Care Home: Riverside Grange

What the care home does well People have a full care needs assessment prior to their admission to the home. The home obtain assessment information from care management and from other professionals involved with the person`s care, as well as completing their own assessment information. Care programmes, risk assessments and behaviour management plans are detailed and clearly inform staff about how care should be provided for the person concerned in a way that promotes their privacy and dignity. The home has developed good working relationships with outside agencies and visiting professionals - this includes a regular surgery with a Senior Consultant Psychiatrist. Staff refer any health issues to the appropriate agencies quickly and ensure that routine health care needs are met. The organisation has good staff recruitment practices in place and staff have regular opportunities for training to enable them to keep their practice up to date. The home is maintained in a clean and hygienic condition and furnished and decorated in a domestic style. Any complaints made to the home and any safeguarding issues identified are dealt with professionally. The arrangements in place for holding money belonging to people living at the home are robust. What has improved since the last inspection? For a period of four weeks from the time of their admission, people have some one to one support from staff to help with their transition into residential care. It has also been agreed that no new people will be admitted to the home during this four week settling in period. All care and ancillary staff have undertaken training on dementia care and have reported that this has raised their level of understanding of how this affects the people they support. An outside organisation has been providing some social activities for people within the home and 1:1 time from staff has allowed activities to take place that engage people who are known to become challenging. Advice has been taken from a dietician and menus have recently been amended to provide more finger foods; snacks are also available throughout the day. The home is in the process of preparing laminated menu cards that will include pictures of the meals on offer - this will promote choice and independence for the people living at the home. Medication policies, procedures and practices are now robust and any medication that requires storage at a low temperature is stored in the medication fridge. Staff now receive formal supervision from a manager on a more regular basis and they are are on target to meet the need for people to have supervision six times per year. The level of agency staff employed at the home has reduced, although they acknowledge that this needs to reduce further and plan to recruit more permanent staff. Staff from the local authority and primary care trust (PCT) have been working closely with the home - there are now more robust risk management plans in place. Increased 1:1 support for service users is enabling risk management plans to be followed by staff and this has reduced the number of incidents occurring between service users. What the care home could do better: Some information included in care plans is not completed consistently and this could result in staff not having up to date information about the people they care for. Information recorded in care plans should be recorded on the correct forms, otherwise this could lead to confusion and give the impression that some areas of care have not been met. Verbal references must not be accepted as evidence that people are safe to work with vulnerable people - written references must always be obtained prior to someone commencing work. Written references should be dated when they are recieved to evidence that they were in place before the new employee started work. Weekly fire tests must take place consistently to be effective as a tool to reduce the risk of a fire occurring. It would be useful for a copy of all accident and incident reports to be saved with care records so that this information can be cross referenced to care programme documentation. The home should continue to work towards 50% of care staff being trained to NVQ Level 2 and 3 in Care. The manager should continue with the process of applying for registration with the Care Quality Commission. Key inspection report Care homes for older people Name: Address: Riverside Grange 2052a Hessle High Road Kingston upon Hull East Yorkshire HU13 9NN     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Diane Wilkinson     Date: 1 8 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 36 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) 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 Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: Riverside Grange 2052a Hessle High Road Kingston upon Hull East Yorkshire HU13 9NN 01482647446 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: administrator.riversidegrange@hica-uk.com Humberside Independent Care Association Limited care home 33 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: To admit two service users under pensionable age. Date of last inspection Brief description of the care home Riverside Grange is a purpose built home that provides residential care for older people who have complex needs associated with dementia. It is owned by the Humberside Independent Care Association (HICA), which is a not for profit organisation. The building is on Hessle High Road, about one mile from the centre of Hessle, in the East Riding of Yorkshire. The area has a good variety of shops, pubs, banks and other facilities and there are local bus routes between Hessle and Hull. The home is built over two floors and there is a passenger lift to the first floor. There are thirty-three single bedrooms, all with en-suite facilities. There are four bathrooms, one shower room and two lounge/dining rooms. In addition to this, there is a large conservatory connected to the downstairs lounge. Care Homes for Older People Page 4 of 36 1 6 0 1 2 0 0 9 0 0 Over 65 33 33 Brief description of the care home There is a small garden area by the car park to the front of the home and a secure garden for residents, which is located to the side of the home and can be accessed via the conservatory. Double-locking doors can be found throughout the home to ensure the safety of people who are mobile and wish to walk about the home. The local authority block-purchase all of the beds in the home so any admission has to go through their assessment process as well as the homes. Information about the service provided can be found in the homes statement of purpose and service users guide; both are available on request from the manager. Care Homes for Older People Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection report is based on information received by the Care Quality Commission (CQC) since the last key inspection of the home on the 16th January 2009, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day; it began at 10:15 am and ended at 5:45 pm. On the day of the site visit the inspector spoke on a one to one basis with the manager and two members of staff. