Care Home: St David`s Nursing Home For Disabled Ex-servicemen and Women

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What the care home does well The home has a intermediate care unit which is well managed and residents are enabled to maximise their independence. Care planning and risk management on the intermediate care unit are well managed with evidence of input from the resident and their representative. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The activities provision at the home is excellent and is based on residents interests and abilities.The home has a full activities programme to meet residents individual and group needs. All the activities staff must be commended for providing an excellent service. The home has an open visiting policy and visiting is encouraged. Information regarding advocacy services is available. The meal provision is excellent and offers choice and variety to meet residents individual needs and preferences. The home has a complaints procedure and complaints are dealt with appropriately. Safeguarding adults procedures are in place and are followed, and any issues are reported. There is an ongoing programme of redecoration and refurbishment. The home provides a good standard of accommodation. The grounds are well maintained.The home has policies and procedures in place for the management of infection control. The home is well staffed to meet the needs of the residents. NVQ training in care and other training in topics relevant to the care of the residents is ongoing to provide staff with the skills and knowledge to care for residents effectively. There are good systems in place for the recruitment and vetting of new staff. The Manager has the qualifications and experience to run the home. Monies held on behalf of residents are being managed and are securely stored. What has improved since the last inspection? We found that there had been an improvement in the completion of pre-admission assessments prior to the resident entering the home. There has been an improvement in the completion of care plans, however we still found shortfalls at this inspection and they have been commented upon in the section below. There has been an improvement in the management of medications, with the introduction of auditing processes. However, some shortfalls were identified in medication management and are commented on in the section below. Bedrail risk assessments were being completed and consents were being obtained. We noted some improvements in the management of records, however further work and monitoring is required in this area. What the care home could do better: We identified areas where it was clear that work had been done following the last inspection, however shortfalls still identified show that more work is needed to bring these areas up to a good standard. On the general nursing unit and on Lord Mark unit some care plans were still very general and did not fully identify the needs of the resident. For some residents on the general nursing unit moving and handling, continence and nutritional assessments were not available. Where they were available they were brief and generalised. Shortfalls were identified with the secondary dispensing of medication on the intermediate care unit. Concerns were raised with the management of warfarin and controlled drug patches. Some work has been done to find out information regarding the wishes of residents in respect of their care in the event of health deterioration and end of life care needs, however further work is needed in order to ensure all residents are offered the opportunity to express their wishes and to have them discussed, recorded and respected. There have been some improvements in the auditing of medication and care plan audits are also taking place. With the care plan audits we suggested that there is a clear system in place for addressing the shortfalls identified. It is essential that these auditing systems are more robust that there is ongoing monitoring of all aspects of the home and any shortfalls can be identified and addressed without delay. Ongoing monitoring and further improvements must be made in the area of record keeping. Not all staff had undertaken health and safety training to include moving and handling within the required timescale. From the records viewed it was not clear that all staff to include night staff had undertaken fire drill training. Shortfalls were also identified with the testing of the fire alarm system. Dorgard door closures were not always functioning and we recommended that all dorgard equipment be reviewed. It has been necessary to partially re-state some of the requirements from the last inspection, as they had not been fully met. Key inspection report Care homes for older people Name: Address: St David`s Nursing Home For Disabled Ex-servicemen and Women Castlebar Hill Ealing London W5 1TE     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Rekha Bhardwa     Date: 0 9 1 2 2 0 0 9 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 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: St David`s Nursing Home For Disabled Exservicemen and Women Castlebar Hill Ealing London W5 1TE 02089975121 02089972447 stdavids.office@virgin.net Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): St David`s Nursing Home for the Disabled Ex-Servicemen and Women Name of registered manager (if applicable) Ms Jane Mcauley Type of registration: Number of places registered: care home 68 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 68 The Registered Person may provide the following categories of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP Physical Disability - Code PD The seven beds in the John Poland Rehabilitation Unit are to be used for service users requiring intermediate care, and not for permanenet placement. Date of last inspection 0 9 0 7 2 0 0 9 0 68 Over 65 68 0 Care Homes for Older People Page 4 of 30 Brief description of the care home St Davids Nursing Home is situated in spacious grounds in a residential area of Ealing. The home is accessible by bus and the nearest underground and mainline station is Ealing Broadway. The home has a central courtyard that provides a pleasant area in which people living at the home and their visitors can sit. There is a patio area outside the activities room and also a pathway around the garden with a summerhouse, affording attractive areas for people to sit out in. The home provides nursing care for ex-service personnel and there are currently 2 units for this, plus there is an intermediate care unit consisting of 7 flats, used for rehabilitation. All the bedrooms are single. There are spacious communal sitting and dining rooms. The fees range from £741 to £1,200 per week. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection carried out as part of the regulatory process. A total of 22 hours was spent on the inspection process, and was carried out by 2 Inspectors. One of which was a pharmacist Inspector. The pharmacist Inspector carried out a full inspection of the medication management in the home. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 15 residents, 8 staff and 1 healthcare professional were spoken with as part of the inspection process. The CQC Annual Quality Assurance Assessment (AQAA) document completed by the home has also been used to inform this report. Prior to this key inspection we carried out two random inspections on 09/7/09 and 25/8/09. Care Homes for Older People Page 6 of 30 What the care home does well: What has improved since the last inspection? What they could do better: We identified areas where it was clear that work had been done following the last inspection, however shortfalls still identified show that more work is needed to bring these areas up to a good standard. On the general nursing unit and on Lord Mark unit some care plans were still very general and did not fully identify the needs of the resident. For some residents on the general nursing unit moving and handling, continence and nutritional assessments were not available. Where they were available they were brief and generalised. Shortfalls were identified with the secondary dispensing of medication on the intermediate care unit. Concerns were raised with the management of warfarin and controlled drug patches. Some work has been done to find out information regarding the wishes of residents in respect of their care in the event of health deterioration and end of life care needs, however further work is needed in order to ensure all residents are offered the opportunity to express their Care Homes for Older People Page 7 of 30 wishes and to have them discussed, recorded and respected. There have been some improvements in the auditing of medication and care plan audits are also taking place. With the care plan audits we suggested that there is a clear system in place for addressing the shortfalls identified. It is essential that these auditing systems are more robust that there is ongoing monitoring of all aspects of the home and any shortfalls can be identified and addressed without delay. Ongoing monitoring and further improvements must be made in the area of record keeping. Not all staff had undertaken health and safety training to include moving and handling within the required timescale. From the records viewed it was not clear that all staff to include night staff had undertaken fire drill training. Shortfalls were also identified with the testing of the fire alarm system. Dorgard door closures were not always functioning and we recommended that all dorgard equipment be reviewed. It has been necessary to partially re-state some of the requirements from the last inspection, as they had not been fully met. 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 8 of 30 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 9 of 30 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. Prospective residents are assessed prior to admission to the home, to ascertain if the home is able to meet their needs. The home has an effective intermediate care unit, where residents are helped to maximise their independence and return home or to supported living. Evidence: We viewed examples of the pre-admission assessments and these had been well completed and provided a good picture of the resident and their needs. Where available, copies of the social services assessments are also obtained, plus copies of hospital discharge information was also available. The home has a 7 bedded intermediate care unit which is staffed with a team of Registered Nurses, care staff, physiotherapists and an occupational therapist. The unit is purpose built with facilities for physiotherapy and occupational therapy. Each Care Homes for Older People Page 10 of 30 Evidence: resident has their own room which has a kitchen area, living room, bathroom and bedroom. We were informed that the unit now has 4 physiotherapists working in the day and there is also some evening cover. We viewed one service user plan on the intermediate care unit. This was comprehensive and identified long and short term goals for rehabilitation. There was evidence that the resident had been involved in the formulation and review of the care plan. Weekly multi-discilinary team meetings take place and there is active involvement from the local GP in the rehabilitation plans for the residents. The staff have been successful in rehabiltating residents and moving them back into the community. The unit is well managed with the staff working well as a team. Care Homes for Older People Page 11 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plan documentation does not always provide an up to date picture of each resident and their needs, and therefore the resident is at risk of not having their needs fully identified and met. There is evidence of input from healthcare professionals, ensuring the health needs of residents are being met. Although there has been an improvement in the medication management in the home, shortfalls identified at the inspection could still place residents at risk. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. There is some information available for end of life care, however more work is still needed in this area so that the wishes of all residents and their representatives are identified and can be respected. Evidence: We viewed a sample of care plans on each unit. On the intermediate care unit the service user plan documentation was comprehensive and detailed the short and long term goals for rehabilitation. There was evidence of regular input from the resident and or their representative. Regular reviews and updates of the care plans were taking place. Care Homes for Older People Page 12 of 30 Evidence: On Lord Mark unit we noted that there were some improvements in service user care plan documentation. However further improvements were required. One care plan viewed was very general and had not been personalised to the individual resident. Some aspects of how the needs of this resident were to be met were not detailed. There was some evidence of input from the resident in the formulation of the care plan. For another resident who had recently returned from hospital there had been no new care plans formulated for new needs. On the general nursing unit two care plans were sampled. For one resident not all nursing needs had been clearly identified. Nursing actions that were being carried out were not clearly documented in the care plan. The care plan for one resident had not been updated to reflect changes made by a health care professional. There was no input from the resident and or their representative. In the other care plan viewed the care plan had not been personalised to meet the needs of the resident and was very general. Some documentation on this unit had not been dated. The need to ensure all care plans are accurate and up to date was discussed with the Manager. There has been some improvements in the area of care planning with further work required in this area. It is essential that more attention is required to ensure that records are managed in line with current legislation and guidance. In addition the audits of the service user plan documentation were in place but it was not clear what system is in place to check that the shortfalls identified had been addressed. On the intermediate care unit and Lord Mark unit skin, moving and handling, incontinence, nutrition, falls and moving and handling assessments were available and had been regularly reviewed. In addition to this staff completed risk assessments for specific areas of risk that had been identified. On the general nursing unit for one resident there was no moving and handling assessment, no continence or nutritional assessment. This was despite the resident having a care plan in place which stated that they were at high risk of malnutrition. For another resident the moving and handling assessment was brief and did not detail the equipment that was required in their moving and handling needs. We viewed wound care documentation on one unit. We found that there was a separate care plan for each wound. Details of dressing regimes, wound products to be used and pain charts were available. There was evidence of input from the tissue viability nurse specialist. Within the service user care plan documentation we also found evidence of input from healthcare professionals to include dietician, speech and language therapist, physiotherapist, GP and occupational therapist.We spoke with one Care Homes for Older People Page 13 of 30 Evidence: healthcare professional visiting the home. They commented that the staff were helpful and professional in their approach with the residents. We carried out a specialist pharmacist inspection to assess how safely medicines were handled in the home. We inspected the Medication Administration Records (MAR) in all units in the home and checked the recording of receipts, administration and disposal. We audited several samples of medication against the MAR to see if records were accurate. We looked at controlled drugs, storage of medication and two care plans. We noticed that recording was much improved in the home and that records of receipts and disposal were good.There was good practice of carrying forward balances of medication from the previous medication cycle and this allowed us to audit several samples of medication to see if it was being administered as prescribed. We looked at recording of administration throughout the home and noticed just two gaps in records. In one case we noted that the medication was not in the Monitored Dosage System and were therefore able to assume that it was given. For the other, a sachet of calcium, a count showed that it was not given. When medicines were prescribed as a variable dose such as paracetamol or lactulose they were given and recorded accurately. We counted 15 samples of medication in the main unit and these were all correct and indicated that overall medication was being given as prescribed. We did notice however that a patch applied for pain relief was being given at the wrong time interval. We noticed in the Rehabilitation unit that two residents were able to selfmedicate and that there were risk assessments in place and secure storage in their rooms. One resident was able to take medication from the original pack but the other was having their medicines secondarily dispensed by nursing staff. We asked the home to review this practice from immediate effect because of the risk of error. Records of other medication in this unit showed that it was being managed safely. In a third