Care Home: Paternoster House Care Centre

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What the care home does well There was good information available to inform people about the services and facilities available at Paternoster House. Visitors told us they were always made welcome at the home. The provider organisation undertakes a thorough annual review of the service provided for the people living at Paternoster House. This enables the manager to focus attention on areas of identified shortfall to benefit the residents.Paternoster House Care CentreDS0000069329.V378285.R01.S.docVersion 5.2Relatives told us: “We feel the overall care for (person’s name) is absolutely brilliant, staff do a really good job there” and “(person’s name) is always washed, looking smart and well kept” and “Overall I am very happy, (person’s name) has put weight on and eats more now”. What has improved since the last inspection? Since the previous inspection of this service a permanent manager has been recruited to post. This has brought about some improvements to the overall running of the service including the monitoring of complaints and safeguarding referrals. Residents, staff and visitors told us that stability in the management team has improved morale in the home. Residents told us: “Lots of changes recently but all for the better” and “The management is always open for people to approach and say if they do or don’t like something”. A visiting health care professional told us: “Since the new manager it has been very positive here, it’s improving”. Visitors told us:” Things are improving since the new manager has been here”. Some refurbishment has taken place in the home to improve the environment. The Service User Guide has been made available in a larger print format to make it accessible for people with impaired vision. The programme of staff supervision has been improved to provide regular formalised support for all members of the staff team. The overall tidiness of the home has improved, equipment and trolleys that previously caused potential hazards in communal hallways are now stored safely. What the care home could do better: Pre- admission assessments, undertaken prior to people entering the home, need to include more detail about individuals’ needs and preferences. This is so that people can be confident their personal choices will be respected and the provision of care can be tailored to meet peoples’ needs from the start. Daily records need to show detail of the care and support provided for people. This will help ensure a consistent approach and good quality of care for people, help the manager to audit the care being provided and ensure that staff are following the guidelines in the care plans. Medication administration practices need to improve to ensure that people are kept safe and healthy.Paternoster House Care CentreDS0000069329.V378285.R01.S.doc Version 5.2 More stimulation would benefit the people living at the home, especially those people on the nursing unit isolated in their rooms. More work needs to be done to explore peoples’ individual interests and pastimes they enjoyed before entering the home and transfer that learning into individualised activity packages for people. Consideration needs to be given to providing quiet lounge areas away from the large communal spaces especially on the dementia units. This would provide an area for people to go if they did not enjoy the general hustle and bustle of daily life on the unit or if people became anxious or agitated. Consideration needs to be given to creating an environment that supports people living with dementia to identify their own personal space and orientate themselves around their home. Staff need to make sure that residents are not left in lounges without any supervision when the ‘hot trolley’ is on the unit in readiness for mealtimes. This is to avoid potentially dangerous incidents occurring. Key inspection report CARE HOMES FOR OLDER PEOPLE Paternoster House Care Centre Paternoster Hill Waltham Abbey Essex EN9 3JY Lead Inspector Jane Greaves Key Unannounced Inspection 08:30 9 and 10th November 2009 th DS0000069329.V378285.R01.S.do c Version 5.3 Page 1 This report is a review of the 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. 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. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) 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. www.cqc.org.uk Internet address Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Paternoster House Care Centre Address Paternoster Hill Waltham Abbey Essex EN9 3JY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01992 787202 01992 651401 paternoster@barchester.com www.barchester.com Barchester Healthcare Homes Ltd Care Home 138 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (84), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (4), Old age, not falling within any other category (3), Physical disability (25), Physical disability over 65 years of age (80) Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. 9. Persons of either sex aged 65 years and over, who require nursing care by reason of dementia (not to exceed 84 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a mental illness (not to exceed 4 persons) Persons of either sex, aged 40 years and over, who require nursing care by reason of a physical disability (not to exceed 20 persons) Persons of either sex aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 80 persons) Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 3 persons) Persons of either sex, under the age of 40 years, who require nursing care by reason of a physical disability. Five persons, over the age of 50 years, who require nursing care by reason of dementia The total number of service users accommodated in the home must not exceed 138 persons No more than 8 people may attend the home on a daily basis in addition to those service users accommodated. 18th November 2008 Date of last inspection Brief Description of the Service: Paternoster House is a large two-storey purpose built establishment. It is situated in a semi - rural location on the outskirts of the small town of Waltham Abbey and near to the western fringes of Epping Forest. It is on a main bus route and road links such as the M25 and M11 are within a five-mile distance. The home is divided into four distinct units called Parklands, Uplands, Woodlands and Meadowlands. It is decorated and maintained to a good standard. The home can accommodate a total of 138 people. There are 114 single rooms, 79 ensuite; and 12 double rooms, 10 ensuite. The home provides care to older persons who require nursing care due to physical illness or disability, nursing care for persons with dementia and nursing care for younger adults with a physical disability. A statement of purpose and service user guide is available. Current fees range from £590.00 to £1,176.73 per week dependent on peoples’ assessed needs. