Care Home: New Milton Nursing Home

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What the care home does well This is a small nursing home where personal relationships are easily and well established. There is a fairly static and cohesive staff group providing continuity of care for people living there. Visitors are welcomed into the home and encouraged to be involved in social and other activities where possible. Several people visit daily and two were spoken with. Both spoke very highly about the standards of care, also saying that they were kept informed of progress and contacted if there were any concerns about their relatives. Both spoke highly of staff and the warm, close relationships between visitors and staff were clear. One daily visitor spends many hours with her husband who has high dependency needs. He needs assistance with feeding. She is involved in this and enjoys the direct personal involvement. This is a good example of shared care. The atmosphere is very relaxed and resembles a large family group. This was evident and confirmed by both staff and visitors. Verbal and written comments received from staff and people living in the home were very positive. All spoke highly of the staff group saying that they were helpful, kind and very supportive. What has improved since the last inspection? Significant improvements were required at the time of the last inspection and we have carried out two random inspections to ensure this happened. Improvements have been made in the following areas: Food and fluid charts are now completed correctly, fluid it totaled daily and referrals made to the GP where there there is inadequate intake. Nutritional plans are now more robust. The medication system has vastly improved. There is now an ongoing count of medication - All medication received is checked and medication from the previous cycle added, ensuring that it is possible to audit the system at any time ensuring the correct medication has been received, administered and is available. There are protocols for all PRN (as required) medication. Variable dose medication is recorded to ensure audit of the system. There has been further medication training for nursing staff. Night staff now have responsibility for ongoing audit and checking of medication, ensuring medication can not be out of stock. PRN medication not used for specific periods of time are reviewed with the GP, many discontinued. Complaints are now all recorded with outcomes and timescales met. Half the staff group have had training in the Mental Capacity Act and Deprivation of Liberty Safeguards - important in the home meeting their obligations to assess and take account of peoples capacity. Training for the reminder of staff should be carried out as soon as possible. Recruitment procedures have improved ensuring appropriate checks and references are obtained prior to employment. The documentation has improved with input from an employment group. The home has initiated a quality review system in the form of surveys to people using the service and relatives. The results are made available to people in the home and are particularly useful for people considering admission. This needs to be repeated at intervals and can identify areas that may need change or improvement. Staff supervision has been established and there is now an annual appraisal for all staff. The Statement of Purpose/Service Users Guide has been updated and also now include details of weekly charges. There is now more input into recording systems by care staff - previously only nursing staff did this. An Activities Organiser has been appointed to lead on activities but involving staff in partnership. This has extended the range and improved the quantity, type and quality of the activities with input from people living in the home. People using the service, relatives and staff confirmed this is good progress and has improved quality of life. The home are involved in the Gold Standard Framework - to deliver a good standard of care for all people nearing the end of life. This includes multi-disciplinary working including palliative care specialists. Advanced planning ensure that at the end of life people choose where they wish to be, the care they will receive and can be assured a pain-free death. Staff have embraced this very enthusiastically and feedback from relatives is extremely positive. The home are seeking accreditation under the GSF framework. This is will be a very positive achievement. A training matrix now identifies training completed and also future training needs. What the care home could do better: Lessons have been learned from a recent Safeguarding referral. Referral to Tissue Viability Specialists must be made at an early stage where pressure sores do not respond to treatment and further deterioration occurs. It is important as an indicator of general health that all people are weighed monthly and where there are concerns about weight loss this should be weekly. This will ensure close monitoring and result in early referral to health care specialists. We suggest that regular staff meetings should be held to provide the opportunity for staff to express their views about service provision. They are closest to the delivery of care and can make objective comments and suggestions for improvement. A risk assessment must be completed for the use of a call system extension cord where there has been an identified risk. It is important that staff are aware of the risks involved and must have clear instructions about the removal of the cable. Some care planning records are dated and some