoples comfort and pleasure. There are systems in place for maintaining infection control. Evidence: The home was comprised of four purpose built units, with the layout was appropriate for the people using the service. The entrance to each unit was controlled by an electronic key-pad system and codes were frequently changed. Relatives on Darby told us at the random inspection on 3 February 2010 that they had raised funds to provide improved door security systems. The grounds were safe and tidy, with considerable garden maintenance undertaken since the last key inspection. A number of rooms on all units had patio doors leading out to the gardens. There was ample car parking in the grounds to the home. The administration offices, main kitchen and laundry were located in a central block. We looked at the kitchen and laundry facilities, which were clean, tidy, well equipped and well organised. We were told at a previous inspection in September 2008 that the home would be completely refurbished and redecorated. This had not happened and we were told at the key inspection in September 2009 that the organisation had decided to redirect Care Homes for Older People Page 25 of 40 Evidence: the planned resources elsewhere. The Primary Care Trust conducted infection control audits in 2008 and 2009 on Saltwells, which were not satisfactory and as a result Saltwells was completely redecorated and refurbished. We noted at the random inspection on 3 February 2010 considerable improvements to the environment on Saltwells, with the redecoration, new furnishings, new commodes and 30 new nursing profile beds. The environment on the other units, as reported at previous inspections, looked tired and shabby. At the random inspection in February 2010 and at this inspection relatives told us that the unit had not been touched for over 10 years, the bathrooms were cold and there was no heating on at times when people were bathed. They told us, we have complained and made our views know but nothing ever gets done about it. The relatives stated, we are fighting a losing battle everyday and we have watched them scrub the carpets every day on occasionally it smells, but the cleanliness has been pretty good. We asked the Responsible Individual to accompany us whilst we looked around Darby. We saw furniture, which was broken and repaired but still posed a risk of injury, miss-matched curtains, stained walls and damaged toilet and bathing facilities. The Responsible Individual gave us assurances that the home was going to be fully audited on 17 March 2010, with decisions made for a total refurbishment of the premises. She also agreed to take a damaged bathroom out of use until decisions were made about its renovation or replacement and she assured us that she would instigate an immediate repair of the staff toilet, which had no lid on the cistern. Staff told us it had been in the state of disrepair, for a long time. Each unit had a variety of aids and adaptations such as grab rails assisted baths and wheelchairs. All units had a full nurse-call system in place which appeared to be in full working order. We viewed a sample of bedrooms with the persons permission where possible. Some were personalised with photographs, pictures, ornaments and smaller items of furniture, though this was not so evident on Primrose. The majority of bathroom and toilets we viewed were clean or in the process of being cleaned. There were posters showing people how to wash their hands properly and there were disposable gloves and aprons in the bathrooms and toilets. The majority of sluices and soiled linen areas also appeared clean. We noted that none of the radiators or hot water pipe work was guarded on any of the four units. Although we were told they were all thermostatically controlled, with evidence in the maintenance records of them being checked regularly; we did not see Care Homes for Older People Page 26 of 40 Evidence: individual written risk assessments, which were regularly reviewed for each person. Though the home general appeared clean, we noted that there were still malodours in some locations throughout the site. Care Homes for Older People Page 27 of 40 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 number and skill mix of staff do not always ensure that people receive consistent standards of care. There are recruitment processes, which provide adequate safeguards for people living at the home. There is a training programme in place to equip staff to have the knowledge and skills to meet peoples needs. Evidence: We looked at staffing rotas but we were not shown evidence as to how the home manager or unit managers monitored or revised staffing levels in accordance with peoples occupancy and dependency levels. This meant that staffing levels may not be adjusted to meet each persons changing and in some instances increasing needs and dependency levels. In discussions with people living at the home, relatives, staff and others that the home was frequently short staffed and people had to wait unacceptable lengths of time for attention. We observed that mealtimes were particularly hectic, especially on three units and people were left waiting for assistance after eating. Each unit was staffed with a qualified nurse on all shifts, this had been increased to two nurses on early shifts to ensure medication was administered in a timely way. Previously six carers were on the early shift and this had been reduced to five carers on morning shifts. There were four carers on late shifts and two carers on night duty. We were told that the majority of people required assistance of two staff for personal care and mobility and there were a large number of people requiring assistance with feeding, though these numbers fluctuated, especially due to the nature Care Homes for Older People Page 28 of 40 Evidence: of admissions to Saltwells unit. The people with dementia, especially at Windmill and Primrose units also needed continual supervision. We looked at staffing rotas, which showed that there were usually 2 nurses and 5 carers on each unit on the morning shift and 2 nurses with 4 carers for the late shift, and a nurse and 2 care staff at night. The home was supplementing staffing levels with agency nurses. The responsible individual told us they had a list as long as your arm of those agency