Care Home: Oak Tree Court

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What the care home does well Overall comments from people living and working at the home were positive. Staff stated that they were always given up to date information about the needs of the people they supported and received training that was appropriate to their role. One person commented that team working was good and there was good co-ordination of staff. People living at the home said that they received adequate information about the home before they moved in and 11 of the 12 people said that they ALWAYS received the care and support that they needed. People knew who to speak to informally if they were unhappy and how to make a formal complaint. 11 of the 12 respondents felt that staff ALWAYS listened and acted on what they said. All staff who completed questionnaires said that they knew what to do if someone had concerns about the home. Staff spoken with during the inspection were happy with the training that they received and the support from managers and senior staff. Training and supervision records seen confirmed that there is a system in place for staff training and on going supervision. Anyone wishing to move into the home has their needs assessed to ensure that it is the right place for them. A care plan of someone who had recently moved to the home contained full information about the person and there was evidence that the care plan had been drawn up in consultation with them. The home provides a comfortable safe environment and there is sufficient equipment in place to meet the needs of the people living at the home. To promote the health and safety of people living and working at the home, equipment is regularly tested and serviced. What has improved since the last inspection? In response to the concerns raised with the Care Quality Commission and the Local Authority the home has taken steps to improve medication administration practices. All nurses have completed Nursing and Midwifery Council (NMC) competency standards for medication administration and the manager has introduced competency checks. Medication rounds are now conducted by two nurses to provide a further system for checking. At the random inspection concerns were raised that fluid balance charts did not give a daily total and therefore information was unclear. These charts have now been amended to include this information. Care plans for people who have diabetes have been up dated to ensure that they give comprehensive information about the individual. This ensures that staff have guidance about how diabetes affects the specific person. What the care home could do better: At the random inspection some shortcomings in medication administration practice were highlighted and requirements were made. One requirement was for the home to have a suitable system in place to allow the audit of medication. At the time of the key inspection some improvements had been made in the medication auditing system.The home needs to make sure that where people are unable to make decisions for themselves and decisions are made on their behalf then there must be clear care plans to show the rationale for the decision. All decisions made must be in line with the Mental Capacity Act 2005. Although most people appear happy with the care that they receive outcomes for some people gave cause for concern. For example although there appear to be systems in place to check the amount of fluid people receive, 3 people were found to be dehydrated on admission to hospital, although one person may have had a medical condition that contributed to this. There are quality assurances systems in place to monitor the standard of care provided. The management need to ensure that these systems take account of the outcomes for people as well as care processes. There should be a robust audit of registered nurses` clinical skills to ensure that they are up to date and in line with good practice guidelines. The home also need to look at ways that people are able to make choices about their day to day lives particularly around the food that they eat and how they engage in activities. Currently the last meal of the day is at tea time and there is no evidence that people are offered snacks during the evening. Although one person said that they were sure they would be given something if they asked, evening snacks should be offered to everyone. This ensures that people who maybe unable to request food have the opportunity for an evening snack. The home also need to ensure that language used, both written and spoken, promotes peoples privacy and dignity. Key inspection report Care homes for older people Name: Address: Robins Close Nursing Home Middle Green Road Wellington Somerset TA21 9NS     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: Jane Poole     Date: 0 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 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: Robins Close Nursing Home Middle Green Road Wellington Somerset TA21 9NS 01823662032 01823665010 robinsclose@majesticare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Majestic Number One Ltd Name of registered manager (if applicable) Miss Mathilda Ngomane Type of registration: Number of places registered: care home 61 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is 61 The registered person may provide the following category of service only: Care home with nursing (Code N) to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home Robins Close has been part of Majestic Number One since September 2001. The home offers nursing and residential care. The registered manager of the home is Matilda Ngomane. The Home is situated in the countryside on the outskirts of Wellington, surrounded by lawn and gardens, which now includes a new level access sensory garden. The home is Care Homes for Older People Page 4 of 32 Over 65 