Care Home: Regent Hotel

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What the care home does well The provider has acknowledged the shortfalls identified in this report and is anxious to work with the Care Quality Commission to improve the quality of the service provided to people. The majority of staff have worked at the home for some time and know the residents well. They have the residents best interests at heart and want to ensure that they are safe and well cared for. The acting manager told us that over 50% of care staff had completed a national vocational qualification (NVQ) in care at level 2 or 3. We accepted this information as correct, however, we could not confirm it during the day. Although there are some areas of the home that are looking tired and in need of decoration, the home is very pleasantly situated, facing the sea front. The lounge has been recently decorated and a relative commented on how nice it looked. Most of the bedrooms have en-suite toilets and sinks and some have showers or a bath. Visitors are welcomed at the home at any time and we observed family members coming and going throughout the day. What the care home could do better: The home must make sure that peoples` needs are assessed prior to their admission and that any risks are identified. Each resident must have a comprehensive care plans detailing what their needs are and how these are to be met. There must also be comprehensive behaviour management plans to guide staff in how to support people consistently, when they experience behaviours that are challenging to others. Good assessments and care plans that are updated when needs change will help staff to look after people more fully. Staff need to make sure that they date the records they complete. Monitoring charts could be filled out more comprehensively and there could be more information about the care provided each day to people, with follow through to the next shift when required. People had access to health professionals but staff must be more aware of when to follow up health issues with them. They also need to be more vigilant about hygiene issues for particular residents, especially following meals, but also around the home in general. Medication must be managed more effectively so that people receive their medicines asprescribed and so that records are accurate. There needs to be more activities and occupations for residents. This will prevent people from becoming bored and help to keep them stimulated and feel included in their community. People must be supported in making more choices about their daily living to give them more control. This will help people to recognise more that Regent Hotel is their home where their views will be listened to and actioned. There have been some negative comments about the provision of meals and these must be looked into and addressed. There could be a more improved system, especially around the timing of checking out whether people want the main meal at lunchtime, designated on the menu. This would leave more time to prepare the preferred alternative. Residents need to be more aware of the complaints process, as we were told in discussions and surveys that they were not sure what to do and who to speak with. The home needs to make sure that all staff receive training in how to safeguard vulnerable adults from abuse. This will make them more aware of the policies and procedures and ensure that any incidents are dealt with confidently and appropriately. Management must ensure that the environment is risk assessed and checked more frequently so that any issues of concern can be identified quickly and addressed. They could also make sure that repairs of equipment or replacements are completed promptly. There needs to be more staff on duty at peak times or a better deployment of existing staff so that peoples` needs can be fully met, and those with specific risks can be more closely monitored. Once the auditing of training has been completed, the home must have a training plan that covers the shortfalls in mandatory training, such as safeguarding adults from abuse, fire safety and medication competence. It should also include service specific training, for example dementia care and conditions that affect older people. This will ensure that staff have the skills and knowledge to meet residents needs. The home needs to have better overall management. There have been management changes over the last six months, which have led to inconsistencies and a lack of communication. The quality monitoring system needs to be improved so that important environmental checks are carried out, residents views are obtained and actioned, and the views of staff and visiting professionals are sought. Staff should have more frequent fire drills to ensure they know what to do in case of a fire emergency and weekly system checks should be fully carried out and identify the zone checked. The home must be a safer place for residents. This will only be achieved by good risk management and care planning, more in depth staff training and supervision, improved communication, environmental checks and prompt action when issues are identified. Random inspection report Care homes for older people Name: Address: Regent Hotel 11 North Marine Drive Bridlington East Yorkshire YO15 2LT two star good service 04/03/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Beverly Hill Date: 0 3 0 8 2 0 1 0 Information about the care home Name of care home: Address: Regent Hotel 11 North Marine Drive Bridlington East Yorkshire YO15 2LT 01262673338 01262403607 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Elizabeth Annie Finney Type of registration: Number of places registered: Conditions of registration: Category(ies) : Sandylane Ltd care home 29 Number of places (if applicable): Under 65 Over 65 29 29 dementia old age, not falling within any other category Conditions of registration: Date of last inspection Brief description of the care home 0 0 0 4 0 3 2 0 0 9 Regent Hotel is a large detached building situated on the front of Bridlingtons North Beach. It is part of a residential area away from the town centre. Local shops and amenities however, are only a short walk from the home. Limited parking is available behind the house. On-street parking is close by but because of the homes position on the seafront, there is a fee for this. The home is currently registered to provide accommodation and personal care for up to twenty-nine older people, some of whom may have dementia. Care Homes for Older People Page 2 of 24 Brief description of the care home Regent Hotel has mainly single bedrooms, the majority of which have ensuite facilities. Some of the en-suites