duplicated, for example weights are recorded in 3 different places. Some information is conflicting and should be removed to provide only a current working document for staff to follow to meet the assessed needs of people. All medication must be signed for by staff at the point of administration. There must be no gaps of MAR sheets. This will ensure that people have the medication prescribed for them to ensure their health and wellbeing. Key inspection report Care homes for older people Name: Address: New Milton Nursing Home Rear 1841 Leek Road Milton Stoke-on-Trent Staffordshire ST2 7AD     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: Peter Dawson     Date: 0 6 0 4 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: New Milton Nursing Home Rear 1841 Leek Road Milton Stoke-on-Trent Staffordshire ST2 7AD 01782542573 01782542573 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr Anandutt Rucktooa Name of registered manager (if applicable) Mr Anandutt Rucktooa Type of registration: Number of places registered: care home 23 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Th maximum number of service users to be accommodated is 23 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 over 65 years of age (DE)(E) 7 Old age not falling within any other category (OP) 23 Date of last inspection Brief description of the care home New Milton Nursing Home is a single storey property that is set back from the main road in an area of Stoke-on-Trent. It is owned and managed by Mr Rucktooa. The home provides both residential and nursing care for 23 people. The accommodation offers nineteen single and two shared bedrooms. Three of the single rooms have enCare Homes for Older People Page 4 of 32 Over 65 7 23 0 0 Brief description of the care home suite facilities, as do both of the shared rooms. The home has an open plan lounge dining room that also serves as the only communal space available. The garden is accessed from the dining area. There is a central kitchen and laundry. The home has three bathrooms. One has an assisted bath, one has an easily accessible shower unit and one doubles as the hairdressing room. Fees for the home are recorded in the Service User Guide as required, further information can be obtained from the home direct. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection was carried out on 1 day by 1 inspector and was unannounced; this means the people using the service and staff did not know we were coming. Our last key inspection of this service was on 17th June 2009 when we made 8 requirements and 16 recommendations. We carried out a Random inspection of the service on 17th August 2009 to check compliance with the requirements made. We found that two requirements had not been met. We found that where people were nutritionally at risk, individual records of food and fluid intake had not been recorded or monitored and also that the administration of medication in the home was still unsafe. We removed evidence of this and took enforcement action by issuing a statutory requirement notice on 11th September 2009. This required compliance with the notice by 25th September to avoid further legal action being taken. We carried out a further Random Inspection on 2nd October 2009 and found that the home had complied with the statutory notice - food and fluid charts were completed and monitored correctly Care Homes for Older People Page 6 of 32 and the necessary changes had been made to ensure a safe system of medication was in place. The focus of this unannounced Key Inspection was therefore, to ensure continued compliance under the regulations and meet the required National Minimum Standards for Older People. Before visiting the home we sent out and received written surveys from 8 people living in the home and 4 from members of staff. These were returned directly to us ensuring confidentiality. The service also completed an Annual Quality Assurance Assessment (AQAA) - a legally required self-assessment document outlining the standards of care being provided. This focuses upon what the service does, how they evidence this and any areas in need of improvement. This was returned to us on time and gave us the information we needed and asked for. There were 17 people in residence and we spoke with many of them during the inspection. We also spoke with 4 visitors and all members of staff on duty. We were able to observe interactions between people living in the home, staff and visitors. We looked at care plans, risk assessments, wound care records, medication records, staffing records and a range of other records relating to the inspection process. We inspected the communal areas of the home and a sample of bedrooms. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? Significant improvements were required at the time of the last inspection and we have carried out two random inspections to ensure this happened. Improvements have been made in the following areas: Food and fluid charts are now completed correctly, fluid it totaled daily and referrals made to the GP where there there is inadequate intake. Nutritional plans are now more robust. The medication system has vastly improved. There is now an ongoing count of medication - All medication received is checked and medication from the previous cycle added, ensuring that it is possible to audit the system at any time ensuring the correct medication has been received, administered and is available. There are protocols for all PRN (as required) medication. Variable dose medication is recorded to ensure audit of the system. There has been further medication