61 61 0 0 2 4 0 7 2 0 0 9 Brief description of the care home well presented and has ample parking. The home accommodates up to 61 people in total. The home is now registered to provide up to 61 nursing places however staffing and accommodation remains in place for 30 with the remainder of people having personal care needs only. Where nursing is provided the corridors are spacious and wheelchair users can be accommodated. There is a large passenger lift between floors. Other parts of the home have comfortable attractive rooms more suited to personal care. The home has been suitably adapted to meet the needs of people in the home. The home is adequately equipped and adjustable beds are provided in the nursing wing. There is a registered nurse on duty at all times. The communal areas are comfortable and well appointed and include a conservatory with views of the garden. There is an ongoing refurbishment programme that includes redecoration and carpets in bedrooms. The fees vary according to peoples dependency and needs and the room occupied. 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: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commissions Inspecting for Better Lives 2 framework. This focuses on outcomes for people and measures the quality of the service under four general headings. These are:- excellent, good, adequate and poor. The last key inspection was undertaken on the 27th July 2009. As a result of concerns raised with the Care Quality Commission and the Local Authority a random inspection was carried out on the 10th February 2010. The random raised further concerns and therefore the key inspection was begun on the 1st March 2010. This report should be read in conjunction with the random inspection report. Care Homes for Older People Page 6 of 32 The key inspection consisted of a full day visit to the home by two inspectors. We, the Commission, were able to speak with people living and working there, observe care practices, tour the building and view records. In addition to the site visit we sent out surveys to local GP surgeries and people living and working at the home. We have also consulted with local health and social care professionals who have carried out reviews of care needs under the Local Authorities Safeguarding Vulnerable Adults policies and procedures. There are ongoing investigations and concerns meaning further reviews will be undertaken in the near future . We received 12 completed questionnaires from people living at the home, 5 from staff members and 2 from a visiting GPs. Some questionnaires had been completed by relatives on behalf of people living at the home. The registered manager and the compliance manager were available throughout the site visit, we were given unrestricted access to all areas of the home and all records requested were made available. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: At the random inspection some shortcomings in medication administration practice were highlighted and requirements were made. One requirement was for the home to have a suitable system in place to allow the audit of medication. At the time of the key inspection some improvements had been made in the medication auditing system. Care Homes for Older People Page 8 of 32 The home needs to make sure that where people are unable to make decisions for themselves and decisions are made on their behalf then there must be clear care plans to show the rationale for the decision. All decisions made must be in line with the Mental Capacity Act 2005. Although most people appear happy with the care that they receive outcomes for some people gave cause for concern. For example although there appear to be systems in place to check the amount of fluid people receive, 3 people were found to be dehydrated on admission to hospital, although one person may have had a medical condition that contributed to this. There are quality assurances systems in place to monitor the standard of care provided. The management need to ensure that these systems take account of the outcomes for people as well as care processes. There should be a robust audit of registered nurses clinical skills to ensure that they are up to date and in line with good practice guidelines. The home also need to look at ways that people are able to make choices about their day to day lives particularly around the food that they eat and how they engage in activities. Currently the last meal of the day is at tea time and there is no evidence that people are offered snacks during the evening. Although one person said that they were sure they would be given something if they asked, evening snacks should be offered to everyone. This ensures that people who maybe unable to request food have the opportunity for an evening snack. The home also need to ensure that language used, both written and spoken, promotes peoples privacy and dignity. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People wishing to move to the home have their needs assessed before moving in to ensure that Robins Close is the right place for them. Initial care plans are reviewed promptly with anyone who has moved in to ensure that they are happy with the proposed plan of care and support. Evidence: The home has a statement of purpose and service user guide. A copy of these documents is available in each room so that people have this information when they move in. We looked at the personal file of one person who had recently moved to the home. An assessment of their needs and preferences had been carried out before the person moved in and a basic care plan had been drawn up. The manager stated all staff are informed about the needs of new people before they are admitted to the home. This Care Homes for Older People Page 11 of 32 Evidence: ensures that staff are aware of the care that new people will require and any preferences that they may have. The home