have a bath or a shower. The home also has two assisted bathrooms. The home has a large communal room, which overlooks the bay. This is divided into a lounge area at one end and a dining area with a few easy chairs at the other end. There is a small dining room to offer more space and choice for residents. There is a small garden area at the front of the home with seating and tables available. The weekly fees range between £362 and £450. There may be a top up fee dependent on the size of the bedrooms. Additional charges are made for optional extras such as hairdressing, chiropody and personal items like newspapers and specific toiletries. Information about the home can be found in the statement of purpose and service user guide located in the entrance. Care Homes for Older People Page 3 of 24 What we found: We decided to complete a random inspection of Regent Hotel in response to concerns about risk management and care planning highlighted during a joint visit by a member of the local authority safeguarding team and a health and safety officer. A safeguarding investigation is still progressing. We found that there were some concerns about risk management and care planning and have issued the provider with a warning letter to ensure that action is taken to address the shortfalls. We will continue to monitor the home closely and it is possible that an early return visit will take place to check on progress. The provider advised that they had become aware of some management shortfalls in January 2010 and had started an internal investigation with subsequent disciplinary action. Two weeks prior to this site visit, the registered manager of a sister home took over responsibility for managing Regent Hotel to address the shortfalls. The provider has also employed an experienced person to assist the manager with regards to care plans, risk assessments and other important records. The following is our findings from this site visit: Choice of Home We examined four care files during the visit and it was clear that not everyone admitted to the home had their needs assessed prior to admission. The home had templates of assessment documentation for staff to use. However, to improve, this needs to cover all the areas identified in standard 3 of the Care Homes Regulations and detail how the persons health or condition affects their activities of daily living. It is important that all people admitted to the home have their needs thoroughly assessed to enable staff to be sure the home is able to meet their needs. Without this assessment important care may be missed at the care planning stage or the person may have to move to another home. One of the four care files examined had an assessment and care plan produced by the local authority. The home needs to obtain assessments and care plans for all residents funded by the local authority, prior to admission. The home needs to write to the potential resident, or their representative, following their pre-admission assessment, formally stating their ability to meet the persons needs. Health and Personal Care All four of the care files examined did not have detailed plans of how needs were to be met. This was to be expected in three of the care files, as there was no assessment of the persons needs. The care plans in place were generic and covered personal care and general social care only. Staff commented on how the person mobilised in the general Care Homes for Older People Page 4 of 24 social care plan. There was an information sheet on nutrition, which gave staff some details about food preferences and where the person likes to eat their meal. It also stated the homes meal times, rather than, as indicated on the form, the residents preference times. One care plan we examined was for a person who had recently had a serious accident in the home. The section on personal care described a person who was very independent with all personal care tasks only requiring minimal assistance, and the general social care plan described how the person mobilised unaided and attended the home for day care and periods of respite. In reality, the person was a permanent resident, experienced confusion, tried to leave the building on several occasions, had cellulitis and very swollen legs, had wandered into the dining room and fallen out of a window fracturing her hip and had recently returned to the home following surgery. The care plan in place bore no resemblance to the needs of the resident. A second care plan had some information in the general social care section regarding behaviours that could be challenging to other residents and staff. Staff were completing a seven day, behaviour record for a health professional. The behaviour chart used codes from 1-6 recorded at fifteen minute intervals, 1 being, asleep and 6 being, challenging verbal/physical aggression. The entry for 2/8/10 at 1pm recorded 45 minutes of code 6 but there was no information about what the behaviour was, who it was directed at, whether it was verbal or physical aggression nor what the staff did to support the person and manage the situation. The person did not have a risk assessment detailing the risks involved with the behaviours that can be challenging and there was no behaviour management plan in place to guide staff on what the behaviours were and what approaches to use to manage any incidents in a consistent way. We spoke to staff members and they described the action they took during any incidents and these differed between them. It was important that staff had clear guidelines in order for support for the person to be consistent and based on advice from professionals involved in their care. The two other care plans we examined were similarly lacking in detail about the range of care needs the residents experienced. For example, one person had a history of pressure sores to their heels and had required district nurse intervention. The risk assessment stated they were at risk of pressure sores but there was no effective care plan to relieve pressure and prevent a re-occurrence of the sores. Other residents were noted to have dementia care needs but the care plans failed to address this. We examined a fifth, additional care plan, as there was a medical record that stated the person was discharged from hospital with a broken skin area that was sore and infected. The care plan had not been updated with this information and there was no guidance in how staff were to manage this element of care. The care plans must cover all health, social, emotional and psychological needs, have clear guidance for staff in how the needs are to be met, must be updated when needs change and evaluated monthly to ensure its ongoing use