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes This was an unannounced key site visit that took place over 2 days totalling 13 hours At this visit we considered how well the home meets the needs of the people living there and how staff and management support people. A tour of the premises was undertaken; care records, staff records, medication records and other documents were assessed. Time was spent talking to, observing and interacting with people living at the home, visitors and staff. Prior to the site visit the manager had completed and sent into the Commission for Social Care Inspection the homes Annual Quality Assurance Assessment (AQAA). This is a self assessment document required by law and tells us how the service feels they are meeting the needs of the people living at the home and how they can evidence this. Before the site visit a selection of surveys had been sent to the home for distribution to residents, relatives and staff. Views expressed by visitors to the home during the site visit and in surveys responses have been incorporated into this report. Feedback on findings was provided to the manager throughout the inspection and the opportunity for discussion and clarification was given. We would like to thank the residents, the manager, the staff team and visitors for the help and co-operation throughout this inspection process. What the service does well: There was good information available to inform people about the services and facilities available at Paternoster House. Visitors told us they were always made welcome at the home. The provider organisation undertakes a thorough annual review of the service provided for the people living at Paternoster House. This enables the manager to focus attention on areas of identified shortfall to benefit the residents. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.2 Page 6 Relatives told us: “We feel the overall care for (person’s name) is absolutely brilliant, staff do a really good job there” and “(person’s name) is always washed, looking smart and well kept” and “Overall I am very happy, (person’s name) has put weight on and eats more now”. What has improved since the last inspection? What they could do better: Pre- admission assessments, undertaken prior to people entering the home, need to include more detail about individuals’ needs and preferences. This is so that people can be confident their personal choices will be respected and the provision of care can be tailored to meet peoples’ needs from the start. Daily records need to show detail of the care and support provided for people. This will help ensure a consistent approach and good quality of care for people, help the manager to audit the care being provided and ensure that staff are following the guidelines in the care plans. Medication administration practices need to improve to ensure that people are kept safe and healthy. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.2 Page 7 More stimulation would benefit the people living at the home, especially those people on the nursing unit isolated in their rooms. More work needs to be done to explore peoples’ individual interests and pastimes they enjoyed before entering the home and transfer that learning into individualised activity packages for people. Consideration needs to be given to providing quiet lounge areas away from the large communal spaces especially on the dementia units. This would provide an area for people to go if they did not enjoy the general hustle and bustle of daily life on the unit or if people became anxious or agitated. Consideration needs to be given to creating an environment that supports people living with dementia to identify their own personal space and orientate themselves around their home. Staff need to make sure that residents are not left in lounges without any supervision when the ‘hot trolley’ is on the unit in readiness for mealtimes. This is to avoid potentially dangerous incidents occurring. 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. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 6. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents will be given ample information on which to make a decision about the home. The pre admission assessment may not always contain enough detail to ensure peoples’ needs are met according to their individual wishes and preferences. EVIDENCE: We saw a copy of the Service User Guide and Statement of Purpose. These documents contained all the relevant detail to inform potential and existing residents about the range of services the home provided. A copy was available in large print for those people with impaired vision. The registered manager told us that comprehensive literature and information about the service was either given, or sent to, all prospective residents Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 10 including a copy of the home’s statement of terms and conditions prior to them making a firm decision to move in. The Provider had an informative web site which included comprehensive details about the service offered at Paternoster House for people looking for a care home. The manager’s AQAA stated: ‘A full assessment prior to admission takes place and residents are provided with a contract of terms and conditions’. The manager acknowledged that not all people received letters to confirm that the service could meet their needs and offering them a place on this basis. She reported that now the service had a full time administrator once more, this would be automatically done. The manager, matron or a trained senior member of staff visited prospective residents prior to admission to make a decision as to whether the home can meet the person’s needs. Information was obtained from other parties, including relevant health care professionals to assist in assessments. We looked at pre admission assessments for 5 people, 2 of whom had been recently admitted to Paternoster House. These assessments included only very basic information about peoples’ support needs and preferences including phrases such as ‘total nursing care required’. There was insufficient information to provide the detail necessary to inform staff how