unit we audited 8 samples of medication in their original packages and found the counts to be accurate. We were however concerned for two residents prescribed warfarin, because counts of tablets suggested that they may have received an incorrect dose. The home was to investigate this after the inspection. We noticed that storage was secure throughout the home. Controlled drugs balances were all correct and the home was using professional lancets to check blood glucose. We looked at two care plans and noticed that there were comprehensive records of visits by health care professionals such as the GP,occupational therapists, dieticians and physiotherapists. There was evidence of review of medication either by the GP or the hospital. One resident was recently prescribed rectal diazepam for seizures and we noted that there was no protocol in place for its use or a seizure chart. We looked at two residents prescribed nutrition by tube because of swallowing difficulties and noted that there were protocols in place and regular visits and review by the dietician. Overall we Care Homes for Older People Page 14 of 30 Evidence: recognized that the home had made significant progress in managing medication safely. We still have concerns though where medication is more complex such as in the case of the residents prescribed varying doses of warfarin and patches requiring application every 72 hours. The home was not able to provide satisfactory explanations for the errors we identified but did send us after the inspection a new local procedure for administering patches and said that they were introducing new checking procedures for warfarin. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. There was a good atmosphere throughout the home, and staff were observed interacting well with the residents. Bedrooms are personalised and residents can bring in their own belongings, with rooms looking homely. Staff commented that since the last inspection there was better team work. Since the last inspection, the Manager has introduced a End of life issues form. This was in place for some residents but not for all residents. Although the form contains some information regarding residents wishes for the future, the information needs to be expanded to include health deterioration and emergency situations. This is so that the information is comprehensive, up to date and staff have the information they need to react appropriately and respect the wishes of the resident and their representatives. The Manager stated that they have input when required from the palliative care nursing team. Care Homes for Older People Page 15 of 30 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The activity provision for the home is excellent, with a programme of stimulating activities and outings to meet the individual needs, abilities and wishes of the residents. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the residents rights, choices and opinions are heard and respected. The food provision in the home is of a very good standard, offering variety and choice, to meet individual needs and preferences. Evidence: The Manager stated in the AQAA that The Home has increased its level of in-house activities which has led to greater resident stimuli and participation. This increased level of activity has improved the sociability and self-esteem of many of the Homes residents. The Home provides entertainment from outside bodies on a regular basis, such as singers, musicians and theatre groups. Residents also benefit from links with associated bodies enabling annual visits to the Royal Garden Party and St. Jamess Palace. Other outings include visits to local places of interest, such as Syon Park, river trips and picnics. Care Homes for Older People Page 16 of 30 Evidence: The home has four staff who are responsible for providing activities in the home. Two are full time and two are part time. The programme of activities is displayed in areas throughout the home. There is a range of activities to include group and individual sessions. Several outings are arranged outside of the home. Information was seen in the service user plans viewed regarding residents interests and hobbies. We observed some of the activity sessions taking place and it was clear that the residents were participating in an animated manner and really enjoying the activity. On the second day of the inspection a school choir was visiting the home and undertaking a carol concert. Representatives from several different religious groups visit the home on a regular basis. The home has an open visiting policy and visiting is encouraged. We did not speak to any visitors at this inspection. Information regarding advocacy services to include Age Concern and financial advocacy services was on display in the home. We viewed the kitchen and it was clean and tidy. There was a good supply of fresh, frozen, tinned and dried foodstuffs, and evidence of stock rotation. Food is appropriately stored and a daily record of fridge and freezer temperatures is maintained. Residents are offered several choices of meals each day. Since the last inspection a food survey had been undertaken and changes made to the menu following this. The Chef has also started attending the residents meetings in order to gain feedback on the food being provided. We noted that fresh fruit and snacks were available throughout the day. The Chef confirmed that they are able to cater for various diets including soft, puree, low salt and halal. Residents confirmed that they are offered a choice of meals and that they enjoy the meals provided at the home. Care Homes for Older People Page 17 of 30 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. The home has clear complaints and safeguarding adults policies and procedures in place, and these are followed, thus protecting residents. Evidence: In the AQAA the Manager