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The manager submitted information about the service prior to the site visit by completing and returning an Annual Quality Assurance Assessment (AQAA) form. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. As part of the inspection process we sent survey forms to some health and social care Care Homes for Older People Page 6 of 36 professionals and members of staff, and the home handed some surveys to relatives on our behalf. We received completed surveys from one health care professional, one member of staff and one relative. Responses were mostly positive and no areas of concern were raised. Comments included, they are working with some challenging residents and appear to be doing everything to improve standards, in sometimes difficult situations and the carers do a very good job of caring for people who are in a situation that we and them can only try to imagine. Other anonymised comments are included throughout the report. At the end of this site visit, feedback was given to the manager and senior manager present on our findings, including requirements and recommendations that would be made in the key inspection report. Because the returned surveys had not been received by the day of the site visit, further feedback was given to the manager when the draft report was completed. The homes administrator told us that the current fee for residential care is £521.02 per week. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? For a period of four weeks from the time of their admission, people have some one to one support from staff to help with their transition into residential care. It has also been agreed that no new people will be admitted to the home during this four week settling in period. All care and ancillary staff have undertaken training on dementia care and have reported that this has raised their level of understanding of how this affects the people they support. An outside organisation has been providing some social activities for people within the home and 1:1 time from staff has allowed activities to take place that engage people who are known to become challenging. Advice has been taken from a dietician and menus have recently been amended to provide more finger foods; snacks are also available throughout the day. The home is in the process of preparing laminated menu cards that will include pictures of the meals on offer - this will promote choice and independence for the people living at the home. Medication policies, procedures and practices are now robust and any medication that requires storage at a low temperature is stored in the medication fridge. Care Homes for Older People Page 8 of 36 Staff now receive formal supervision from a manager on a more regular basis and they are are on target to meet the need for people to have supervision six times per year. The level of agency staff employed at the home has reduced, although they acknowledge that this needs to reduce further and plan to recruit more permanent staff. Staff from the local authority and primary care trust (PCT) have been working closely with the home - there are now more robust risk management plans in place. Increased 1:1 support for service users is enabling risk management plans to be followed by staff and this has reduced the number of incidents occurring between service users. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 36 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for Standard 3. Standard 6 was not assessed on this occasion as there is no intermediate care provision at the home. People have a full care needs assessment prior to any decision being made about admission to the home; various people are consulted as part of the decision making process. There are specific admission arrangements in place that reflect the complex needs of the people living at the home. Evidence: We looked at the care records for three people living at the home. They all included a pre-admission assessment along with a personal profile, a brief medical history and a current pen picture. When the placement is commissioned by a local authority, a community care assessment and care plan is also obtained from the care management team. This information, along with information obtained from family and health care professionals, is used to develop an individual care programme for the person newly Care Homes for Older People Page 11 of 36 Evidence: admitted to the home. The manager told us that they are trialling a new assessment form - this assesses a persons needs around communication, lifestyle, skin integrity, environment, transfers, standing and sitting etc. and each area of need is allocated a score. If they find the form to be more useful then the current version, it will be introduced for the whole organisation. The Annual Quality Assurance Assessment (AQAA) form completed by the manager records that, although the home is registered for 33 people, they currently have 21 people living at the home. They have agreed with their management team and commissioners that they do not intend to increase these numbers greatly. It has also been agreed that, when someone moves into the home, no other new residents will be admitted during the following four week period. This allows time for the new person to settle into the home and for staff to get to know people and fully assess their care needs, before another new person is admitted. In