people prefer to be cared for and what peoples’ individual needs and preferences are. The Matron told us that a lot of the personal and individual detail was handed over to staff verbally for them to establish the plan of care. This did not provide us an audit trail to show that peoples’ needs and choices were being recognised during the assessment process so they could be met in daily practice. Evidence was available in the care plans to show that peoples’ previous medical history was obtained together with family history as part of the admission process. Medical observations were taken on admission to the home to assess peoples’ state of health on arrival at the home. Relatives we spoke with during this inspection process told us that they felt supported during the admission process and they had visited the home, prior to their relative moving in permanently, to help them make the decision about whether Paternoster House was the right home for their relative. The home does not provide intermediate care. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 receive good basic care however, shortfalls in aspects of recording and medication practice mean that residents cannot be assured that all their needs would be met. EVIDENCE: The home had received considerable input from the Primary Care Trust and Essex County Council social work team during the past year, coinciding with the new manager coming into post. These outside agencies and our previous inspection of this service had highlighted considerable shortfalls in areas of risk assessment and care planning. Since the previous inspection of this service, actions had been taken to develop care plans and risk assessments to address all areas of peoples’ clinical and social care needs. The care plans we looked at did not flow directly from pre admission care needs assessments. An example being a pre admission assessment for a Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 12 recently admitted resident stated: ‘Needs 2 carers to provide all personal hygiene’. The care plan identified the need for 2 carers without the assessment identifying what the specific needs were. There was no detail recorded in the pre admission assessment to indicate how the person needed the support to be provided however the care plan provided a detailed description of how these areas of support should be delivered. It was not clear where this personalised information came from, the Matron told us she gave a verbal handover to staff of the detail about how people needed or wished their care to be delivered. However, this did not provide an audit trail to confirm that peoples’ care was being provided in accordance with their personal wishes and that their preferences were being listened to. The care plans we sampled covered areas such as communication, personal hygiene, continence, mobility, moving and handling, skin care, nutrition and hydration, pain management, diabetes, sleeping and social activity. Instruction for staff to follow in order to meet peoples’ needs was detailed however, it was not possible to assess if this information transferred into practice as the daily records were scant and varied in the amount and quality of information that was recorded. One person’s records we looked at stated: ‘(person’s name) has had a bath and hair wash this morning which they enjoyed. Took all their meals and fluids well. Had a comfortable afternoon sitting in the lounge reading a newspaper. Had their hygiene and care needs met throughout the day, no changes noted’. The records told us what the person had done with their day and that they had enjoyed themselves however the comment ‘Had their hygiene and care needs met’ did not provide evidence of the individual personal care and support provided. Other daily notes we looked at contained recording such as ‘all care given’ and ‘assisted with all personal hygiene’. The manager and Regional Operations Director, who was present for feedback at the end of the first day of the inspection, agreed that these statements did not provide detail of the care and support provided for the person. One care plan we looked at stated that the individual’s preference was to have a shower and hair wash every 3rd day, preferably in the morning. The daily records showed that the person had 5 baths/showers in October and 7 in September despite their clearly recorded wishes of every 3rd day. These records were not always organised. One care plan we saw had two bathing record sheets in different parts of the care folder, this could cause confusion when monitoring and auditing outcomes for people. We saw some care plans that clearly described how people wished to be cared for. An example being: ‘(person’s name) likes to go to bed before 20:00. Before settling to sleep (person’s name) enjoys a cup of tea and a sandwich. (person’s name) likes to sleep with 2 pillows, the light off, window slightly open and door closed. (person’s name) needs to be checked during the night every hour quietly and discretely as they don’t want to be disturbed’. This provided good person centred information to enable staff to meet the Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 13 individual’s needs. This person was able to verbally express their needs and preferences and was able to confirm to us that this plan of care was suitable to meet their needs. Risk assessments were included within the care plans we sampled for areas such as mobilising, weight loss, nutrition, risk of falls and the risk of pressure sores. The risk assessments identified the area of risk and provided instruction for staff to follow to keep people as safe as possible. Supporting tools such as Waterlow assessments were used to identify and assess areas of risk. One of the care plans we sampled showed us that the person was not able to use the call bell system and stated that a risk assessment was in place for this however there was no risk assessment present in the file. Family members we spoke with subsequent to this visit told us their relative was able to mobilise with assistance and that whenever they visited they walked around the home for short distances with them however, they had observed that staff always used a hoist and wheelchair to move the person around rather than prompt and encourage them to move with assistance. The care plan had showed us that this person was assessed as at risk of developing pressure sores, it would therefore be beneficial for this person to be assisted to maximise their mobility where possible. The home received Clinical Nursing support from within