stated that As part of the Homes Policies & Procedures, St. Davids provides a formal complaints procedure. All complaints are treated seriously and dealt with promptly. The home has not received any complaints in the last six months. Residents spoken with confirmed that they knew how to make a complaint. Complaints received are also viewed by the committee members and are checked at the Regulation 26 visits. The home has a safeguarding adults procedure in place and also follows the Ealing safeguarding adults procedures, and the Manager confirmed that any issues identified are reported to the safeguarding team. Staff receive training and updates in safeguarding adults. We were informed that there had been two safeguarding referrals made to Ealing safeguarding team. Care Homes for Older People Page 18 of 30 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. The home is being well maintained thus, providing residents with a clean, homely and quality environment to live in. Infection control procedures are in place and are followed, thus protecting residents, staff and visitors. Evidence: We carried out a tour of the home. Overall the home was being well maintained and there was evidence of redecoration and refurbishment taking place. Since the last inspection a covered walkway has been installed between the main unit and Lord Mark unit. This will ensure that residents and staff can access both units safely in all weather conditions. Tracking hoists have been fitted to the ceilings of several bedrooms on the Lord Mark unit with further plans in place to have these fitted to all the bedrooms on this unit.Work is also underway to upgrade several of the bedrooms in the general unit and where possible develop en-suite facilities. The home has ample communal space and has extensive grounds that can be accessed by the residents. We were informed that the London Fire Emergency Planing Authority had visited the home on 21/10/09 and no recommendations were made. We viewed the laundry and it was clean and tidy. There are 2 industrial washing machines, 2 domestic washing machines and two industrial tumble dryers in place. Care Homes for Older People Page 19 of 30 Evidence: Protective clothing is available to include gloves and aprons, and the home has infection control policies and procedures in place. Lord Mark unit has there own laundry facilities. Some issues with the laundry on this unit had been identified and were being addressed by the Manager. The AQAA states that the majority of staff have undertaken infection control training. Hand gels were available throughout the home. The home was clean and generally smelled fresh throughout Care Homes for Older People Page 20 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well staffed, to ensure that the needs of the residents can be met at all times. The systems in place for vetting and recruitment are robust thus, safeguarding the residents. Training provision in the home is good, thus providing staff with the skills and knowledge to meet the residents needs effectively. Evidence: The home was being well staffed to meet the needs of the residents. The Manager stated that she was in the process of recruiting some more Registered Nurses. Since the last inspection staff are periodically moved to work on the various units within the home. Since the last inspection the staffing levels have been increased on the Lord Mark unit in line with the dependency needs of the residents. Catering, ancillary, maintenance and administration staff are employed in numbers to meet the needs of the home. The majority of the care staff are qualified to NVQ level 2. In the AQAA the Manager states that NVQ 3 training is being planned for the majority of care staff. Staff spoken with at the inspection confirmed that there is an extensive training programme and that they do have access to training within the home. We viewed 2 sets of staff employment records.Both contained an application form, medical declaration, proof of identity, a POVA First and Criminal Record Bureau check, Care Homes for Older People Page 21 of 30 Evidence: 2 references and photograph. Since the last inspection the Manager maintains a checklist of all records that are required and obtained in respect of employment. The home has an induction programme that meets the Skills for Care Common Induction standards. There was also evidence of other training being undertaken by staff to include sessions in topics relevant to the diagnoses and needs of the residents. The Manager said that they do have in-house training sessions. Plans are in place for staff to undertake palliative care training and all Registered Nurses to undertake training in medication administration. Specific health and safety training is commented on under Standard 38. Care Homes for Older People Page 22 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Manager has the qualifications and experience to manage the home. The systems in place for quality assurance require further work, as they do not ensure effective audit and review in all areas. Systems are in place for the management of health and safety within the home, however some shortfalls identified could pose a risk to residents. Evidence: The Manager is a first level nurse who has completed the Registered Managers Award. She also has thirty years of nursing experience and has several years experience of care home management. She is currently undertaking a teaching degree and is also an assessor for the NVQ qualification. The Manager undertakes ongoing training relevant to her role and the needs of the residents living at the home. Staff spoken with said that the Manager is approachable and works hard in the interests of the residents. The home has systems in place for quality assurance, however more work is needed in this area to ensure the systems are implemented effectively. The