staff they would not use again because they were not satisfactory. We spoke to nursing staff on Windmill who said that agency nurses tended to be good and it was rare they have a bad one. Although she added she audited the medication after an agency nurse has done them just in case. As highlighted at the Health and Personal Care section of this report there was a serious medication error attributed to agency nurses and the records of a PEG feed were incomplete. Relatives on Darby unit told us, They cant cope with all the needs of the people, the agency nurses leave a lot to be desired they are not up to scratch they dont know the people and they dont know the care, they cant get any staff. We were told during the inspection visit that the home was experiencing difficulties retaining and recruiting experienced staff, especially trained nurses. There were organisational recruitment procedures available. We looked at a sample of staff files and found the recruitment and selection of staff was generally conducted to make sure appropriate checks and clearances were obtained. We were told that all new staff had a two-day induction during which they were additional to care staff numbers. The training matrix was supplied by the home at the time of the inspection and showed that there were still gaps but the home had planned dates to make sure that staff had received training appropriate to their role. Staff spoken to commented that they had found training relating to tissue viability and diabetes very helpful. Care Homes for Older People Page 29 of 40 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. The management arrangements do not always provide effective safeguards for every person using this service. There are systems for consultation with people living at the home, with views sought and acted upon. Evidence: The home has had three new home managers since April 2007 and has been without a permanent Registered Manager since November 2006. The current home manager was recruited in March 2009 and she had recently undergone a fit person interview. The registration decision had not been communicated to the home at the date of this inspection. At the previous key inspection, the recent random inspection in February 2010, and at this second key inspection we saw that the home manager had been provided with considerable support from the organisation. For example the Quality and Compliance team and a quality and compliance manager had been working with the home for almost a year. We were told that the management of the home had been restructured, Care Homes for Older People Page 30 of 40 Evidence: though this process was not yet complete. In addition to the home manager a new post of general manager, with non-clinical responsibilities, had been created and the deputy manager post had been deleted. There was a new unit manager on Saltwells, who was making improvements and the former deputy was in post as unit manager on Primrose and was developing her role as Dignity Champion. The unit manager on Darby had very recently been allocated some supernumerary hours but was heavily dependant on agency nurses, who were not always effective and created extra monitoring work for her. At previous inspections the management of the home told us that there was a structured staff supervision system. However we noted at the random inspection that though there were some records of staff supervision available, there was no summary matrix, so it was difficult to assess if supervision was consistently undertaken across the four units. There was evidence of supervision taking place for a nurse staff on 8 January 2010. Additionally, there was evidence of some group supervision session taking place for care support workers in November 2009 but it was not clear from the records if these sessions covered all staff, nor was it clear if supervision activity is monitored by the management team. At this inspection we spoke to a number of staff, one nurse informed us she did not have sufficient time for one-to-one supervisions with her staff. Another member of staff told us they has recently completed the customer care training with BUPA, and was doing the personal best award with BUPA that encourages staff to see things from the persons point of view putting yourself in their shoes, when asked about supervision, the response was, not brilliant but we do get some, not that often though. On another unit a member of staff told us about supervision and appraisal yes but not that often, we have had a memo about it recently so I think they are trying to improve. The home had a quality plan, which reviewed all areas of the home at least annually. We were told that in addition there were frequent audits of all aspects of care, including care plans, medication and pressure ulcers; and quarterly audits of accidents and complaints by the Quality and Compliance Manager. The regional manager, who was also the Responsible Individual, visited the home at least monthly and produced Regulation 26 reports about the conduct of the home. Although there were some significant improvements, the quality audit systems had failed to identify and rectify the findings of outcomes for people seen at this inspection visit. People living in the home were recently surveyed as part of BUPAs satisfaction campaign, areas highlighted for improvement were activities and environment, both of these sections scored a lower satisfaction rate than the same time last year. There were only four people across the whole site that responded to the surveys so the Care Homes for Older People Page 31 of 40 Evidence: results may not be a proportionate view of the service but they mirrored our findings during this inspection. We looked at a sample of heath and safety, fire safety and maintenance documentation, which was satisfactory and well organised. We also looked at accident records and Regulation 37 notifications. An analysis and evaluation had been put in place to identify trends and risks, which could be controlled or minimised to maintain each persons health and safety. Although we saw significant improvements to care records, the care provided and medication, we also saw issues of concern highlighted in this report. We have informed the BUPA senior management that we will continue to hold regular management review