the Barchester organisation. The manager told us she had found this invaluable whilst settling into her post. Information recorded within the care plans showed us that regular healthcare support was provided for the people living at Paternoster House, including GP, Dietician, and Chiropodist services. We spoke with healthcare porfessionals who were visiting residents at the home during the course of this inspection. They confirmed their contunued working relationship with the home. On our initial tour of the home when we arrived we saw a qualified nurse administering medications to the residents. This was being done in a calm, and relaxed manner with the nurse waiting patiently whilst each person took their medication. We looked at a sample of Medication Administration Records (MARs) from two units in the home. There were some gaps in recording where medications had been given but not signed for by the person that had administered them. There were instances where the pre printed prescribed instructions on the MARs supplied by the pharmacy had been altered by staff. On one unit for example, one person’s medication was instructed to be given twice daily. The instructions on the MARs had been changed to ‘one per day to be given in the evening’. This amendment had not been signed or dated to indicate who had made the alteration, when this had been done and why. It was explained to us that instructions on the pharmacy MARs contradicted the instructions on Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 14 medication pack. On another unit in the home we saw amendments to the MARs that had been signed by two qualified staff members to confirm they had been checked for accuracy. The manager told us they were exploring a new pharmacy supplier as the current one was not effectively meeting their needs. Medication records included an up to date photograph of each resident to reduce the risk of errors in identification. There was a list of staff signatures at the front of each MAR folder so that it was possible to identify at a glance who had administered medication. We looked at the medication maintained within the home. This was stored in locked trolleys in locked treatment rooms. The majority of medications were supplied by the pharmacy in Monitored Dosage System blister packs. On one unit we noted that bottles of liquid medications were dated to indicate when they had been opened however packs of tablets weren’t dated. This needs to be done to provide an accurate audit trail of medications held at the home. Medication fridge temperatures were monitored to ensure that medications were kept safely. There were some controlled drugs held at the home, these were safely stored. We sampled some records of these, the amount of medications held tallied with the controlled drug register. One healthcare professional told us that they found a lack of available dressings throughout all areas of the home when they visited to change peoples’ dressings. They told us that the approach to peoples’ skin care was reactive as opposed to proactive. For example, they found that one person’s daily notes contained repeated entries on consecutive days about a person having patches of red skin. The skin then broke down in this area and was reported to healthcare professionals as being a grade 2 pressure sore. In practice this wound was found to be a grade 4 pressure sore when professionals visited. We spoke with other healthcare professionals who told us: “The girls are quite good at referring to us if they have any worries” and “Staff are responsive to instruction most of the time”. Residents told us: “If you have anything wrong with you, it’s straight to the hospital. We have a doctor that visits at least twice a week”. Relatives told us: “We feel the overall care for (person’s name) is absolutely brilliant, staff do a really good job there” and “(person’s name) is always washed, looking smart and well kept” and “Overall I am very happy, (person’s name) has put weight on and eats more now”. We observed and overheard staff interacting with residents in a respectful way. We saw that people knocked on doors before entering peoples’ rooms and addressed people in the manner they preferred. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 15 We saw communal stocks of the net pants worn with incontinence pads. We were told these were not named for individual residents but were replaced with new ones every few days. This practice did not promote peoples’ dignity. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 had some opportunity for stimulation and recreation however this was not always tailored to their specific interests and needs. Overall people were satisfied with the food provided. EVIDENCE: The home’s Statement of Purpose stated: ‘An Activities Organiser is employed on a full time basis. A full range of activities is available, guided by resident preferences. These activities will contribute to the overall personal needs, health needs and preferences of service users to ensure the individual’s inclusion in the community’. The manager’s AQAA acknowledged that the service could improve by providing ‘More tailored activities for people with dementia’ and stated improvements over the past 12 months included: ‘The social and recreational programme has been developed to include the needs of all people living in the home’. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 17 Care plans we looked at showed us that peoples’ interests they had prior to entering the home were recorded however, there was no evidence to show us that activities provided at the home were tailored to take into account individuals’ preferences. The assessment undertaken prior to people entering into the home did not contain information about peoples’ wishes in relation to stimulation and occupation. There were two full time and one part time activity co-ordinators employed to provide stimulation and engagement for all the people living at Paternoster House. An activity programme available on notice boards around the home showed us that people were offered the opportunity to take part in arts and crafts, play games and do jig saws. The programme included forthcoming events such as the Winter Fete and a trip to the Zoo. There was a coffee shop for residents in the small dining room situation near the central hub of the home and activity staff told us that people were invited out for pub lunches. We were told there was live entertainment provided for residents most weeks and outings in the minibus were arranged to places such as