Manager has introduced audits for medication, and although there has been an improvement in Care Homes for Older People Page 23 of 30 Evidence: this area, some shortfalls were still identified. Care plan audits have been introduced and there has been some improvements in the service user care plan documentation. However some shortfalls were identified at this inspection. Residents and relatives meetings take place every two months and minutes of these meetings were available. Staff meetings take place as do heads of care meetings. Resident surveys have been completed for food provision and changes have been made following this survey. Regulation 26 visits on behalf of the Responsible Individual had been taking place, and reports of these visits were available. The home holds small amounts of personal monies on behalf of residents. Clear records of income and expenditure are kept, and receipts are available. We were informed that the records are regularly audited by the homes accountants. We noted that there had been some improvements in the management of records at the home. Further improvements are required in this area to ensure that records are managed and maintained in line with current legislation and guidance. We sampled the maintenance and servicing records and those viewed were up to date. The fire risk assessments for each unit are updated bi-annually. Risk assessments for equipment and safe working practices were available new risk assessments had been developed for new risks identified. Fire drills had been taking place however it was not clear that all day and night staff had taken part in the drills, and the need to ensure this was discussed. The last recorded fire alarm test was dated 11/8/09. No Further fire alarm checks had been carried out. The staff training matrix evidenced that staff had received fire training. There was evidence of most staff undertaking training in health and safety topics. However there were some staff who had not undertaken this training for over a year. Action must be taken to ensure all staff undertake training and updates in health & safety training topics to include moving and handling at the required intervals, and that the home has evidence of this training having been completed. We noted that on one dorguard on a bedroom door was not functioning and staff had placed a wedge to keep the door open. We discussed this with the Manager and recommended that all dorgards were reviewed to ensure that they were fully functioning. Care Homes for Older People Page 24 of 30 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 25 of 30 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 7 17 Service user plans must be up to date and accurately reflect the needs of each resident. They must be reviewed and updated whenever there is a change in the residents needs. This is to ensure that staff have up to date and accurate information to follow when caring for the resident. 25/01/2010 2 8 13 All residents must have a moving and handling, continence, nutritional, skin and risk of falls assessment in place. These should reflect the needs of the resident. This is to ensure that the needs of the resident can be met safetly. 25/01/2010 3 9 13 That medicines are administered from containers dispensed and 11/01/2010 Care Homes for Older People Page 26 of 30 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 labelled by the community pharmacist and are not secondarily dispensed in the home. This is to prevent the risk of error. 4 9 13 That the home continues to robustly audit medication with particular attention to more complex medicines with variable doses such as warfarin and patches. This is to ensure that medicines are administered as prescribed to maintain the health of the residents. 5 9 13 That protocols are in place for all residents prescribed rectal diazepam or other medicines to manage seizures and that separate charts are in place to monitor the frequency of seizures. This is to allow a review of the medical condition of the resident and the effectiveness of the medication. 6 11 12 Further work is needed in the area of end of life care to provide residents and their families with the opportunity to discuss the 26/02/2010 11/01/2010 11/01/2010 Care Homes for Older People Page 27 of 30 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 care they want in the event of health deterioration and during their final days. so that their wishes are clearly identified, recorded and can be respected. This is to ensure that their wishes are clearly identified, recorded and can be respected. 7 33 24 The quality assurance system must be further developed so that all areas are audited, monitored and any shortfalls identified and addressed in a timely manner. This is in order to continually review and improve outcomes for residents. 8 37 17 All records required under Schedule 17 of the Care Homes Regulations 2001 must be maintained in line with current legislation and guidance. They must be clear and up to date. This is to safeguard residents, staff and visitors at the home. 9 38 23 Fire alarm checks must be carried out at periodic intervals and clearly recorded. 25/01/2010 25/01/2010 25/01/2010 Care Homes for Older People Page 28 of 30 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 to ensure the safety of all residents living at the home and the staff working at the home. 10 38 23 For there to be evidence that health & safety training and fire drills have been completed by all staff at the required intervals. This is to keep their knowledge up to date and protect residents, staff and visitors. 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 25/01/2010 1 38 All dorgards being used in the home should be reviewed to ensure that they are in working order. Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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