employs both male and female staff and the file seen showed that the person moving in had expressed a preference about the gender of the person who assisted them with personal care. The file showed that a member of staff had met with the new person they day after they moved in to discuss their care plan. Intermediate care is not provided. Care Homes for Older People Page 12 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans give clear guidance about the needs of people living at the home. The home monitors the health care needs of people including nutritional and skin care needs, however there is evidence that the outcomes for some people are not satisfactory. Spoken and written language used does not always promote peoples privacy and dignity. Evidence: Everyone living at the home has a care plan that is personal to them and covers a wide range of issues. During this inspection we looked at 8 care plans in detail. A further 3 care plans relating to wound care were also examined. Care plans seen gave information about the persons physical needs and basic information about their past history and life style choices. Care Homes for Older People Page 13 of 32 Evidence: Care plans seen stated that food and fluid taken daily should be recorded and in all cases these had been completed. Care plans seen stated the target amount of fluids that each person should have in a 24 hour period and the manager stated that she checks the food and fluid charts daily. The registered nurse on duty at the time of the inspection was able to identify people where the home had concerns about the amount they ate or drunk. These concerns had been shared with professionals outside the home. Records seen showed that people were maintaining a stable weight. Whilst records seen during this inspection indicated that people were receiving adequate food and fluid, there have been concerns raised that 3 people were found to be dehydrated on admission to hospital. In view of these concerns the home needs to take immediate action to ensure that care staff are competent in completing charts and that trained nursing staff have the skills to effectively monitor clinical practice and ensure that outcomes for people can be measured. Records of food eaten did not always state what the meal was, for example staff had written 1 full plate of dinner and 1 hot soft diet. It is recommended that staff write the actual meal eaten to ensure that they have a clear record of the food eaten and are able to identify likes and dislikes and promote dignity. One person whos chart recorded soft diabetic pudding on several occasions was seen to be enjoying pureed mince and vegetables on the day of the inspection. At the random inspection carried out on the 10th February 2010 concerns were raised about the quality of information in care plans relating to people who were diabetic. A recommendation was made that care plans contained information about the individuals acceptable blood sugar levels and the signs and symptoms of hypoglycemia, so that staff were able to respond to any concerns. Action had been taken to address this and the care plan seen in respect of a person with diabetes had been amended to include this information. Regular testing of this persons blood sugar showed that it was within the recommended levels. One person living at the home was being given medication covertly. Although there was a fax from the persons GP to say that the medication could be crushed and placed in food there was no care plan giving a rationale for this practice. There was no assessment of the persons capacity and no information to state that it was in line with the persons best interests to be given this medication covertly. This was raised at the random inspection and a requirement was made to ensure that clear instructions were available to staff for medicines that are given covertly. In another care plan a relative had signed a consent form stating that they were in agreement with the use of bed rails. The home must ensure that where a person lacks capacity to make a decision Care Homes for Older People Page 14 of 32 Evidence: and decisions are made on their behalf this is done in line with the Mental Capacity Act 2005. The home has a range of pressure relieving equipment. We looked at care plans of people identified as having pressure damage. We could see that the wound had been photographed and that care records of dressings were being completed according to the care plan guidance. Whilst some wounds were long standing there was evidence that generally they had improved and that some wounds had healed completely. Signatures on some treatment records were not clear. The home carries out a monthly audit of all wounds and this is recorded. Care plans stated how often people needed to be assisted to change position to minimise the risk of pressure damage. Charts relating to assisting people to change position did not always clearly reflect the care plan. Throughout the day of the inspection we observed people who were assessed as being at high risk of pressure damage and it was noted that their position in bed was changed and they were assisted to move to a comfortable chair for part of the day. Staff observed generally spoke to people in a respectful manner although at times it was noted that there was limited interaction or explanation when staff carried out a task with someone. In the lounge after lunch one member of staff loudly announced who they had assisted to the toilet, which did not promote peoples privacy and dignity. One person spoken with said staff are kind another said the staff were sweet. One person wrote on their questionnaire Care staff are always friendly and polite. Another wrote Staff are very caring. 