Paradise Park and for shopping. The activity record sheets in peoples’ care plan folders were not up to date so it was not possible for us to confirm what activities people had taken part in. Residents told us: “In the summer they take people out to places such as Southend”. Relatives shared their concerns about little stimulation being offered to people. “Would like to see more personal interaction between staff and residents in the quiet times”. An activity co-ordinator told us “There are now more resources available for us to provide activity and occupation for people” and ‘we are developing how staff are involved in activities. The manager told us she was investigating learning resources to enhance the staff skills in providing activity and stimulation for those people living with dementia. We spoke with people on the nursing units at the home. They told us there was little in the way of stimulation provided for them. We saw one person reading a newspaper and others watching television however many were isolated in their rooms reporting they did not receive any 1:1 time from activity staff. The dementia units had items for people to touch, engage with and cuddle such as hats, scarves, bags, dolls and soft toys. We saw a chest of drawers with various ‘treasures’ for people to find, one had items stored within however others we saw remained empty. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 18 We did not see residents being involved in the daily routines of the home however, staff told us that people were encouraged to help lay the tables and we saw feather dusters and dust pans about for those people who wished to be involved with household tasks. The manager told us that once the Head of Dementia Services took up their post this will help in developing person centred care plans and provide more opportunity for engagement and stimulation for those people living with dementia. We saw residents playing indoor skittles on one unit, cheered on by staff and visitors. People living at the home enjoyed the services of a visiting hairdresser and were provided with the opportunity to take part in Holy Communion. The manager’s AQAA stated: ‘We actively encourage residents to maintain contact with families, friends and the local community. We do this by welcoming visitors at any time and by regularly inviting community groups into the Home for various activities and events. We encourage and enable residents to visit people and places outside the Home and to take escorted walks in the gardens and local areas’. Visitors we spoke with as part of this inspection confirmed to us they were able to visit their relatives at any time and were always made welcome by the staff team. The visitors’ book showed us that people visited the home freely during the course of the day. We saw that people were encouraged to bring their own possessions into the home to help them feel relaxed and at ease. Daily routines were generally structured however if individuals voiced a particular preference about their day this was respected. We took lunch with residents in the main dining room on the ground floor. It was a calm environment with people given assistance in a sensitive and unobtrusive manner. Copies of the menus showed us there was an option of a cooked breakfast daily, two options for the main meal of the day and a cooked option or sandwiches at supper time. People told us: “usually the food is very good”, “Food is nice, it’s beautiful” and “I don’t like the food much, it is all foreign dishes”. Visitors told us: “My relative doesn’t like the food, says it is too bland and not seasoned enough” and “The food is beautiful here, X has actually put weight on in the time they have lived here”. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 19 We visited the kitchens; they were well equipped and clean, there were ample food stocks available. The manager told us about ‘themed restaurant evenings’ held at the home where family members were invited to join residents for the experience. Examples to date had been a Chinese evening and an Irish evening, the manager told us these evenings had been a success and that more were planned for the future. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall people feel confident that their views will be listened to and they are safeguarded by the home’s policies and procedures and staff training. EVIDENCE: The manager’s Statement of Purpose stated: ‘If you have a complaint about any aspect of the service or care please speak to the Nurse in charge. If the Nurse in charge is not able to resolve the problem please speak or write to the General Manager. All complaints will be investigated and we undertake to inform you of the outcome within 28 days or such shorter period as is reasonable’. The manager’s AQAA stated ‘We address concerns and complaints in an appropriate manner and in accordance with the Organization’s policies and procedures. We make the complaints procedures available to all residents and visitors to the Home. We encourage people to air their views regarding the services provided’. The AQAA told us that 8 complaints had been received since the pevious inspection of this service and that none of these had been substantiated. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 21 We looked at the record of complaints held at the home. At the beginning of the folder was a summary sheet providing detail of the issues raised, including issues raised verbally. There were records available to show what had been done in response to the written complaints. For example, a letter acknowledging the complaint, then a record of any investigation, where appropriate followed by a letter to the complainant, informing them of the outcome of the investigations. There was no evidence available to show what had been done to address the issues raised verbally. This needs to be documented so that people can be confident their concerns are being taken seriously and acted upon. Visitors told us: “I would be very comfortable to raise any concern with the management”. There had been some instability in the management team over recent years until the recent employment of a permanent manager. Some people told us they had brought up issues with interim management and they had not been dealt with to their satisfaction. This had meant they had lost some faith however; most people we spoke with said things had improved considerably since the new manager had been in post. We arrived at the home early on the day of this visit and undertook an unaccompanied tour of the home before the