in meeting needs. We also noted that there were no personal profiles or life histories in the care files we examined. These would provide staff with background information about the residents and their families, their likes and dislikes, their preferences for care and support, their previous interests and hobbies and would also help staff to have a better understanding of the person in their care. The care plans could then be made more person-centred. Care Homes for Older People Page 5 of 24 When spoken with, staff were reasonably clear about how they manage personal care tasks, despite some of the information not written down in plans. This was due to the length of time the staff had cared for the residents. However, this reliance on a verbal exchange of information from staff to staff could mean that important care will be missed. Good, clear care plans would also help new staff gain information much quicker and enable them to be confident in the knowledge that they know how to meet peoples needs. The care files included various risk assessments for moving and handling and pressure sores. There were also individual risk assessments, for example, for one person who wanders at night. The individual risk assessments need to be more detailed about the risk and the action staff need to take to minimise the risks. For example, one person liked to wander about the home and had on occasions left the building and on others had opened windows and doors. On a recent occasion they had opened a window on the ground floor, climbed out and had fallen and fractured their hip. Their risk assessment mentioned hazards as, wandering at night, poor vision and unsteadiness, and that the resident could be harmed if their en-suite light was not left on, if there were obstacles in their way, if they were not using their walking stick or if the correct moving and handling techniques were not used. Staff stated the risk was adequately controlled by ensuring the light was on and an obstacle-free environment. Further actions were to observe day and night and ensure the resident wore their glasses. There was no risk assessment regarding the residents attempts to leave the building and that they had also tried to take another resident with them, there was no mention that the resident opened windows if they were not locked, despite a monthly report dated 7/6/10 to 5/7/10 highlighting this and there was no guidance for staff in how to minimise these risks. Six residents had bed rails in place but there were no risk assessments that conformed to health and safety guidance. Information from the risk assessments that were in place was not carried forward to the care plans. If staff used the care plans to guide them in the care of the residents, they would be lacking vital information. There was evidence that people had access to health care professionals for advice and treatment. People were registered with a general practitioner and district nurses and community psychiatric nurses visited specific residents. Staff completed a medical records form when the resident received any medical care. We noted that one resident had an infected eye. They had received treatment for this previously but were not receiving any current treatment. It was also noted that their spectacles, finger nails and hands needed cleaning. Another resident was observed almost sliding out of their chair. Staff passed by frequently but didnt notice and their visitor had to request assistance. Staff need to be more proactive and contact the GP for further advice and more vigilant about hygiene and other issues of concern. The acting manager confirmed that a care staff member was now to be positioned in the lounge at all times so they could respond quickly as required. In the three surveys received from residents two people stated that staff were, usually available, one stated, always. Two said that they received the care and support they required, always, whilst the third person said this was, usually. One resident told us, people are very good to you. A relative told us they were very satisfied with the care, mum is much better here than at the previous home - she is a lot happier. The only issue Care Homes for Older People Page 6 of 24 is the staffing levels. One care file indicated that the person was at risk of falls and indeed, when the accident book was checked, they had 18 recorded falls in May and five in June 2010. Records highlighted that staff had acted appropriately as the resident had seen their GP and community psychiatric nurse who had referred them to the falls clinic, their medication had been reviewed and a walking aid provided. Recording of care and dating of records needs to be improved to ensure there are clear and consistent records. Staff recorded the care they provided daily on a weekly evaluation sheet. There were separate sheets for AM, PM and at night. Staff indicated yes or no, as to whether care needs and personal hygiene tasks had been met, commented good, fair or poor for diet and fluids, ticked a box relating to, toileting needs and made a very brief statement when asked to comment on problems or what the person had done that day. There was also a weekly tick box for bathing, hair, nail and foot care and any GP or district nurse visit. It was difficult to follow the pattern of care in one file examined, as, out of twelve record sheets, only five were dated. The comments box was small and dictated the amount of information staff could write. Staff tended to comment on meals at each entry. It was noted in the comments for one resident, legs continue to be a concern. The antibiotics dont seem to be working, however, there was no indication of what the concern was or what staff did about it, and there was only one other mention of it, having a little trouble with her legs. The four-weekly evaluation sheet did include information about the persons cellulitis and swollen legs and that creams were to be applied and antibiotics taken. It also mentioned that the resident tried to leave the building and was capable of opening doors and windows if not locked. It also commented that the person, eats quite well but can also move food about the plate without eating eating it. None of these needs had been updated into the care plan, which was the intention of the evaluation of care sheet. There was no monitoring charts for pressure relief in place despite a resident having a pressure sore. The management of medication required improvement to ensure people received their medication as prescribed and to ensure clear records were maintained. We examined the medication administration records (MARs) and generally medication was signed into the home when