meetings to monitor the progress made regarding the homes improvement plan; and where the required improvements are not made within the timescales set for them, we may take enforcement action. Care Homes for Older People Page 32 of 40 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 8 12(1) The registered persons must 01/11/2008 ensure that special care records such as food, fluid balance charts and turn charts are in place, with care provided appropriately recorded and monitored. This will ensure residents health and well being is maintained Care Homes for Older People Page 33 of 40 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 To ensure that there are 01/05/2010 health care assessments, risk assessments and care plans, which include all of each persons assessed needs, the active involvement of the person / or representative; and are updated to accurately reflect all changes to health and needs. This is to ensure care for each persons health and well being is properly provided at all times. To ensure that staff make timely referrals to health care professionals for specialist assessment, support and advice, with action taken to diligently follow instructions for each persons care needs. 01/05/2010 2 8 13 Care Homes for Older People Page 34 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will ensure that staff take required actions to promote peoples health and well being. 3 9 13 The service should make 01/06/2010 arrangements to ensure that records are kept of all medicines leaving the home. This is to safeguard people using the service from risks of harm 4 9 13 The service should make 01/05/2010 arrangements to ensure that controlled drugs are stored securely in accordance with the requirements of the Misuse of drugs Act 1971, the Misuse of Drugs (Safe Custody) Regulations 1973 and in accordance with the guidelines from the Royal Pharmaceutical Society of Great Britain. This is in order to ensure that controlled drugs are stored safely to prevent misuse. 5 9 13 The service must demonstrate that a system has been established to check staff compliance and practices. 01/05/2010 Care Homes for Older People Page 35 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to safeguard each person using the service from risks of harm. 6 9 13 Detailed information must be provided about protocols for administration of all PRN as and when needed medications and monitoring arrangements for service wide compliance. This is to safeguard each person using the service from risks of harm. 7 16 22 To diligently record and 01/05/2010 report all complaints, with actions clearly identified to demonstrate robust investigations of all concerns or referrals to other appropriate agencies as necessary; and ensure these records are available for inspection. This is to ensure that the people who use the service are safeguarded. All staff must receive appropriate safeguarding training and the homes and Safeguard and Protect procedures to protect vulnerable people must be implemented and followed diligently at all times. 01/05/2010 01/05/2010 8 18 13 Care Homes for Older People Page 36 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to safeguard all persons living at the home from risks of harm. 9 19 23 The plans to ensure the environment meets the needs of everyone living at the home must be implemented in a prioritised timescale. This is to maintain the well being of all persons using the service. 10 27 12 The management must 01/05/2010 demonstrate that the number of staff on duty are skilled and trained and in sufficient numbers to meet all of the needs of each person using the service at all times. This is to ensure that the health, well being and safety of people living at the home can be assured at all times. To ensure quality monitoring 01/05/2010 systems are effective and demonstrate that positive quality outcomes are consistently achieved for all persons living at the home. This is to safeguard the health, well being and safety of people living at the home. 01/06/2010 11 36 12 Care Homes for Older People Page 37 of 40 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 12 36 12 To ensure that there is an effective structured staff supervision system, which demonstrates staff are supported, developed and monitored to provide safe, high quality standards of care. This is to maintain and promote the health and well being of people using the service. 01/05/2010 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 1 There should be comprehensive information about all services provided at the home in the Statement of Purpose and information about fees should be included in the service user guide to give people full information about the service to help them make decisions about the choice of home. Each person living at the home should be given an up to date, accurate contract of residence with details of their individual fees and Registered Nurse Care Contribution (RNCC) reimbursement where applicable, signed date and witnessed. The care records for people with PEG feeds should include instructions for correct position whilst feeds are in progress and checks to show that the PEG tube has been rotated 360 degrees every 24 hours to avoid the risk of buried stump syndrome. This is a previous unmet good practice recommendation. The correct pressure setting for pressure relieving mattresses should be recorded in each persons care 2 2 3 8 4 8 Care Homes for Older People Page 38 of 40 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 records with regular documented checks. This is a previous unmet good practice recommendation. 5 12 Activities organisers should be involved in residents meetings, so that people can share their ideas and preferences for activities and social events. There should be daily menus produced in appropriate formats, such as large print or pictorial, suitable for people with dementia or sensory impairments to assist their understanding and help them make realistic choices. People living at the home should be involved in developing alternative menu formats. 6 15 Care Homes for Older People Page 39 of 40 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. Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 40 of 40 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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