training for nursing staff. Night staff now have responsibility for ongoing audit and checking of medication, ensuring medication can not be out of stock. PRN medication not used for specific periods of time are reviewed with the GP, many discontinued. Complaints are now all recorded with outcomes and timescales met. Half the staff group have had training in the Mental Capacity Act and Deprivation of Liberty Safeguards - important in the home meeting their obligations to assess and take account of peoples capacity. Training for the reminder of staff should be carried Care Homes for Older People Page 8 of 32 out as soon as possible. Recruitment procedures have improved ensuring appropriate checks and references are obtained prior to employment. The documentation has improved with input from an employment group. The home has initiated a quality review system in the form of surveys to people using the service and relatives. The results are made available to people in the home and are particularly useful for people considering admission. This needs to be repeated at intervals and can identify areas that may need change or improvement. Staff supervision has been established and there is now an annual appraisal for all staff. The Statement of Purpose/Service Users Guide has been updated and also now include details of weekly charges. There is now more input into recording systems by care staff - previously only nursing staff did this. An Activities Organiser has been appointed to lead on activities but involving staff in partnership. This has extended the range and improved the quantity, type and quality of the activities with input from people living in the home. People using the service, relatives and staff confirmed this is good progress and has improved quality of life. The home are involved in the Gold Standard Framework - to deliver a good standard of care for all people nearing the end of life. This includes multi-disciplinary working including palliative care specialists. Advanced planning ensure that at the end of life people choose where they wish to be, the care they will receive and can be assured a pain-free death. Staff have embraced this very enthusiastically and feedback from relatives is extremely positive. The home are seeking accreditation under the GSF framework. This is will be a very positive achievement. A training matrix now identifies training completed and also future training needs. What they could do better: Lessons have been learned from a recent Safeguarding referral. Referral to Tissue Viability Specialists must be made at an early stage where pressure sores do not respond to treatment and further deterioration occurs. It is important as an indicator of general health that all people are weighed monthly and where there are concerns about weight loss this should be weekly. This will ensure close monitoring and result in early referral to health care specialists. We suggest that regular staff meetings should be held to provide the opportunity for staff to express their views about service provision. They are closest to the delivery of care and can make objective comments and suggestions for improvement. A risk assessment must be completed for the use of a call system extension cord where there has been an identified risk. It is important that staff are aware of the risks Care Homes for Older People Page 9 of 32 involved and must have clear instructions about the removal of the cable. Some care planning records are dated and some duplicated, for example weights are recorded in 3 different places. Some information is conflicting and should be removed to provide only a current working document for staff to follow to meet the assessed needs of people. All medication must be signed for by staff at the point of administration. There must be no gaps of MAR sheets. This will ensure that people have the medication prescribed for them to ensure their health and wellbeing. 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 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the necessary information before making a judgment about the suitability of the home for them. Assessments are always completed prior to moving into the home. Evidence: The Statement of Purpose and Service User Guide are available in the reception area for visitors and a copy is given to people who use the service. It is stated that these documents could be made availble in alternative formats. Both documents were updated in August 2009 following the last key inspection and the weekly fees have now been included. The home will continue to update this this information that gives a clear account of the services provided. People are always assessed in their current environment prior to moving into the home. Relatives confirmed that people were invited to visit the home before admission, although this may not always happen, for instance if people are in hospital Care Homes for Older People Page 12 of 32 Evidence: awaiting discharge. This is nevertheless, the homes preferred option. In the sample of care plans seen we saw comprehensive pre-admission assessments in place. These were used as the basis for informing care planning information. Care Homes for Older People Page 13 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Further improvements in aspects of care planning and health care monitoring, including medication will ensure peoples health care needs are fully met. Evidence: When we carried out our last Key Inspection of this service on 17/6/09 we found serious shortfalls in areas of medication and aspects of health care, particularly