it was delivered in monitored dosage systems. However, there were gaps in signing in medication and carrying it forward to the next MAR, for deliveries outside of this weekly system. This made auditing medication difficult. Some people had been unable to have medicines that were prescribed to them because of poor stock control and there were some gaps in administration, without a code to say why it was omitted. We also noted that one person was prescribed a medicine to be taken weekly, however, staff had missed the day they should have had it, which was four days prior to this site visit. They were advised to contact the GP during the inspection and seek advice. Some residents were prescribed creams or ointments but there was no, or only intermittent, evidence of their application. One person was prescribed a pain relief cream Care Homes for Older People Page 7 of 24 three times a day but the evidence suggests it was applied once a day at 5pm with sometimes a second application in the morning. Some residents had declined to take their medicines, sometimes for days at a time but there was no evidence that the persons GP was contacted so they could prescribe the medicine in an alternative format or at another time of day. When medication was prescribed mid-cycle, staff hand wrote the instructions onto the MAR. For good practice it is recommended that there be a witness to countersign the instructions to avoid any mistakes. There was an occasion noted when staff had hand written instructions outside the MAR boxes designated for that purpose, and then failed to record whether it was administered at all. There was another occasion when a staff member had written incorrect information on the MAR stating that the medicine contained paracetamol when it didnt. The controlled drugs (CD) book had not been completed effectively so that the amount remaining in the book did not tally with the actual stock. This error had occurred when residents had died in the home and their controlled drugs returned to the pharmacy. Staff had indicated the residents death but not what had happened to their remaining controlled drugs. Hence, the medicine appeared to be still in stock. This was the case for four entries of pain relief patches in the CD book and staff will have to seek advice from the pharmacist about correction. The deputy manager confirmed that the patches had been returned to the pharmacy. Daily Life and Social Activities We noted that there were very little social activities or occupations for residents. Some people were content to sit near the windows and look out at the sea and watch the world go by, but other people said they were bored. Those with dementia care needs had little stimulation. Residents spoken with and surveys received from them confirmed this. Comments were, a lot sleep, no there are none - my son used to take me out but they live abroad now and no-one here takes me out. I would love to go for a walk, its boring - there is nothing to do, something could be done to entertain the residents, as it is very boring and I would like to go out more for a cup of tea and to go and sit by the sea. In discussions and surveys staff also confirmed that there were limited activities in the home, it would be better if service users could have more entertainment within and outside of the home, there are no activities other than movement to music - we used to have bingo. No-one ever goes out because there is not enough staff and we have movement to music on Thursdays and monthly church services. In three surveys from residents, two said they had activities, sometimes and one person said, never. It was clear that staff recognised the need to provide more stimulation but staffing constraints prevented this. We were concerned during the visit that there appeared to be limited choices and decision-making for some residents, which can lead to a culture of institutionalised care. We were told that some residents were supported to get up at 5am, as night staff needed to start early. This is unacceptable and must be investigated and stopped. Staff also told us that a church service was held monthly in the home and Holy Communion given to all present. Staff were unsure if people had a choice about this. Staff and residents also told us that people were restricted in where they could eat a full cooked breakfast, i.e. in the dining room only. One resident also missed their weekly bath, meaning they went two Care Homes for Older People Page 8 of 24 weeks in between baths, as the staff were too busy. There were also negative comments about the choices of meals. For example, one choice was provided for the main meal at lunch and catering staff visited each resident at about 10am to check that they wanted this option. If people preferred something else there was little time left before lunch at 12 noon to prepare anything. People told us the alternatives to the main meal were sausages and fish cakes and the sandwiches at tea-time were very repetitive. Some comments were, the tea is just not strong enough and we have sandwiches for tea at 5pm and they are taken out again at 9pm and they are wet. Of the three surveys we received from residents, one stated they liked the meals, always, one said this was, usually and the third stated, sometimes. Staff stated in surveys and discussions, I think the meals could be improved as well, there are limited biscuits for the tea rounds, only one for each resident usually and the dining room is just not big enough and there is a separate place for people who need assistance. The dining room was small and could not accommodate all the residents at once. The home would have to have two sittings if people wished to eat there. People must be allowed to choose their preferred rising and retiring times, where they choose to have their meals, and be given the opportunity to participate in occupations and social stimulation. Staff were very busy and management changes at the home had impacted on the organisation of shifts. One resident was observed saying, hello to staff but they didnt respond. We also observed staff assisting people to eat their meals at lunch time. Staff were wearing plastic aprons and hair nets and we questioned whether this was required. Complaints and Protection When asked, some residents were unsure about how to make a complaint. This should be explained to people again to make sure they feel able to complain freely and with confidence that their complaint will be addressed. We noted that very few staff had received any training in the protection of vulnerable adults from abuse. Staff, in discussions, did state they would report any poor practice or allegations of abuse but there