11 of the 12 people who completed questionnaires answered ALWAYS to the question Do you receive the care and support you need? 10 of the 12 people answered ALWAYS to the question Does the home make sure that you get the medical care you need? After serious concerns were raised with the Commission a full medication audit was carried out by a pharmacy inspector from the Commission on the 10th February 2010, therefore this standard was not inspected on this occasion. Requirements and recommendations made at the random inspection are included in this report. At the time of the key inspection the home had begun to put in place systems to audit medication and monitor any improvements in practice. Care Homes for Older People Page 15 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is an activity programme in the home offering a wide range of activities, social events and trips out. People are not always given choices about how they spend their time or the food that they eat. Evidence: The home employs two part time activity workers who organise activities for the whole home. Each month a programme is given to everyone so that they can decide which activities they would like to take part in. There is also a monthly newsletter. One activity worker was spoken with during the inspection. They said that there is a range of group activities and they also see people in their rooms. There are two bus trips a week and each month there is a social event that friends and families are invited to. Activities include arts and crafts, quizzes, games, music, hand massage, knitting and reading. Local clergy from various denominations visit the home to offer communion to those who wish to participate in a group or on an individual basis. There are photographs in the home of the activities that people have taken part in including a recent Valentines party. One person said Activities are very good. Care Homes for Older People Page 16 of 32 Evidence: 10 of the 12 people who completed questionnaires answered ALWAYS to the question Does the home arrange activities that you can take part in if you want? The other two people answered USUALLY. One person wrote on their questionnaire Activities are very good. During the day it was noted that in one lounge a large TV was on without sound, music was playing and the activity worker was organising a game at the same time. No one was asked if they were watching the TV before the sound was turned down and no one living at the home was consulted on the choice of music. We discussed this with the activities co-ordinator on duty and also suggested that people might benefit from a wider approach to activities in which some care staff might also become involved. A hairdresser visits the home 3 times a week and there is a small shop where people can buy essentials. At the time of the inspection some people living at the home appeared unkempt, the manager stated that these were people who chose not to use the services of the visiting hairdresser. One person commented on their questionnaire, under the section What could the home do better? More care needed looking after residents clothing and thereby improve residents daily presentation. People said that they were able to have visitors at any time and one person said that they enjoyed going out with their family. Questionnaires received confirmed that visitors are always made welcome. The main meal of the day is at mid day with a lighter meal in the evening. There is a choice of two main courses and a member of staff said that people chose their meal the day before and this was recorded. The choice for people who required a soft diet was listed on the menu preference sheet as soft and it was unclear if these people had been able to make a choice about their meal. There are two dining rooms in the home but people are able to eat in their rooms or elsewhere if they wish to. Lunch was observed in both dining rooms. The meal was served plated complete with vegetables and there was no evidence that people made a choice about the vegetables they had or the size of portions. One person said nice food and plenty of it. In answer to the question Do you like the meals in the home? 7 people answered ALWAYS and 5 said USUALLY, It was observed that people who chose to eat in their rooms were taken their meal on a tray. Both courses were on the tray meaning that hot puddings became cold while people ate their main course. One person was unclear about which course to eat first Care Homes for Older People Page 17 of 32 Evidence: so was seen to eat both together. One person eating their food in their room was trying to eat whilst laid down and no one had assisted them to sit up and eat in a more comfortable position. Food intake charts did not show that any snacks were offered after the evening meal. One person said that no snacks were offered but they thought that if they asked for something the staff would ensure that they had something. Care Homes for Older People Page 18 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a complaints policy and all complaints are investigated. Evidence: The home has a complaints procedure that is available to all. All complaints, formal and informal, are recorded and investigated. A complaints log is kept and this showed that investigations appropriate to the complaint are undertaken and outcomes are recorded. Everyone who completed a questionnaire said they knew who to speak with informally if they were not happy and how to make a formal complaint. Where allegations have been made against staff members the staff member has been suspended whilst investigations are carried out by the most appropriate authority. 