addition to this, any new person admitted to the home is allocated funding for one to one time to be spent with them for the first four weeks of their stay. The manager told us that she and/or a senior member of staff always visit prospective residents to undertake a care needs assessment. She had an appointment the following day to visit another care home to see someone who wished to move into Riverside Grange. Care Homes for Older People Page 12 of 36 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for Standards 7, 8, 9 and 10. A persons privacy and dignity is respected by staff. Care programmes, risk assessments and behaviour management plans are a thorough record of a persons individual strengths and needs, and how people should be supported by staff. Medication practices are robust and ensure that people receive their prescribed medication safely. Evidence: Individual care programmes are developed for people living at the home - these are based on information obtained by the home at the time of the initial care needs assessment and from information obtained from care management. We noted that care records include a photograph of the person concerned - a photograph helps new staff with identification and assists the emergency services should someone go missing from the home. The content of care plans is agreed by the person concerned or by their representative whenever this is possible. Care Homes for Older People Page 13 of 36 Evidence: Because the home offers a service to people with complex behavioural needs, each person living at the home also has a patient passport. This is a document that records that the person concerned has dementia - people can take it to the hospital whenever they have an appointment or need to be admitted for treatment. The patient passport includes the persons name, date of birth, national insurance number, any allergies, their next of kin and their religion. It also lists things I like/things I dont like and I need help with ...... This provides nursing staff with clear information about the persons care needs. Each care programme records a persons needs within ten key areas, i.e. personal care, dressing, night care, mobility, eating/drinking, health needs, leisure and occupation, emotional care, safety needs and communication. These areas incorporate a persons strengths and needs and a care programme support plan. There are detailed behaviour management plans in place to support any challenging behaviour that is identified in assessments and care programmes. These plans identify any behaviours that may occur, how to prevent these behaviours, the action that should be taken by staff, a list of dos and donts, advice on keeping the person occupied and the level and types of risk involved. Following any incidents, staff complete behaviour management charts to record the details of the incident, including any identified triggers. This information is shared with health care professionals as part of the ongoing assessment process. The home specialise in providing care for people with dementia related conditions and, because of this, there is a high incidence of incidents between people living at the home. The home currently send safeguarding alerts to the local authority for any incidents that occur between service users, and a notification is also sent to the Care Quality Commission. The local authority are paying for one to one funding to support some of the people at the home who are displaying challenging behaviour; this is arranged for the times that have been identified when people seem to be most unsettled and has reduced the number of incidents that are occurring. One to one time is recorded on a specific form to evidence that this level of support has been provided. There were some gaps in recording and the manager told us that staff sometimes record this time on daily diary sheets. We advised that this information should be recorded on one form so that it can be monitored easily. Each care plan is accompanied by a risk assessment for nutritional needs, falls, pressure care, safety in the bedroom and moving and handling. These assessments result in a score that indicates the level of risk involved. In addition to standard risk Care Homes for Older People Page 14 of 36 Evidence: assessments, there are risk assessments in place that are specific to the needs of the person concerned, such as smoking and safety/risk of assault. Care programmes and risk assessments are reviewed although we noted that monthly evaluation forms are not completed consistently - there are gaps of several months in some records. People are weighed as part of nutritional screening and food and fluid intake charts are used when nutrition is an identified area of risk. There are also charts to record baths and showers and a bowel monitoring form. We saw that some of the charts in use had not been completed consistently and advised the manager that these charts should be used consistently if needed, or not at all. The manager told us that the weighing scales had been broken and that is why some weight charts were out of date - these have now been repaired. There is a form in use to monitor care needs and behaviours during the night and we noted that all of these were up to date. We saw the records for one person who has a bed rail fitted to the side of their bed. There are risk assessments in place for the use of bed rails and we saw that these are reviewed as needed. The manager told us that the handyman checks the bed rails each month to ensure that they remain safe. We suggested that these checks should be done weekly, and advised the manager to check the they are working with the latest guidance from the Medicines and Health Care Regulatory Agency (MHRA). Care records evidence that there is regular liaison with health care professionals and that advice is sought and followed. Best Interest meetings have also been held when decisions have had to be made about people who lack capacity - we noted that the appropriate people are involved in these meetings. The manager recorded in the AQAA, There is a six week surgery at Riverside Grange held by Dr. Bestley, Senior Consultant Psychiatrist, where he reviews clients who have psychological and acute behaviour problems. Dr. Bestley visits the clients and makes