relating to food and fluid intake charts for those at risk. We made requirements to address these issues. When we visited again to check compliance on 17/8/09 we found that these matters had not been properly addressed to ensure the health, wellbeing and safety of people in the home. We issued Statutory Requirement Notices - legal documents to ensure compliance with the requirements we made. We carried out a Random Inspection of the home on 2/10/09 to check compliance and we found that all the issues in elation to health care and medication had been satisfactorily addressed. On this inspection we have focused upon checks to ensure that there is still compliance in those areas. Care Homes for Older People Page 14 of 32 Evidence: At the time of this inspection there was only one person with a food and fluid intake chart who was assessed to be nutritionally at risk. Records showed the charts had been completed well and accurately over the previous week that the charts related to. There were daily totals of fluid and details of daily food intake. The records showed that the situation had been closely monitored and improvements had been made in both food and fluid intake. In fact we saw the person enthusiastically eat a large portion of roast chicken, chips and vegetables, followed by a large dish of rice pudding. In this instance the nutritional deficiency had been identified at and early stage, action taken to encourage food and monitor intake. The records accurately recorded the events. We looked at a sample of care plans that gave a comprehensive account of the actions required by staff to meet the health and personal care needs of each person. We saw risk assessments in place for nutrition, pressure damage, falls, moving and handling and bed rails and these had generally been reviewed regularly. We found some of the information repetitive and dated. Some information needs review and updating to ensure that only current needs are recorded and confusion can be avoided. An example in relation to one person was the moving and handling assessment indicating the person was still weight bearing and using a walking frame - in fact she was no longer weight bearing and a full body hoist used for all transfers. We looked at records relating to pressure damage and other wound care. We found that one person has persistent pressure damage over a long period of time. Specialist Tissue Viability Nurses had been contacted and were overseeing the treatment plan. The required pressure relieving mattress was in place and we saw the person sitting on the required pressure relieving cushion in the lounge area and sitting out for only the prescribed short period of time. In relation to this person, practice and wound care records were good, vital to ensuring there was no further deterioration in the longestablished condition. One other person had pressure damage and records showed treatment and improvements. We saw that 3 other people previously had pressure damage that had healed, although the wound care records did not conclude the treatment. A recent Safeguarding referral relating to a deterioration following admission of a person with a pressure sore indicated that a referral had not been made to external Tissue Viability specialists. The home are aware of the need for swift referrals and their internal procedures need to detail the need for early action. We were satisfied on this visit that pressure ulcers and other wound care was being actively documented and monitored and that Tissue Viability Specialists swiftly involved where appropriate. Care Homes for Older People Page 15 of 32 Evidence: We looked at records in relation to people being weighed regularly. Monthly weights were being recorded, although we found that in the previous month only half the people had been weighed. We also identified a weight loss for one person of 4kg in February, this was not picked up by the home and further checks showed a similar universal loss for most people during that month, although weights had resumed their previous levels in March. This was clearly an error and should have been identified by the home. Weight is clearly one important indicator of health and wellbeing. Some people with low weights were also weighed monthly - good practice indicating more regular (weekly) weighing is necessary. We looked in detail at the medication system and found that the shortfalls identified on the last Key Inspection and first Random Inspection had been adequately addressed. Those issues related to most areas of medication including: receipt, storage, administration and disposal of medication. The system at that time was found to be unsafe. On this inspection we found that the changes we saw on the last Random Inspection had been maintained. Ongoing audits of the system have continued and identify where action is required. We did find that there were still some gaps on MAR (Medication Administration Records) in instances where medication had been given but not signed for. The Manager will discuss this further with the staff responsible. We did find one instance where the number of tablets given had not been recorded - the prescription instruction were for one or two tablets three times per day - the number given had not been recorded. These issues need to be dealt with to ensure improvements continue but we were satisfied that progress had been made in providing a safe system of medication in the home. The home is in the process of introducing the Gold Standard Framework - the aim is to provide a gold standard of care for all people nearing the end of life. This