2 referrals have been made to the Local Authority under their Safeguarding Vulnerable Adults policy and procedure. The home has co-operated fully with these procedures which are currently ongoing. As previously stated where decisions are being made on behalf of people who lack capacity to make them for themselves the home are not following the Mental Capacity Act. Staff spoken with were not familiar with the Act and it is strongly recommended that training is made available to ensure that people living at the home are protected. Care Homes for Older People Page 19 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. Robins close provides a comfortable safe environment for the people who live there. Standards of cleanliness throughout the home are good. Evidence: Robins Close is a large home with accommodation set over three floors. All areas are fitted with a call bell and fire detection system. It is set in a semi rural position on the edge of the small town of Wellington. There is a variety of communal areas throughout the home where people are able to spend time. A sample of personal rooms was viewed. It was noted that people were able to bring personal possessions with them when they moved in, which gave many rooms an individual feel. The home is reasonably maintained and there is a programme of refurbishment to redecorate and up grade areas. All areas of the home were clean and there is suitable hand washing facilities throughout the home. People who completed questionnaires answered ALWAYS (9) or Care Homes for Older People Page 20 of 32 Evidence: USUALLY (3) to the question Is the home clean and fresh? Care Homes for Older People Page 21 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a robust recruitment procedure which minimises the risks of abuse to people who live at the home. People working at the home are happy with the training opportunities provided but the home needs to ensure that all trained nurses have up to date clinical knowledge and skills. Evidence: People spoken with during the inspection said that there were adequate numbers of staff on duty at all times. The manager stated that during the day there are 9 carers and one registered nurse on duty. Overnight there is one registered nurse and 3 carers on duty. Rotas provided at the inspection confirmed this. The managers hours and all ancillary hours are in addition to this. Staff who completed questionnaires answered ALWAYS (3) or USUALLY (2) to the question Are there enough staff to meet the individual needs of all the people who use the service? The home produces a training and development plan each year that identifies the training to be provided for each job role. In view of the recent concerns, about the nursing care for some people, a robust audit of nurses clinical skills needs to be carried out and training implemented where shortfalls are identified. Care Homes for Older People Page 22 of 32 Evidence: Staff spoken with felt that they had access to good training which was appropriate to their role. Training records are kept on the computer and it can be clearly seen the training staff have received. Up-dates and expiry dates are identified. We case tracked two people and found that the training needs identified by their job role had been undertaken and were up to date. For example a senior carer had undertaken medication handling training and dementia awareness. There was evidence that care staff received regular manual handling and fire training up-dates. One member of staff commented on their questionnaire that there was Training for all staff and another wrote I attend training sessions on a regular basis to up date my knowledge of all I do? After the random inspection carried out on the 10th February 2010 the pharmacy inspector wrote The registered manager told us that she has recently introduced competency checks for all registered nurses. We were informed that all registered nurses had been required to complete the Nursing and Midwifery Council (NMC) competency standards for the administration of medication. The registered manager confirmed that there were no formal systems for monitoring the competence of the senior care staff responsible for administering medication on the residential wing of the home. The registered manager stated that she regularly walks around the home and observes senior care staff administering the medication and that procedures are discussed at formal staff supervision sessions. We were able to see evidence of this in the staff files examined. There are opportunities for staff to gain National Vocational Qualifications at the home. 6 staff have level 2 qualifications and 3 have level 3. 5 staff are following a Train to gain Programme and 3 are currently being assessed for NVQ. There are five staff who because of their qualifications gained in other countries (often nursing) are deemed to have equivalent qualifications to an NVQ. There is a list of 8 staff waiting to commence their qualifications. We viewed the recruitment files of the 2 most recently appointed members of staff. These gave evidence of a robust recruitment procedure which minimises the risks of abuse to people who live at the home. There were records of Criminal Records Bureau (CRB) checks and written references had been obtained prior to the person beginning work in the home. Files showed that the new staff had begun an induction programme. All staff who completed questionnaires said that the home had carried out checks such as CRB and references before they began work. The homes registration has been amended to enable the number of people requiring Care Homes for Older People Page 23 of 32 Evidence: nursing care to increase to 61. We heard from the manager that plans were underway to review staffing to enable this to happen. At the time of this inspection the compliment of registered nurses was not sufficient to provide nursing care to 60 people. Rotas provided indicate that there is currently a team of only 4 registered nurses. Care Homes for Older People Page 24 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. The home is effectively managed and there are quality assurance systems in place, however these systems need to look at outcomes for people in addition to processes used. Evidence: The registered manager of the home is Mathilda Ngomane who has been at the home for over 6 years. She is a qualified general nurse and has many years experience of working with older people. People spoken with said that the manager was very approachable and visible in the home. It was observed that people living and working at the home appeared very comfortable with the manager. 