suggestions for behaviour management or medication changes, then makes contact with the GP and the clients families to discuss the problems and his recommended medication changes. The AQAA form recorded that Continuing Health Care reviews are ongoing - these involve the service user, their family, care coordinators and a member of the management team. These reviews have resulted in three people living at the home being funded by the NHS and their care reviews are now arranged by the Continuing Health Care team. Staff have done some training on dementia care mapping; the manager told us in the AQAA form that this highlighted good interaction between service users and staff but Care Homes for Older People Page 15 of 36 Evidence: also that staff need further training on dementia care. Since that time, both care staff and ancillary staff have undertaken Vocationally Related Qualification (VRQ) training in Understanding dementia. The manager told us that feedback from staff about this training was very positive and they said that they learned a great deal that would help them to work with people with dementia. The home were also advised to develop life story books for the people living at the home and they are in the process of doing so. We looked at the systems in place for the safe administration of medication. There is a dedicated medication room at the home; this provides storage for two medication cabinets, one that is used on the ground floor and one that is used on the first floor. Some medication is stored in the medication fridge that is also kept in the medication room. Temperatures are taken and recorded daily to ensure that medication that requires storing at a cool temperature is stored safely. There is also a controlled drugs cabinet in the medication room; we checked a sample of the drugs and the associated records and found these to be accurate. The controlled drugs for each person are stored in a named container to reduce the risk of errors being made; this is good practice. Controlled drugs are recorded on the medication administration record (MAR) chart plus the controlled drugs book. We noted that Temazepam and Diazepam are both stored correctly and recorded as controlled drugs; this is good practice. We examined the MAR charts held for each person living at the home and noted that they were accompanied by additional information to assist staff with administering medication accurately. We noted that there are two signatures to record any handwritten entries on MAR charts; this reduces the risk of any errors being made. We found no gaps in recording on the day of the site visit. We saw that some people have been prescribed medication that is not provided by the pharmacist in blister packs. Staff told us that they record on the label the date that this medication is opened and taken out of the store cupboard; this date is also recorded on the MAR chart. This assists with stock control and helps to reduce errors being made by only one pack of medication being opened at any one time, and is good practice. We saw the records for any unwanted or unused medication that is returned to the pharmacy. This information was recorded in detail on the returns sheet and is signed by a member of staff and the pharmacy driver when the medication is collected. Senior staff who are responsible for the administration of medication have had Care Homes for Older People Page 16 of 36 Evidence: appropriate training via the organisation. The manager told us in the AQAA form that four senior staff have commenced a Vocationally Related Qualification (VQR) on medication that is due to be completed in January 2010. All senior staff including carers who wish to progress to become senior personal carers will be completing this course - the course also includes an assessment of competency. At the last key inspection two requirements were made about the administration of medication and both have now been met. A health care professional who returned a survey told us that staff respect the privacy and dignity of people living at the home, and we observed that this was the case on the day of the site visit. Care plans record how assistance should be given with personal care in the least intrusive way and staff have training on privacy and dignity at the time of their induction to their role. People have single bedrooms so are able to meet with family and friends and health care professionals in private in their bedroom - there are also private areas of the home where meetings can take place. One care plan that we saw included information about how a persons room had been personalised and we were told how relatives are encouraged to take part in this task. Care Homes for Older People Page 17 of 36 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for Standards 12, 13, 14 and 15. A persons previous lifestyle and personal profile are known by staff and efforts are being made to help people to have fulfilling lives. Meal provision at the home is good. Evidence: We saw that care programmes record information about a persons previous lifestyle as well as a current pen picture. There is also a document in place called a personal fact file. This includes information such as a persons favourite food and drink, the school they attended, their favourite colours and their favourite songs/music. All of this information assists staff to understand the persons interests and daily routines and enables people to be supported as they would choose to be. Care programme areas include leisure and occupation and emotional needs. These areas are accompanied by a separate recording form where any activities undertaken by the person concerned are detailed, including visits from family and friends. In addition to this, there is a separate form to record any one to one time spent with the person by key workers. Care Homes for Older People Page 18 of 36 Evidence: The manager told us that people seem happier to engage in occupations rather than leisure activities. They have identified that people who walk up and down the corridors become frustrated because there is nothing to hold their attention when they reach the end of the corridor. The manager told us about their plans to create areas of the home where people can spend time, such as a pub area, an office area, a