involves people in the home, their relatives, staff and health care professionals in assessing, planning and meeting the needs of people nearing end of life care - it is about living well until you die. This includes palliative care specialists and ultimately ensuring people have pain free care. The home are seeking accreditation under this scheme later this year but meanwhile the concepts have been embraced by the home in partnership with external health care professionals and benefited people who have died recently in the home. We spoke with relatives of a person who died at New Milton some weeks previously. They had come to present a gift for other people living in the Care Homes for Older People Page 16 of 32 Evidence: home and spoke highly of the care provided at this home allowing their relative a pain free death in the place of her choice. Care Homes for Older People Page 17 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements in the range of activities have improved quality of life for many. People are encouraged to maintain contact with their family and friends, welcomed into the home at all times. Evidence: Since the last key inspection the range of activities provided has increased significantly. An Activities Coordinator is now employed over several days to lead on activities and all staff are involved in supporting this change. A Wheel of Life (social history) is being established for each person including past photographs and defining life events, building a picture of the persons past life, interests, hobbies and aspirations. Families have been involved in this exercise. This history of life is also be used to stimulate discussion and reminiscence. The range of activities include internal and external activities, people have been on short tips or simply taken to visit local shops and parks. Relatives seen and spoken with during this inspection commented that the activities have made a difference to peoples lives - One relative who visits daily told us Care Homes for Older People Page 18 of 32 Evidence: thatThe activities are excellent. Over Easter, cards and bonnets were made with a competition and food and wine had been provided for all. Entertainment was brought into the home and we all had a marvelous time. All activities are documented and it is clear that the changes have improved quality of life for people at New Milton. We spoke with 2 visitors who visit daily, one commented upon the activities above, another said that his relative had an unsuccessful placement in another home, was admitted to hospital for months but placed at New Milton Nursing Home 4 months ago. She has settled very well. The person said that the Manager had carried out an assessment in hospital in a calm and reassuring way. Any doubts about being able to deal with previous difficult behaviour had not been evident and the admission and subsequent placement was handled well and has been very successful, I am so relieved and pleased. People told us that food provision was good. We saw menus giving a choice of main courses and other options. Catering staff told us that there was no food budget and they simply ordered what people wanted. Relatives also told us that the food was good and people could have whatever they wished. In addition to the people we spoke with during the inspection, we sent out surveys prior to the inspection and received written responses from 8 people and their relatives who made the following comments: I visit and observe on a daily basis how those who are extremely dependent are encouraged to eat the very nice meals provided. This is done always with kindness, so important for these vulnerable people Visitors are always made welcome Families are invited to celebrate special events, every effort is made to make people happy, there is food and entertainment and presents for each person. The level of care is good, as is the knowledge that your relative is in a nursing home worthy of its name. To be honest, I feel that everyone at New Milton try to do the best they can This little nursing home is very nice, it is homely and comfortable Care Homes for Older People Page 19 of 32 Evidence: My mother is bedridden and confused but is always clean and comfortable and responds well to all the staff Staff are very helpful and are always there should you require them - a good working team I came for respite care, could not return home, I was in an environment I was happy in, and stayed Care Homes for Older People Page 20 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be sure that their complaints are acted upon. Safeguarding procedures have identified some shortcomings but the home have learned from this and improved their practice in the area of tissue viability. Evidence: There is a complaints procedure readily available in the home that is clearly written and easy to understand, it explains the procedures and timescales for investigating complaints. At the time of the last key inspection not all complaints had been recorded or handled in accordance with stated procedures and a requirement made to ensure better recording and handling of complaints. Recording and investigations of complaints have improved since the last key inspection and a Compliments, Concerns and Complaints record has been established. The home have had 3 domestic type complaints relating to laundry, equipment etc. These are well recorded and actioned swiftly within the given timescales. We have not received any complaints about this service since the last key inspection. Training in the Mental Capacity Act and the Deprivation of Liberty Standards