manager arrived. Staff we met around the home questioned our presence, this was good to note for the safety and well being of the residents. The manager had a copy of the current Local Safeguarding Adults guidance, procedures and formats. Since the previous inspection of this service the management at the home had been proactive in referring many potential safeguarding incidents to the Local Authority. Many of these related to incidents between residents, and were managed at the time by staff at the home. Discussion with the manager and information in records showed us that the manager had a good awareness of what constituted abuse and what issues needed to be raised with the authorities as alerts. Training records showed us that the staff team had received training in Safeguarding Vulnerable Adults. When we spoke to staff they confirmed that they had undertaken training, and demonstrated a good awareness of adult safeguarding. They told us that they would report any incidents to a senior or manager. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 live in a clean environment that may not be wholly suitable to meet the needs of people living with dementia. EVIDENCE: The home was a large purpose built building that was divided into self contained units with a central communal hub where people could congregate and take part in activities. There was a range of bathing facilities with assisted baths to meet the range of needs of people living at the home. One visitor told us the lack of grab rails next to the toilets severely restricted their relative’s independence. We saw that grab rails were installed for people to support themselves however these Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 23 were not always positioned in the places necessary to maximise peoples’ independence such as whilst using the toilet facilities. The manager’s AQAA stated: ‘Our premises are kept clean, hygienic and free from offensive odours throughout the building’. On our initial tour of the building on arrival at the home we noted some areas where malodours were present. Despite concerted efforts from a team of domestic staff some odours remained in certain areas of the home later in the day. The manager’s AQAA stated that: ‘There are some areas of the home that require attention and continued refurbishment’ and that ‘One unit has been completely refurbished including new sitting room and dining room furniture and furnishings’. The 2007 inspection report identified the lounge & dining space in the dementia units were as one and there was no quiet area for people to have a change of scenery or to be in a quieter space. At the 2008 inspection a small area of the room, previously the nurses’ station, has been partly sectioned off. Discussion with staff, and our observations, at that visit showed that in practice this did not create a calm, quiet space intended to allow people respite from the sometimes noisy or stressful atmosphere in the room. One of the dementia units had been refurbished in the past year, providing a more pleasant environment for people living there however; there was still no quiet space for people to go to avoid the hustle and bustle of daily life. There had been incidents of aggression between residents on the unit and the provision of a calm and peaceful environment for when people become anxious or agitated may be a way of contributing to the safe management of these incidents. All doors throughout the home were uniformly brown and in many cases damaged. As identified at the previous inspection this doesn’t support people to identify their own personal space or to orientate themselves. We saw there were scribbled name labels on the peoples’ bedroom doors on one unit. The writing was very small and not easy to read and did not contribute to respecting the dignity of people. We saw A4 sheets in the office waiting for peoples’ photos and then to be laminated and attached to individuals’ bedroom doors. The manager told us that this is work in progress. The memory boxes that had been noted at the previous inspection visit were either missing from peoples’ bedroom doors or remained empty. The manager told us that people constantly ripped memory the boxes off their doors and that alternative methods of attaching the boxes were being explored. We noted that furniture in the lounge in the dementia units was arranged in small groups moving away from the institutional appearance. The lounge Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 24 areas on the upstairs nursing unit were an awkward shape and did not lend themselves towards creating a pleasant domestic atmosphere. The manager and Regional Operations Director shared some proposed, but not yet finalised, plans for altering this area to create a more pleasing and user friendly environment for people. At the previous visit to the home we noted that the communal hallways were cluttered and untidy giving the feel of a hospital ward, at this visit we noted a great improvement in this area, the home appeared tidy and calm. A resident told us: “You can’t have better rooms; I look out onto a beautiful garden”. Visitors told us: “Heating is inconsistent, in the summer it is often oppressively hot, today it is a cold day, it is warm in the lounge but the corridors and bedrooms are chilly”. We agreed with this statement and found that some residents’ hands were quite cold to the touch. The manager told us of a heating problem that had occurred that morning, this had been addressed but in case there was a repeat of the problem she had prepared extra duvets and portable heaters to ensure people were kept warm. Relative’s survey from the 2008 inspection had commented “for some reason there are always problems with the heating system”. This appears to be an on going issue at the home. A visitor told us “We would like a lock fixing on the bedroom door, we are concerned because we have found that other people have wandered into X’s room and thrown things onto the floor”. We looked at the laundry, it was well equipped and staff reported that any equipment breakdowns were expediently dealt with. We noted 2 rails of unnamed laundry, staff told us that relatives had been contacted by post and asked to look at the rails and identify any missing items. Some visitors we spoke with expressed some dissatisfaction at laundry going astray, zips on cardigans being broken and buttons missing from clothing items. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by the numbers and the developing skills of the staff team. EVIDENCE: Since the previous inspection of this service a general manager and a matron (clinical lead) had been recruited. A deputy manager, specifically for the dementia services, had been recruited and was waiting for the security checks to be completed before starting to work at the home. The manager told us there had been some staff changes since the previous inspection, some established staff had left and new people had been employed. Staffing numbers had now settled down resulting in very few agency staff working at the home. There were 134 staff members employed to work at Paternoster House including management, admin, nursing, care, maintenance, domestic, kitchen and laundry staff. Staff rotas showed us that each unit had a qualified nurse in charge 24 hours per day. This meant there was always 4 qualified staff on duty in the home. Rotas showed us that there was some fluctuation in the numbers of care staff Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 26 on duty. For example one unit sometimes had 3 care staff on the late shift and sometimes 5. The manager told us the rota was not always accurate as care staff amended the rota themselves when they wished to change a shift and this was not always done properly. The manager had identified this as a shortfall and a new system was being developed ensuring that all rota changes are agreed by the management team. In surveys residents told us they felt there were always or usually enough staff available to meet their needs. Relatives we spoke with had varied opinions about whether enough were staff available. Comments such as “sometimes it can take a while to find someone, especially in the early afternoon” “Weekends seem to be a problem” and “there always seem to be enough staff around but they are so busy” Rotas showed us that, in the majority of instances, staff worked a long day shift. This meant they were on duty from 07:30 hrs until 20:30 hrs with breaks. The manager told us this was an area highlighted for immediate attention, especially in the dementia unit, where a working day can be very challenging and where residents may benefit from having a staff team working less exacting hours. The manager’s AQAA told us:’ We have a robust recruitment policy supported by the Company’s recruitment team as well as our own local accountability. All staff are recruited appropriately to ensure the continued safety of residents’. We looked at recruitment records for 2 staff members employed to work at the home since the last inspection of this service. Both files included written application forms. We noted that, in both cases, the periods of previous employment were not fully completed. For example 1992 to 2006, this does not provide sufficient information for management to be sure they have identified and explored any gaps in peoples’ employment history. Satisfactory references had been received for both applicants before they started to work at the home. One file we looked at did not contain a completed Criminal Record Bureau check. The manager checked and confirmed that the disclosure had been applied for but had not yet been received. The person was working at the home under Barchester’s PoVA 1st policy which stated that the person must work under supervision and that the supervising member of staff must be clearly identified on the rota. The manager was able to tell us which staff member was ‘mentor’ for this person however scrutiny of the staff rotas showed us that they were not always on the same shift. It was noted however, that this staff member always worked alongside experienced staff members. The organisation operated a computer system that provided the manager with access to various reports. For example, there was a report about individual employees’ training achievements, an overview of the whole staff teams’ Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 27 needs, and an expiry report that identified which staff members required various training elements and when these were due. We looked at the training records to confirm if the staff team had received appropriate training necessary to keep people safe from harm. The records were not fully up to date however there was a vast improvement since the previous visit in November 2008. Records showed us that 26 people were due for refresher training in food safety, 14 people were due for moving and handling refresher training, 12 people were due for Safeguarding Vulnerable Adults training and 16 people in Health and Safety training. We saw a 12 month planner that indicated what training was planned throughout the year to ensure that Paternoster House had a skilled and knowledgeable staff team to care for the people living there. A qualified nurse and a member of the care staff team had recently undertaken a qualification to enable them to provide moving and handling training for the staff team, this will ensure a training resource is always available within the home. Records showed us that the qualified staff team had undertaken a drug competency assessment before they started to administer medications to the residents. The Computer system also flagged up, in advance, when qualified staffs’ Nursing and Midwifery Council (NMC) registration expired. This enabled management to ensure the staff working at the home held a current registration with the NMC. Residents told us: “They are short staffed at the moment because they’ve all got to get their holidays in”, “The care staff work damned hard” and “We have very good nursing staff”. Visitors told us: “There have been massive changes in the nursing staff over the past couple of years” and “The nurse on this unit, (Person’s name), is brilliant” Staff told us” Feel we are settling down now and improving” and “We are getting lots of support and training”. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 now experience a more stable management approach that promotes their best interests. EVIDENCE: The present manager of the home had been in post since May 2009. The service had experienced considerable instability in the management team over the past three years which means the staff team have lacked consistent guidance over this period. The situation has stabilised and there is now a clear management structure, staff told us “It’s much more organised now”. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 29 The manager has commenced the registered manager’s application process with the Care Quality Commission, is a qualified nurse and has achieved the NVQ 4 award in management. She has 7 years experience in managing care homes and is a trainer for the dementia training ‘Yesterday, Today, Tomorrow’. The manager demonstrated good knowledge of the individuals living at the home and of their personal and social backgrounds. Residents told us: “Lots of changes recently but all for the better” and “The management is always open for people to approach and say if they do or don’t like something”. A visiting health care professional told us: “Since the new manager it has been very positive here, it’s improving”. Visitors told us:” Things are improving since the new manager has been here”. The manager reported that questionnaires had been sent out to relatives as part of this year’s Quality Assurance process. The manager told us that the results of all completed surveys were collated and analysed by Barchester Head Office to identify areas of strength and weakness in the service provision. A report of the findings was then forwarded to the home for action to be taken to rectify any areas of identified shortfall. The copy of the customer satisfaction survey report from October 2008 was provided for us at this visit. 28 people had responded to the surveys and the overall view of the service at that time was not very positive with just 78 of people indicating they would be prepared to recommend the home to others. The manager undertook to send us the report of this year’s survey responses. We saw reports of regular monitoring visits by a representative of the Barchester Group. These identified issues relating to residents’ care, the environment, medication etc. and provided and action plan with dates for improvements to be made. We saw minutes of a residents’ meeting and a relatives’ meeting, the manager arranged these meetings to ensure that all parties involved with Paternoster House had the opportunity to meet with the new management team. It was noted that neither meeting was well attended. Issues discussed included staff recruitment, forthcoming fundraising events, refurbishment plans for the home, activities and laundry. As at the previous inspection, the service doesn’t maintain personal monies on behalf of the people living there. Families were invoiced monthly for such expenses as hairdressing, chiropody, newspapers etc. Each unit had a folder identifying who had supervision with a line manager and when. Qualified nursing staff supervised the care staff and the manager and her deputy supervised the nurses. All supervision records were passed to the Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 30 manager for scrutiny before being filed in each person’s personnel file. Staff we spoke with felt that these sessions provided them with the support they needed and a safe environment for them to raise any areas of concern for them. During our initial tour of the home we saw there were 5 residents unsupervised in the lounge/diner on one of the dementia units. There was a hot trolley plugged in ready for breakfast, this was positioned in the kitchenette doorway. There were jugs of boiling water in the kitchenette. This posed a potential risk to the safety and welfare of the vulnerable people on this unit. Staff told us that there was ‘usually’ a staff member in the lounge area with the residents at this time of day however they had been called away at this time. We looked at records held in the home relating to incidents and accidents forms. These mostly related to falls and resident on resident outbursts, the manager was able to give examples of various discussions and reviews that had taken place to address these issues, this information was not always recorded in the care plans and risk assessments had not always been developed to reduce the risks of a recurrence of the incidents/accidents. The home had a maintenance team responsible for the monitoring of health and safety within the home. Clear and well maintained records were available to show us that regular checks were made of water temperatures, electrical systems, portable electrical appliances, lifts, pest control etc. Where appropriate, outside contractors were brought in to deal with any maintenance issues. Records available included a ‘daily walk around checklist’ to ensure maintenance staff keep on top of issues as they occurred. Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 32 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement A detailed care and support needs assessment must be undertaken prior to people entering the home so that the prospective residents can be sure their individual needs will be met. Medication Administration Records must be accurately completed so people can be assured they receive their medication safely at the correct times. Packs of medication need to be dated when they are started so it is possible to audit the medications stored in the home and given to residents. Amendments to prescribed instructions need to be signed and dated to ascertain who had made the amendment, when and why. 3 OP12 16 Meaningful opportunities for recreation and stimulation need to be provided to take into DS0000069329.V378285.R01.S.doc Timescale for action 31/12/09 2 OP9 13 10/11/09 31/12/09 Paternoster House Care Centre Version 5.3 Page 33 4 OP38 13 account peoples’ individual preferences and previously enjoyed interests. Hot trolleys must not be left unsupervised in communal areas where vulnerable residents may be at risk of burns. 10/11/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP4 Good Practice Recommendations The manager needs to confirm in writing to the prospective resident that the care home can meet their assessed needs in respect of health and welfare. Daily records need to be completed so that it is possible to assess what elements of care and support have been provided for each person. Consideration needs to be given during the redecoration and refurbishment of the dementia units to provide people with an enabling environment taking into account signage and use of colour so that people can identify their personal spaces and orientate themselves around their home. Consideration should be given to ensuring that all units include a quieter lounge area to give residents choice and meet needs. All bedrooms should be fitted with appropriate locks and keys offered to residents, based on risk assessment, to promote greater choice, privacy and dignity. 2 OP7 3 OP19 4. OP20 4. OP24 Paternoster House Care Centre DS0000069329.V378285.R01.S.doc Version 5.3 Page 34 Care Quality Commission Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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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