cinema room and a hairdressing room. It is hoped that people will spend time in these areas to reduce the time they spend walking up and down the corridors, and that by engaging in occupations, this may reduce the levels of anxiety and agitation that are leading to incidents occuring between service users. The home has already purchased a projector and screen so that they can show films in both lounges - these are enjoyed by people living at the home. The pets at the home (budgies and tropical fish) also seem to give people pleasure. The home has a mobile sensory unit and this can be used in lounge areas or in a persons own room. This is designed to hold a persons attention and to relax them. One member of staff has 4 hours identified time each week to offer hand and foot massages and manicures to people - again, this is designed to relax people and engage them in a one to one activity. Some people have one to one time commissioned by the local authority but one person has this provided by the organisation. This is costly but the home feel that this is the only way that this persons needs can be met. We saw in one persons care records that staff are encouraged to play football games with them, and other people spend time in the garden filling bird feeders or hanging out washing - these activities are seen to engage people more than traditional activities would do. We were told that it is difficult to engage people in group activities. However, the home has booked three sessions via an Arts Project that include arts, crafts, drama, creative movement and music and it is hoped that people living at the home will take part. The facilitator will also spend some time with staff over these three sessions so that they are able to run similar sessions themselves. The organisation has appointed an activity manager who will be looking at activities provided throughout the homes belonging to the organisation; they currently work 24 hours per week at Riverside Grange. New activities will come on stream as this person settles into their new role. We saw that visitors are made welcome at the home and are able to visit at any time. One person who returned a survey told us that their relative is supported to keep in Care Homes for Older People Page 19 of 36 Evidence: touch with them and that they are kept up to date about important issues affecting their relative. They told us, The carers do a very good job of caring for people who are in a situation that we and them can only try to imagine and added, the service could pay its staff a better wage system worthy of the job they do. People are encouraged to personalise their rooms and we were shown some bedrooms where family and friends had brought things in from their own home, including pictures and photographs, in an attempt to make people feel more settled. People living at the home are not able to manage their own financial affairs but information about advocacy is available to relatives and we noted that best interest meetings are held to assist people with the decision making process when they lack capacity to do so themselves. There are plans in place for the local Mental Capacity Act coordinator to facilitate training for staff at the home on Deprivation of Liberty. We saw that there is a four week menu on display in the home and this includes two choices of meal at each meal time. At present, staff show people both meals on offer to help them to choose what they would like to eat. The manager told us that they have recently developed a new 3 week menu and that the written menus include pictures and are written in a large font. A dietician has been consulted and, as a result, more finger foods are included on the menu and nibble trays will be introduced in between meals. Managers and chefs within the organisation have already attended a presentation about the new menus and have started to prepare these meals. The home is still waiting for the menus to be displayed - glass cabinets are to be fitted to the wall to display the daily menu and a perspex stand to hold the menu will be placed on dining tables. We saw that food supplements are prescribed for people who may not be eating sufficient amounts of food and that food and fluid intake charts are used for people where this is an area of concern. Staff were seen to assist people appropriately with eating and drinking. The manager recorded in the AQAA that they have, on two occasions, bought fish and chips into the home to replace lunch or the evening meal and that people have enjoyed this, especially eating out of the paper instead of using a plate. They intend to repeat this activity. Care Homes for Older People Page 20 of 36 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for Standards 16 and 18. People are informed about the complaints policies and procedures at the home and their complaints are listened to and acted upon. Staff are aware of the action to take when safeguarding incidents occur - these are referred to the local authority appropriately and steps are being taken to reduce the number of incidents that occur. Evidence: There is a complaints policy and procedure in place and this is displayed within the home, as well as being included in the homes statement of purpose and service users guide. A complaints log is used to record the details of any complaints made and this evidences that complaints are investigated appropriately and people are informed of the outcome. The manager told us in the AQAA form that eight complaints had been received at the home since the last key inspection and that six of these were upheld. Records seen on the day of the site visit confirmed this. One complaint is being investigated by the local authority and an outcome is expected shortly. Complaints made to the home and any comments and concerns expressed are analysed by the organisation so that they can monitor that issues are being dealt with Care Homes for Older People Page 21 of 36 Evidence: appropriately, and whether any patterns are emerging that require further investigation. A relative who returned a survey told us that they are aware of how to make a complaint and that any concerns they have raised at the home have been responded to appropriately. The manager told us in the AQAA form that 59 safeguarding alerts have been sent to