has taken place since the last inspection. About half the staff group have been involved in this training and further training is planned. Staff spoken with had a grasp of this legislation and the implications for people and the home. Care Homes for Older People Page 21 of 32 Evidence: A referral has been made under the Safeguarding of Vulnerable Adults procedures since the last report and members of the multi-disciplinary Safeguarding team have visited the home. This related to a person with a record of pressure sores whilst in long term hospital care. The person was discharged from hospital to New Milton, still with pressure damage requiring specific clinical care. Unfortunately there was poor communication about the discharge and the pressure damage further developed rapidly. Tissue Viability Specialists were not contacted for 3 weeks by the home, although records were indicating this should have happened sooner. The home accept this criticism and staff are now aware of the need to refer for specialist tissue viability assessment at an earlier stage. It is important that the homes written policy and procedures on Pressure Relief are now amended to include this important change. We were advised that the person this matter relates to made good progress and was successfully treated, vastly improving her skin integrity. Care Homes for Older People Page 22 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, well-maintained environment. Evidence: Standards of hygiene throughout the home are good. There is a ready supply of equipment to ensure good hygiene. Some areas (corridors and bathrooms) were cluttered on previous visits, but this has been removed and improved safety and presentation. A sample of bedrooms seen were well furnished, bright and comfortable. People are encouraged to bring small items of furniture and other effects to personalise their bedrooms. The two shared bedrooms have had privacy curtains installed to improve privacy. Some bedrooms have had new floorings, bedding and curtains and some furniture replaced. New window in the laundry has improved ventilation. There is one large lounge area that separates into 3 recessed areas, including one used as the dining or sitting area. A large number of people have meals on small tables beside their lounge chairs. This appears to be from choice, although in written feedback one visitor said It would be nice if everyone could have their meals at the Care Homes for Older People Page 23 of 32 Evidence: table, some have it where they sit all day. There may be physical reasons for this but the home may wish to consider the statement made. When asked what the home could do better, someone in a written survey said It would probably work well if a conservatory were put on the back of the building to give more room, so more people could sit and look out into the garden. There is a call system throughout the home including bedrooms. An issue relating to the safety of a person using this system was identified and amplified in the final outcome area of this report. There is evidence of equipment to assist people with toileting and bathing, there are handrails in relevant parts of the home. The home adequate pressure-relieving equipment in place including alternating pressure mattresses - two high grade units recently purchased. The provider has plans to refurbish/refit the kitchen area. We discussed and agreed the principle of extending the kitchen to include a toilet presently unused off the lounge area. There are 3 other toilet areas easily accessed from the lounge area. There is a small private garden area off the lounge/dining area that people enjoy in the summer months. During this inspection a family arrived to present a new bird table to the home in memory of their relative who recently died. They are still in contact with the home and spoke highly of the care provided to their relative. Care Homes for Older People Page 24 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements in recruitment and training further protect people living in the home. Staff numbers and commitment ensure peoples needs are met. Evidence: The staffing numbers at New Milton are 5:4:3 throughout the 24 hour period - this includes a nurse on duty at all times. There were 17 people in residence at the time of this inspection. The staffing ratio was good, although some people do have quite high dependency needs requiring 2 staff to assist with personal care. 4 people need total assistance with feeding. Additionally hours are provided for an Activity Coordinator. Another person works 4 hours on 3 days assisting with practical and other tasks, but not personal care. There are adequate numbers of hours for catering and domestic staff. A part time handy person is also employed. We spoke with all staff on duty throughout the day of the inspection, many seen at previous inspections. There is a high level of commitment to resident care from all staff and there are clearly good working relationships established. We saw sensitive, reassuring and supportive care being given to all and particularly those who are vulnerable and with high dependency needs. The staffing group is quite static in this home and this provides continuity. Agency staff are now only rarely used to cover for Care Homes for Older People Page 25 of 32 Evidence: nursing staff. All staff have detailed knowledge of the needs of people in the home. They were enthusiastic about resident care and keen to be involved in the inspection process. There were also observed friendly and open relationships with all visitors. In written feedback