were unsure of the full procedures. It is important that people can recognise when abuse or poor practice has occurred and report it with the confidence that it will be addressed and referred to the local authority, as the lead agency, for investigation. Managers need to make sure that they complete a more in depth managers awareness course in their role as referrer and possible investigator. The local authority is currently investigating an allegation made by a resident regarding the care they received at night. One night care worker is suspended pending the investigation. There is also an ongoing joint investigation with the local authoritys safeguarding team and health and safety officer regarding a residents serious accident and fractured hip. There has been an instance when a resident has left the building and was returned by the police, another when a resident was harmed in a serious incident, and there have been occasions when some people have been targeted by an other resident and verbally abused causing anxiety and distress. The lack of effective risk management and comprehensive behaviour management plans means that there is a chance these Care Homes for Older People Page 9 of 24 incidents could continue. Plans must be put in place to ensure the continued safety and welfare of residents living in the home. Environment We carried out a check on the environment during the visit. The home is situated on the sea front with nice views out to sea from the lounge windows. The lounge had been redecorated recently and a relative commented that they were pleased with the result. The home has a separate dining room leading off from the kitchen. This is a small and rather dark room, as the windows face a passage and the walls of the building next door. However, it was clean and tidy and tables were set out with individual tablecloths and place settings. There would need to be two sittings if everyone chose to use the dining room for their meals. Most bedrooms had an en-suite toilet and sink and some rooms had baths or showers. However, most people were bathed in the main bathroom on the second floor, which had a chair lift for ease of access. The bathroom on the first floor was unusable, as it was cluttered with items. This needs to be de-cluttered so it can be used, or made inaccessible if it is to continue to be used as a store room. The toilet next to this bathroom had no hand washing facilities and inappropriately sited toilet paper. The provider may wish to consider an alternative use for these two rooms such as a walk-in shower room. Bedrooms were personalised to varying degrees based on the taste of the occupant. It was noted that the lightweight wardrobes moved very easily and could become a hazard, especially as large safety deposit boxes were stored on top of them and moved forward when we opened the door of one of the wardrobes. This was mentioned to the provider to address. Some areas of the home, including some bedrooms and en-suites, were looking quite tired and in need of modernisation and redecoration. We acknowledge that this is a big task but there needs to be a redecoration/refurbishment plan with timescales so improvements can be planned and monitored. During the tour of the premises we observed some issues of practice that required attention. In one en-suite toilet there were four catheter bags on the floor, two had been used, but all had compromised tubing. All needed to be discarded. There were no tooth brush holders, which meant that the brushes came into contact with other toiletry items, such as soap, some sinks did not have plugs and some of the overhead sink lights were not working. These items were mentioned during feedback to the provider. The home has not had a dishwasher for a year and we were told that the oven thermostat has been broken for several weeks, which has made cooking difficult. The acting manager advised that a new dishwasher and a new part for the cooker has been ordered. Replacement equipment needs to be provided in a more timely way. It was noted in bathing records that the hot water temperature was recorded between 37 and 41 degrees. This could be cool for some residents and should be approximately 43 degrees for an ambient temperature. The home had a system of writing down any repairs or replacements that were required Care Homes for Older People Page 10 of 24 and these were signed off when the task had been completed. Staff need to check the environment more frequently and be more vigilant to ensure that issues are reported quickly. There were other environmental issues that impacted more on the safety and welfare of residents and these are detailed in the section on management and administration. Staffing We were told that the home currently has twenty-five residents and that there were two care staff and a deputy manager or senior on duty each day. We were told there was an additional staff member five mornings a week, specifically to bathe residents. In the mornings, as the deputy manager or senior carer would be administering medication, taking phone calls and dealing with any health professionals, this left the two care staff to support people to rise and dress. The staff member employed to bathe residents stated they usually managed to bathe about four people each morning. We were told that the night staff started to get people up very early in order to help the day staff to ensure the work was completed. As mentioned previously this practice is to stop and people are only to be supported to rise at the time of their choice. Staff in surveys and discussions told us they were rushed and very busy, having little time to sit and chat with people. There were specific busy times and the provider needs to look at staff deployment to ensure these are covered adequately. Comments from staff were, sometimes we have some service users that are quite ill, or we have service users that take two carers - it would be helpful to staff if we had extra staff at some parts of the shift and at times the home could do with more staff, especially when service users are ill. This was also echoed by a resident, who had recently stated they felt rushed, had been spoken to abruptly and had been told by a night carer that they could only see to her once at night when she couldnt get to the toilet in time, as they were too busy. This latter issue is being investigated by the safeguarding team. We also observed during the visit, an incident when a resident said, hello to a staff member and this was not even acknowledged. The home had a training plan on the office wall, which highlighted the training staff had completed. It didnt have dates of completion or when follow