the local authority for consideration. These are mainly as a result of incidents occurring between people living at the home due to their behavioural problems. We saw that there were behaviour management plans in place to inform staff about how to work with people in an effort to reduce challenging behaviour and that one to one time is spent with a number of people living at the home during the periods of the day when they appear to be most unsettled. Although incidents are still occurring, improvements are being made in the way that challenging behaviours are managed and the number of incidents is reducing. All staff have had training on dementia care and on safeguarding adults from abuse. Staff told us in a survey that they receive appropriate training but would like to have training that is more focussed on the needs of the people they support, and allow staff to request extra training if they want it. A health care professional returned a survey to us. When asked what the service could do better, they recorded, Nothing really - they are working with some challenging residents and appear to be doing everything to improve standards, in sometimes difficult situations. A review of people living at the home and the care provided is currently being undertaken by Social Services staff and the Primary Care Trust (PCT). The manager told us that they understand that this review may result in some people moving out of the home. A meeting will be held between Social Services managers and the organisation to discuss progress made and any outcomes decided in February. Care Homes for Older People Page 22 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for Standards 19 and 26. The home is maintained in a clean and hygienic condition; it provides a comfortable and safe environment for the people who live there. Staff have had training on infection control and were seen to follow good hygiene practices. Evidence: The layout of the home is suitable for its purpose, although as previously recorded, they intend to create areas of interest at the end of both main corridors to improve the environment for the people living there. We saw on the day of the site visit that the home is well maintained. The handyman undertakes weekly checks on water temperatures, window opening restrictors and mobility equipment. These checklists are signed by the manager to evidence that safety systems are being monitored. The home is decorated and furnished in a comfortable and homely style with good quality furniture and fittings. The manager told us that they intend to paint bedroom doors in different colours to help people to identify which is their room. The grounds are tidy, safe and accessible to service users, and communal Care Homes for Older People Page 23 of 36 Evidence: accommodation provides ample access to sunlight. There are communal areas and bedrooms on both floors with a passenger lift to the first floor. People remain on the same floor (unless they are going out) so that they can be closely observed by staff to promote their safety. We observed that the home was clean and hygienic on the day of the site visit and no unpleasant odours were detected. We noted that disinfecting gel is available throughout the home and we saw that staff follow good hygiene practices. Deputy managers within the organisation have attended Train the Trainer courses on delivering training on infection control so that these sessions can be arranged by the home as needed. Infection control is considered to be mandatory training by the organisation and staff are required to have annual refresher training following initial training. We saw the laundry facilities at the home and found these to be satisfactory. Care Homes for Older People Page 24 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for Standards 27, 28, 29 and 30. People are usually cared for by sufficient numbers of staff who are recruited properly and trained to undertake their role. However, this is compromised by the regular use of agency staff and the quality of the service will be improved by the recruitment of a stable and consistent team of staff. Evidence: There are various staff rotas in place at the home, including those for managers, day care staff, night care staff and ancillary staff. The number of care staff on duty each shift varies from 3 to 5, plus a senior carer and/or a personal care manager/deputy manager. In addition to this, there are staff working one to one with four of the people living at the home; these extra hours are provided during the morning and afternoon/evening at times when the person appears to be most unsettled. Agency staff are used to provide 1:1 care when this is not available from permanent staff; this was an area of concern at the last key inspection of the home. We discussed this with the manager and were shown information to evidence that the use of agency staff has reduced by more than half. The home acknowledges that there should be sufficient permanent staff to cover the staff rotas (including 1:1 support) and they are working towards this. Whilst they continue to use agency staff, they are being Care Homes for Older People Page 25 of 36 Evidence: provided with the same group of staff whenever possible so that there is some consistency for the people living at the home. Now that staff have had training on dementia care and the home is receiving support from the local authority and PCT, it is hoped that they will be able to retain good care staff. The home has introduced an Employee of the month scheme with a prize of a gift voucher and chocolates for the winner - it is hoped that this will show staff that they are appreciated and help to reduce staff turnover. The home employs an administrator, cooks, kitchen assistants, domestic staff and a handyman - this enables care staff to concentrate on care tasks. We looked at the training matrix in place at the home. This evidences that 34 of care staff have achieved NVQ Level 2 or above in Care. Because there has been a high turnover of staff it has been difficult for the home to maintain the number of staff who have achieved this award at 50 , but more staff are working towards achieving this award. We looked at the recruitment records for three new employees. They all included a completed application form