from staff one person summarised What the home does well by stating It is very good in making people feel as though they are part of the family. Care is very good and activities are going very well. The home now have a training matrix. We were able to see that all statutory training has been completed. The home have 2 approved trainers for moving and handling. All are encouraged to undertake NVQ training only one recently appointed staff member is waiting for this training all other staff either have completed or are involved in NVQ training. Half the staff group have completed training in the Mental Capacity Act and Deprivation of Liberty Standards, required in the last report. There are plans to provide this for the remaining staff. Some shortfalls were identified in staff recruitment at the last key inspection and related to induction, CRB records and references. We looked at 3 staff files and found that they were better organised with clearly identified monitors for recruitment. The provider has secured the services of a recruitment/employment consultant, resulting in clearer and adequate records. We found that ISA/CRB checks had been carried out swiftly for all prior to employment, induction records were in place and all had two written references. Care Homes for Older People Page 26 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements in many areas of management of the home have promoted the wellbeing of people using the service. Evidence: A quality assurance system has been established in the home since the last inspection in the form of surveys sent to people and their relatives. These were completed in February 2010. We saw that they had been summarised and placed on display in the reception areas of the home. Most people had responded to the surveys and expressed satisfaction with service provision. This does replicate the information we received in surveys returned directly to us prior to the inspection. Senior carers have been involved in work off the rota to look at information systems in place and to introduce the Gold Standard system for care. The Manager is also the owner of the home and has a daily presence in the home. He works two days each week as the nurse on duty, providing him with hands-on Care Homes for Older People Page 27 of 32 Evidence: knowledge of the care needs of people and able to monitor the operation of the home. He is readily available and has direct and ongoing contact with people in the home, staff, visitors and other professionals. There were some serious shortcomings identified at the last key inspection that the provider has ultimately addressed, resolved and improved the matters identified. In relation to Health & Safety, we noted that individual risk assessments were in place for people. We became aware that there had been a problem in relation to the extension cable to the call system in a bedroom. The person is unsettled at night and was found some weeks ago with the extension cable around her neck. We noticed that this was still plugged into the call system in her bedroom and were told that a member of staff returning from leave had replaced it unaware of the previous circumstances. A risk assessment must be carried out in relation to this and all staff made aware of the risks. Although raised in the early stages of this inspection we noticed that the cable had not been removed from the room in question when we completed the inspection. Staff meetings have not been held since last year and it is recommended that regular meetings are arranged to allow staff the formal opportunity to raise any concerns or make suggestions about the operation of the home. A system of supervision has been established since the last inspection, but the accent is upon training and information and does not include discussion and reviews of personal levels of achievement and goals. Although there is now an annual appraisal in place for all staff. The AQAA self-assessment document provided prior to this inspection and completed by the provider, gave us adequate information about the quality of care being provided. Care Homes for Older People Page 28 of 32 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 29 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 12 Referrals to Tissue Viability Specialists must be made where treatments do not improve conditions and further deterioration occurs. This will ensure swift specialist advice is available to people. 12/04/2010 2 38 13 A risk assessment must be 12/04/2010 completed for use of call extension where a risk has been identified. Staff must have clear instructions about non-use of the extension cable. This will ensure people are protected when risks are identified. Care Homes for Older People Page 30 of 32 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 7 Some records are dated and conflicting. These should be updated and duplicated records removed. This will ensure staff have only current information about how care needs can be met. People should be weighed monthly and where there are concerns about weight loss this should be weekly. Reasons for significant weight loss must be investigated. This is part of closely monitoring health and wellbeing. All medication administered should be signed for at the point of administration. This will ensure people have the prescribed medication to ensure good health and wellbeing. Regular staff meetings will enable staff the opportunity to express their views about the quality of care. 2 8 3 9 4 32 Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. 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