up, refresher training was required. The acting manager advised that these details were held in individual staff files and they were in the process of auditing training to ensure it was up to date and to plan specific courses. There were some gaps in mandatory training such safeguarding adults from abuse, fire safety awareness and competency checks for medication practices. Staff had received moving and handling training from the acting manager, who had completed a train the trainer course. However, we were told that the acting manager required a refresher moving and handling course to enable her to continue delivering moving and handling training to other staff. Some staff had completed dementia care training but this, along with how to manage behaviours that can be challenging to others, needs to be completed by all carers in the home. There had been some training in the past regarding the conditions affecting older people, however, this can be broadened to ensure that staff have the opportunity to participate in training such as Parkinsons disease, diabetes, strokes, sensory loss, arthritis, catheter care and pressure area care. This will help to provide staff with the knowledge and confidence required to care for people with a range of needs and Care Homes for Older People Page 11 of 24 conditions. The figures regarding training to National Vocational Qualification (NVQ) in care at level 2 or above, were not available to us on the day and training information had not arrived at the time of writing this report. However, staff spoken with confirmed they had access to NVQ training and three surveys received from staff told us they received the training they required for their role. We did not examine staff recruitment files during the visit. However, it is advised that the acting manager check out the staff files to ensure that the required recruitment documentation is in place. Management and Administration We were told that the previous manager had recently left the home and interim arrangements had been put in place. The provider needs to formally write to the Care Quality Commission with the details of these new management arrangements. There is an acting manager in place at present, who is the registered manager for a sister home in the company. The deputy manager was working her last week at the home and a replacement deputy manager had stated work two days prior to our site visit. The changes in management structure will have an effect on the home and staff will need to get used to different management styles. One resident told us how they would miss the previous manager and a comment in a staff survey stated, hopefully the changes (management) will make this an even better home. The provider advised that they had been made aware of shortfalls in care planning from a recent visit by the safeguarding team and had made arrangements for an additional person to work at the home, in a supernumerary capacity, to assist the acting manager to re-write the care plans. There have been some issues with a lack of communication between staff, the previous manager and the provider and relevant information has not been passed on. There was also an occasion when staff reported an issue to the manager but no action was taken to address the situation. The provider completed visits to the home in line with responsibilities detailed in regulation 26 of the care homes regulations. The provider confirmed that they spoke to residents and staff during these visits, satisfied themselves that the home was being managed appropriately and produced a report. We were unable to locate the regulation 26 reports during the visit and these need to be available for future inspections. We did not examine staff supervision during the visit but the acting manager was advised to check that care staff have been receiving formal supervision at least six times a year. This will enable their practice to be monitored, training needs to be identified, enable an exchange of relevant information, and also enable a forum for staff to discuss any issues of concern. At the last annual service review in February 2010 we received several surveys from residents stating that activities and elements of catering could be improved. We contacted the home and alerted the deputy manager to the contents of the surveys and also mentioned these comments in the report that was produced. The deputy manager Care Homes for Older People Page 12 of 24 stated that they would conduct a questionnaire to residents to find out their views and address any shortfall. We could not determine that these questionnaires had been sent to the residents or that the shortfalls had been addressed. A general survey had been sent to residents and relatives in October 2009. In the residents survey, twelve were returned out of twenty-four. The questions covered the accommodation, staff attitudes, food and activities. There were negative comments about food and activities. The summary stated that the activity programme would be looked at but ten months later, the situation remained the same. Residents views must be listened to and action taken to address shortfalls to improve the service, or they may be reluctant to comment in future surveys. Generally, relatives commented positively in the surveys, however, some stated that the opportunity to express choice could be improved. Although there is an annual system of questionnaires, shortfalls are not always actioned. It would also be useful to gain the views of professional visitors to the home and staff members working there. There were several areas in the environment that impacted on safety and welfare. A good quality auditing system would have identified these issues. The environment needs to be monitored more effectively to ensure the home is a safe place for people to live in and staff to work in. For example, six residents used bed rails but there were no protectors in place and one accident record stated a resident had been found with their legs stuck through the rails, causing redness to the back of their knee. In the same time frame the resident had an entry in a medical record that referred to a skin flap on their leg but no other accident record explained the cause. A further entry stated the district nurse visited and noted the skin flap had healed. It was unclear whether the bed rail incident had caused the skin flap but it was difficult to rule it out. There were no foot rests on one of the wheelchairs, which may lead to the occupant trapping their feet when using it and the tyres did not have sufficient air in them. This could affect the braking system. The home had a stair gate at the foot of the stairs on the ground floor