that recorded the names of two referees, training information, details of any qualifications held and previous employment and a criminal conviction declaration. A copy of interview questions and responses are retained. We noted that some staff records were not accompanied by a photograph. A photograph needs to be held with staff records as proof of identity. In all instances a Protection of Vulnerable Adults (POVA) first check had been obtained prior to the person commencing work at the home. Two written references had been obtained, but we noted that these were not dated so it was not possible to verify that they were in place before the new employee started work. The manager told us that they have started to date stamp all incoming post, so in future, any references received would have the date they were received recorded on them. On one occasion a written reference had been accepted. The manager told us that they had telephoned the referee, who told them that they had returned the reference two weeks previously. However, this had not been received by the home. The manager was reminded that only written references can be accepted as evidence that the prospective employee is considered suitable to work with vulnerable people. There are individual training records in place for each member of staff and this information is also recorded on a training matrix for the full staff group. The manager Care Homes for Older People Page 26 of 36 Evidence: told us that staff now undertake a five day induction programme; 4 days are at the organisations training centre and the other day is at the care service. The organisation operates a block induction programme for all new employees. This means that new employees sometimes have to wait for their induction training. Ideally, people should have their induction training before they commence working at the home. However, the manager told us that whilst people are waiting to attend induction training they work under supervision and are used in addition to normal staffing levels - this is evidenced on the staff rota. We were told that some training courses are considered to be mandatory by the organisation - these include safeguarding adults from abuse, back care, food hygiene, fire safety, infection control and health and safety. People are required to attend refresher training on an annual basis on these topics. The manager recorded in the AQAA that there are 45 care staff and 14 ancillary staff working at the home. 41 staff have had training on malnutrition and assistance with eating and 56 staff have had training on infection control. There are plans in place for staff to undertake VQRs in palliative care and nutritional and health needs. The training matrix evidenced that additional training courses are available such as diabetes awareness, challenging behaviour and epilipsy awareness. However, a member of staff recorded in a survey that they felt that staff should be able to attend extra training courses if they choose to do so, so it may be that staff are not aware that these additional training opportunities are there. Care Homes for Older People Page 27 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for Standards 31, 33, 35, 36 and 38. This home is now being managed in the best interests of the people who live there. Areas needing improvement are identified and action is taken to improve the quality of the service. Evidence: There is a new manager in post who is in the process of applying for registration with the Care Quality Commission. She has the experience and skills to manage the care home and has a qualification in Managing Health and Social Care. There are clear lines of accountability within the care home and the organisation. A health care professional told us in a survey, I have been impressed with the management team and care staff, who have been working tirelessly in trying to improve the service they provide. The manager told us that she is due to attend various external management training Care Homes for Older People Page 28 of 36 Evidence: courses shortly, including Cornerstone dementia training, employment law, care of dying people and cultural issues. She also attends monthly meetings with other managers in the organisation where they discuss current issues in the care industry and changes in legislation. This helps to keep the managers practice up to date. At the last key inspection of this service a quality rating of adequate was awarded. Since that time action has been taken to reduce the number of incidents that have occurred between service users, both by the development of robust behaviour management plans and by the provision of one to one care for people at the times of the day when it has been identified that their behaviour deteriorates. Improvements have also been made in the way that staff adhere to medication policies, procedures and practices and some progress has been made in the reduction of hours worked by agency staff. All of these outcomes have resulted in improvements in the quality of care that is provided for people living at the home and has promoted their safety. The company has a corporate quality monitoring system that consists of audits of systems and questionnaires being sent to relatives, staff and professional visitors to the home. Action plans are produced to address any shortfalls found in either the audits or surveys. The manager told us in the AQAA form that they hold client meetings and Friends of Riverside meetings as forums for people to discuss their views and make suggestions. However, because these are poorly attended they rely more on information they gather via sending out quality surveys. They told us, Although the QA system has been in place this is an area that needs to be focused on as the information that is received can form the basis of an action plan for Riverside Grange to look at ways to develop and improve the service for the benefit of all clients, now and in the future. This development should continue so that there is a fully operational quality system in place that enables people to affect the way in which the home is operated. We have not received copies of the reports made following Regulation 26 visits to the home as requested at the last key inspection; these reports must be available for inspection