1 member of staff wrote on their questionnaire I think Robins Close is very well run and I have high regard for the home manager. She does a very excellent job. The company has a clear management structure that gives clear lines of accountability and responsibility. At the time of this inspection the companys compliance manager was also at the home carrying out one of their regular audits. Care Homes for Older People Page 25 of 32 Evidence: There are quality assurance systems in place which include regular audits of records and practice. The home seeks peoples views by 3 monthly satisfaction questionnaires and monthly meetings for people living and working at the home. We were able to see the minutes of meetings held with Heads of Departments, Registered Nurses and people who live in the home. Although there are systems in place to monitor the quality of care there continues to be unsatisfactory outcomes for some people. The management needs to ensure that all quality assurance systems are able to measure outcomes for people as well as processes in place. The area manager carries out monthly visits in line with regulation 26 of the Care Homes Regulations 2001 and records of these visits have been made available to the Commission. To ensure the health and safety of people living and working at the home a maintenance person is employed and records are kept of all maintenance. Equipment is regularly tested and serviced by outside contractors. The manager acts as a financial appointee for two people living at the home and assurances were given that this is in the process of being handed over to a more appropriate body. The home also allows people to deposit small amounts of money for safe keeping. A sample of these monies was seen and records kept correlated with monies held. There is a clear system in place for recording money, receipts are obtained and two signatures are in place for all transactions. The home reports all significant incidents to the Commission. There are up to date certificates of insurance and registration. Care Homes for Older People Page 26 of 32 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 8 12 The registered person must 05/03/2010 ensure that nutritional care plans are fully reflective on an individuals assessed needs and that all interventions required to meet those needs are clearly recorded. To ensure the health and well being of people using the service. 2 9 13 The registered manager must ensure that a suitable system is in place to allow the audit of medicines. So that staff can check that medicines have been given as prescribed. 05/03/2010 3 9 13 The registered manager 05/03/2010 needs to ensure that clear instructions are available to staff for medicines that may be given covertly and that these are reviewed regularly. To make sure that medicines are given appropriately and in a consistent manner. 4 9 13 If a medicine is prescribed with a variable dose, a record must be made of the amount that is given. 05/03/2010 Care Homes for Older People Page 27 of 32 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 So that it is clear how much medicine the person has received. Care Homes for Older People Page 28 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 12 (1) The home must enough that systems for monitoring food and fluid intake are robust and take account of outcomes for individuals. To ensure people receive adequate nutrition and hydration. 12/04/2010 2 9 13 The registered manager must ensure that a suitable system is in place to allow the audit of medicines. So that staff can check that medicines have been given as prescribed. 05/03/2010 3 9 13 If a medicine is prescribed with a variable dose, a record must be made of the amount given. So that it is clear how much medicine the person has had. 05/03/2010 Care Homes for Older People Page 29 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 9 13 The registered manager needs to ensure that clear instructions are available to staff for medicines that may be given covertly and that these are regularly reviewed. To make sure that medicines are given appropriately and in a consistent manner. 05/03/2010 5 9 12 (1) [a] The home must ensure that where a person lacks capacity to make a decision and decisions are made on their behalf this is done in line with the Mental Capacity Act 2005. To ensure that people Rights are protected. 12/04/2010 6 30 18 (3) The registered person must carry out a robust audit of registered nurses clinical skills and implement training where shortfalls are identified. To ensure that nursing staff have up to date clinical skills to enable them to ensure that everyone receives appropriate care. 30/05/2010 7 33 24 The management must 30/04/2010 review the quality assurance systems in place. Care Homes for Older People Page 30 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To ensure that outcomes for people, as well as processes used are satisfactory. 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 2 10 15 The home should ensure that only language that promotes peoples privacy and dignity is used in the home. The home should offer people, including those who require a soft diet, choices of food, condiments and portion size. Main courses and puddings should be served separately. 3 18 It is strongly recommended that all staff receive training in the implications of the Mental Capacity Act 2005. 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). 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