and on the first floor, to prevent residents wandering upstairs. However, the ground floor gate was positioned on the third step up so if any resident did come down the stairs, when they reached it, it was just above knee level. There was a risk of falling over it at this point. This has been mentioned to the acting manager and the local authority health and safety officer to check out. One of the bedrooms had an extension lead with several plugs installed. This was hanging from the chest of drawers and affected the opening of it. The provider needs to install more appropriately placed sockets if the resident requires extra electrical equipment and ensure any extension lead overload is checked out as safe with an electrician. We were told that the tea pots used by staff, leaked when pouring the tea, which could cause injuries and needs to be checked out. We were told that there had not been any fire drills for over a year. As there were seventeen staff members that still required fire safety training it was important that this was checked out and addressed to ensure that staff knew what to do in cases of fire emergencies. We checked the fire alarm test records and it was unclear whether these had been completed as accurately as the documentation suggested. There was a Care Homes for Older People Page 13 of 24 discrepancy between a fire system service result and a weekly alarm test record. This was mentioned to the acting manager and provider to ensure that weekly and accurate fire alarm tests are completed. It is recommended that a different fire zone be tested each time and this zone recorded on the test sheet. The fire system service report highlighted faults with the detectors and the provider stated that these had been fixed. The provider is to send evidence of this to the Care Quality Commission. What the care home does well: What they could do better: The home must make sure that peoples needs are assessed prior to their admission and that any risks are identified. Each resident must have a comprehensive care plans detailing what their needs are and how these are to be met. There must also be comprehensive behaviour management plans to guide staff in how to support people consistently, when they experience behaviours that are challenging to others. Good assessments and care plans that are updated when needs change will help staff to look after people more fully. Staff need to make sure that they date the records they complete. Monitoring charts could be filled out more comprehensively and there could be more information about the care provided each day to people, with follow through to the next shift when required. People had access to health professionals but staff must be more aware of when to follow up health issues with them. They also need to be more vigilant about hygiene issues for particular residents, especially following meals, but also around the home in general. Medication must be managed more effectively so that people receive their medicines as Care Homes for Older People Page 14 of 24 prescribed and so that records are accurate. There needs to be more activities and occupations for residents. This will prevent people from becoming bored and help to keep them stimulated and feel included in their community. People must be supported in making more choices about their daily living to give them more control. This will help people to recognise more that Regent Hotel is their home where their views will be listened to and actioned. There have been some negative comments about the provision of meals and these must be looked into and addressed. There could be a more improved system, especially around the timing of checking out whether people want the main meal at lunchtime, designated on the menu. This would leave more time to prepare the preferred alternative. Residents need to be more aware of the complaints process, as we were told in discussions and surveys that they were not sure what to do and who to speak with. The home needs to make sure that all staff receive training in how to safeguard vulnerable adults from abuse. This will make them more aware of the policies and procedures and ensure that any incidents are dealt with confidently and appropriately. Management must ensure that the environment is risk assessed and checked more frequently so that any issues of concern can be identified quickly and addressed. They could also make sure that repairs of equipment or replacements are completed promptly. There needs to be more staff on duty at peak times or a better deployment of existing staff so that peoples needs can be fully met, and those with specific risks can be more closely monitored. Once the auditing of training has been completed, the home must have a training plan that covers the shortfalls in mandatory training, such as safeguarding adults from abuse, fire safety and medication competence. It should also include service specific training, for example dementia care and conditions that affect older people. This will ensure that staff have the skills and knowledge to meet residents needs. The home needs to have better overall management. There have been management changes over the last six months, which have led to inconsistencies and a lack of communication. The quality monitoring system needs to be improved so that important environmental checks are carried out, residents views are obtained and actioned, and the views of staff and visiting professionals are sought. Staff should have more frequent fire drills to ensure they know what to do in case of a fire emergency and weekly system checks should be fully carried out and identify the zone checked. The home must be a safer place for residents. This will only be achieved by good risk management and care planning, more in depth staff training and supervision, improved communication, environmental checks and prompt action when issues are identified. Care Homes for Older People Page 15 of 24 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 16 of 24 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 8 13 Updated and reworded requirement When people have areas of need that are assessed as a risk then there must be a clear and detailed written plan of care describing what the home is doing to minimise that risk. If peoples abilities change from one day to the next then a plan needs to be written to describe different ways of managing that risk. This will make ensure staff have accurate and up to date information to provide consistent support to help people remain safe. Previous timescale of 30/04/2009 remains unmet. 