at all times. We spoke to the homes administrator about the arrangements in place for handling peoples money. When money is handed to the home for safekeeping by a relative they are given a receipt to evidence this, and receipts are also obtained for any purchases or expenditure made on behalf of the person concerned. There is a safe system in place to record money used by staff to buy items for people living at the home. We were told that there is always cash available at the home if a resident asks to be given some of their money, and staff have access to this when the administrator is not at work. Care Homes for Older People Page 29 of 36 Evidence: Financial records are held on a database but written receipts are held so that records can be checked for accuracy. We checked a sample of monies held against associated records and found these to be accurate. We looked at the records in place at the home for staff supervision and noted that the form used to record staff supervision gives pointers about what should be discussed at these sessions. The manager told us that she supervises the deputy managers, ancillary staff, the homes administrator and the handyman, and deputy managers supervise care staff. We saw that good progress is being made towards staff having six meetings per year with a manager so that they are able to discuss how they are working and any training needs they may have. One supervision session per year focuses on training and development needs information from these is passed to the training department so that they are able to incorporate staff training needs into the annual training programme. We looked at a sample of health and safety documentation held at the home. All fire safety systems and equipment have been checked by a competent contractor and in addition to this, weekly checks take place on fire fighting equipment and the fire alarm system. These checks were slightly out of date but a fire drill had taken place on the 16th January 2010 and this evidenced that all equipment at the home was working as it should and that staff responded to the fire alarm appropriately. We reminded the manager that weekly checks must take place consistently. The manager told us that there had recently been a fire in the laundry room started by a tumble dryer and that the Fire Officers who attended the home were impressed with the reaction from staff. There is a list of room occupants with information about their mobility needs stored with fire records; this is to assist with an evacuation of the premises should this ever be needed. The electrical installation test was undertaken in May 2005 and is valid for five years this will need to be retested in May 2010. The passenger lift and mobility hoists have been serviced by a competent person and there is a current gas safety certificate in place. The handyman undertakes a variety of weekly checks including window opening restrictors, the nurse call system, mobility equipment and water temperature tests. In addition to these, a test to detect the presence of Legionella in the water system is undertaken by an external contractor; this test is due to be done again. Care Homes for Older People Page 30 of 36 Evidence: We looked at the documents used for recording service user accidents in the home. These are completed appropriately but we noted that this information is not recorded in care programmes; this would be useful in monitoring that care programmes are up to date and that staff are working with current information. The manager told us that the new care plans they intend to introduce should enable information recorded in accident records to be cross referenced to care programme records. Staff undertake training on health and safety topics at the time of their induction to their role, and then on an annual basis as part of mandatory training. Care Homes for Older People Page 31 of 36 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 32 of 36 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 13 The manager must check 31/03/2010 that they are working with the latest guidelines issues by MHRA on the use of bedrails, and increase safety checks to weekly. This is to ensure that people are protected from the risk of harm when they have bed rails fitted to their bed. 2 27 18 The home must continue 31/05/2010 with their plans to reduce the number of agency staff working at the home, and to retain the staff that they have. This is to provide consistency of care for the people living at the home. 3 29 19 Only written references must be accepted by the home. 31/03/2010 Care Homes for Older People Page 33 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is needed to evidence that only people considered to work with vulnerable people are employed. 4 38 23 Weekly tests of the fire alarm system must take place consistently. This is to needed to ensure that the fire alarm system is working correctly, to protect people from the risk of harm 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 31/03/2010 1 8 Any forms used to record information associated with the care programme should be used consistently and accurately so that the level of care provided can be monitored. The home should continue to support people to achieve NVQ Level 2 or 3 in Care so that they have a qualified staff group. This could also help with staff retention. Returned references should be dated on receipt so that there is evidence that they had been obtained by the home prior to the person commencing work. Staff records should include a photograph of the person concerned to confirm their identity. The manager should continue with plans to apply for registration with the Care Quality Commission. Reports of visits made to the home under Regulation 26 of the Care Homes Regulations should be available for inspection at the home at all times. 2 28 3 29 4 5 6 29 31 33 Care Homes for Older People Page 34 of 36 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 7 38 It would be good practice for accident/incident forms to be held with care records so that these details can be cross referenced with information in the care programme. Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 36 of 36 - 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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