10/09/2010 Care Homes for Older People Page 17 of 24 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, 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 3 14 People must have their needs assessed prior to admission. This will enable staff to be sure the persons needs can be met in the home and will help to prevent care being missed or the person having to move on to another home. 31/08/2010 2 7 15 Each resident must have a comprehensive plan of care that details what their assessed needs are, gives clear guidance to staff on how they are to be met and is updated when needs change. This will ensure that staff have full and accurate information about how to care for and support people. At least ten care plans must be completed by the timescale for action date. 30/09/2010 3 8 13 Staff must ensure that residents health needs are 31/08/2010 Care Homes for Older People Page 18 of 24 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 closely monitored and be more proactive when seeking follow up to any medical issue. This will help to ensure that health professionals are aware of changes in health needs and enable them to adjust their treatment. 4 9 12 People must receive their 31/08/2010 medicines, including creams, ointments and eye drops as prescribed. This will help to ensure that peoples health, welfare and treatment plans are not compromised. 5 12 16 People must be provided with 10/09/2010 the opportunity to participate in meaningful activities and occupations. This will ensure people are stimulated and prevent boredom. 6 12 14 Peoples social needs must be assessed thoroughly and included in their care plans. This will enable activities to be tailored in line with peoples preferences, previous hobbies and interests and ability to participate. 7 14 12 People must be supported to 31/08/2010 make more of their own choices and decisions about Page 19 of 24 10/09/2010 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 aspects of their daily lives. This will enable people to feel more in control about their lives and enhance self esteem. 8 18 18 Staff must receive training in 30/09/2010 how to safeguard vulnerable adults from abuse. This will ensure that all staff will be able to recognise poor practice and abuse and know what to do should they witness it. 9 19 23 There must be a redecoration 30/09/2010 and refurbishment plan produced with timescales for completion of tasks. This will enable steady progress and improvements to be monitored. 10 27 18 There must be sufficient staff 31/08/2010 deployed at all times to meet the needs of the residents. This will ensure that care is not missed and safety and welfare not compromised. 11 30 18 Gaps in mandatory training, such as fire safety, safeguarding adults from abuse and medication competence, must be addressed, and all staff supporting people with dementia must receive training. 31/10/2010 Care Homes for Older People Page 20 of 24 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will ensure that staff have the required knowledge, skills and confidence to support people and meet their needs. 12 38 13 A risk assessment of the 31/08/2010 environment must be completed to ensure that any areas of concern are identified and addressed. Those areas that have been highlighted in the body of the report must be addressed. This will help to ensure that peoples safety and welfare is not compromised. 13 38 13 People using bed rails must 31/08/2010 have risk assessments completed in line with health and safety guidance. This will determine the need for the rail, any risks involved in its use and that it is the correct rail for the person, bed and mattress in use. 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 3 The home should formally write to people following any pre-admission assessment stating its capacity to meet the persons identified needs. The home should ensure that all assessments completed by the local authority are obtained prior to the admission of Page 21 of 24 2 3 Care Homes for Older People 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 the resident. 3 7 Care plans should be personalised to contain more preferences and wishes about the care provided and should contain information about how staff will support people to maintain their independent living skills. The recording of care in daily records could say more about the care provided, how the person is, how they spend their day, and all records should be accurately dated. Monitoring charts, obviously put in place for a reason, for pressure relief, nutritional intake and for specific behaviours, should be fully completed to ensure that professionals providing treatment have full and accurate information. There should be clear records of all medicines received into the home and when they are returned to the pharmacy. The controlled drugs book should be updated to detail the correct stock in the home and advice should be sought from the pharmacist about this. There should be a witness signature to any hand written entries on the medication administration record. This will help to avoid mistakes. In light of some negative comments about the choice of meals at tea time and the alternatives provided to the main meal at lunchtime, residents views should be sought and action taken to address any suggestions. Residents should be reminded of the complaints process again, in light of comments from some people in surveys and discussions, that they were unsure about it. The environment should be checked more frequently to enable issues of concern to be identified quickly and addressed, and equipment repaired or replaced promptly. The training on offer regarding conditions affecting older people should be reviewed to include a wider range of issues. The acting manager should apply for registration with the Care Quality Commission quickly to ensure management stability for the home. The views of staff and visiting professionals should be Page 22 of 24 4 7 5 8 6 9 7 9 8 15 9 16 10 19 11 30 12 31 13 33 Care Homes for Older People 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 obtained as part of the homes quality monitoring system. This will broaden the range of views on the services provided to people. 14 33 Regulation 26 reports completed by the provider, after their monthly visit to the home, should be available on request during inspections. It is recommended that fire drills occur at frequent and regular intervals to ensure that all staff know what to do should there be a fire emergency. 15 38 Care Homes for Older People Page 23 of 24 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial 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. Care Homes for Older People Page 24 of 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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