Care Home: St Lawrence

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What the care home does well One person told us: “All the carers look after me well. They are very kind and helpful”. A visitor told us: “I can’t speak too highly of the staff”. We saw that staff are very keen to provide a quality service and that they have the needs of people who live at St. Lawrence as their priority. Where a care plan exists it is detailed and informative and makes clear to staff what a person needs and how this is to be delivered. People are treated with respect and dignity. The standard of personal care provided is high and promotes dignity.St LawrenceDS0000033100.V378117.R01.S.docVersion 5.2Staff recruitment protects people from those unsuitable to work with vulnerable adults. Staff training is promoted. What has improved since the last inspection? There were no previous requirements for the home to meet. What the care home could do better: People must have their needs fully assessed before they are admitted (or readmitted) to St. Lawrence so that the home can be sure it can meet those needs, their care can be fully planned and any risks can be understood and removed or reduced. Care plans must be reviewed and updated when a person’s needs change so that staff are fully informed of what care is to be delivered. The home must have a more robust approach to ensuring equipment, necessary to promote and maintain health, is available when needed. The home should continue to develop meaningful and stimulating activities and outings for people so that their life is fulfilling. Adequate staffing levels must be maintained to ensure the well-being of people at the home is promoted. The home still does not have a registered manager to lead staff and take responsibility for the service provided. The risk from ‘lap belts’, used to prevent people falling from a wheelchair, must be assessed so that any risk identified can be reduced or removed. Key inspection report CARE HOMES FOR OLDER PEOPLE St Lawrence Churchill Drive Crediton Devon EX17 2EF Lead Inspector Anita Sutcliffe Key Unannounced Inspection 12th October 2009 09:30 DS0000033100.V378117.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St Lawrence DS0000033100.V378117.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Lawrence Address Churchill Drive Crediton Devon EX17 2EF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01363 773173 01363 774121 http/www.devon.gov.uk Devon County Council Manager post vacant Care Home 29 Category(ies) of Dementia - over 65 years of age (29), Old age, registration, with number not falling within any other category (29), of places Physical disability over 65 years of age (29) St Lawrence DS0000033100.V378117.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th September 2008 Brief Description of the Service: St Lawrence is a purpose-built care home, owned and managed by the local authority, Devon County Council (DCC). It is situated on the edge of the small, busy town of Crediton. St Lawrence provides a range of services for older people but cannot admit anyone with nursing needs unless the district nursing service can meet the needs. The home has 29 rooms spread over three floors. Rosella is a designated dementia wing and is situated on the top floor. Each floor has its own lounge and dining room, bathroom and toilets. Access from outside is level, and there is a connecting lift to all floors. The home has limited garden space and parking. A provision for residents to smoke has been made under the porch by the front entrance. This home also provides a fifteen place day service for local older people on weekdays. This facility is not regulated by CQC, and is run as a separate service. On certain mornings residents from the home are welcome to join a card group at the day centre. The average cost of care is £556.57 per week at the time of inspection. Additional costs, not covered in the fees, include chiropody, some continence products, hairdressing and personal items such as toiletries and newspapers. Current information about the service, including CQC (CSCI) reports, is available to prospective residents. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . St Lawrence DS0000033100.V378117.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The Commission has collected information about St Lawrence since the previous key inspection 18th September 2008. Toward this inspection we sent surveys to people who use the service (10 were returned mostly completed by their family), staff (8 were returned) and health care professionals (2 were returned). We met with the family of one person resident in the home. The home provided us with information about the service. This includes data, such as how many staff work there and when policies were last reviewed. It also gives the home the opportunity to tell us what they do well, any barriers to improvement and what improvements are planned. We did one unannounced visit to the home. We looked closely at the care of four people who use the service. This included meeting them, speaking with staff about their needs and examining records pertaining to their care. We also observed staff going about their work and their interaction with the people in their care. We saw most of the building and several bedrooms. We examined some policies, procedures and records. We asked questions of staff and the person managing the day to day care, who was present throughout. People who use the service may be described within this report as residents, clients, service users or patients. What the service does well: One person told us: “All the carers look after me well. They are very kind and helpful”. A visitor told us: “I can’t speak too highly of the staff”. We saw that staff are very keen to provide a quality service and that they have the needs of people who live at St. Lawrence as their priority. Where a care plan exists it is detailed and informative and makes clear to staff what a person needs and how this is to be delivered. People are treated with respect and dignity. The standard of personal care provided is high and promotes dignity. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.2 Page 6 Staff recruitment protects people from those unsuitable to work with vulnerable adults. Staff training is promoted. What has improved since the last inspection? 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. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are fully informed about the home and most needs understood prior to admission. EVIDENCE: Eight people who use the service told us that the received enough information to help them decide the St. Lawrence was the right home for them. One told us they did not receive enough information and one person did not know. The home’s Statement of Purpose and Service User’s Guide has been updated in draft form during October 2009 and the manager showed us her plans to further improve the format to aid people with sensory or memory problems. Six people who use the service told us that they had been given written information about the home’s terms and conditions and four said they did not St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 9 know if they had or not. Placement at St. Lawrence is organised through local authority placement and contracting. We looked at assessment of people’s needs and wishes. This is necessary so the home can make a judgement as to whether it is suitable and able to meet those needs. The assessment must provide the information from which a care plan is written describing how those needs and wishes will be met by the home. Two health and social care professionals linked to the service who returned surveys told us that the care service assessment arrangements ensure that accurate information is gathered and that the right service is planned for people. In the care plan of a person who was recently admitted to the home there was evidence of the home sourcing detailed information about the prospective resident’s needs from the placing authority. There was also an assessment of the person’s needs completed prior to admission by the home. However, where a person had recently been discharged from hospital there had been no reassessment of their needs by the home. (See also the Outcome called Health and Personal Care). We discussed with the manager the need for assessment to include information relevant under the Mental Capacity Act and deprivation of liberty safeguards. Currently the home is not recording this information, which it must so that people are properly protected in law. The home is not currently providing intermediate care. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A lack of staff understanding of risk associated with frailty puts people at risk. People are treated with dignity, respect and a genuine desire to provide for their needs. EVIDENCE: Each person living in the home must have a plan of care that accurately reflects his or her care needs and identifies the action required by staff to meet those needs. The plan of care must be reviewed a minimum of monthly in consultation with the person or their representative and updated when the person’s needs change. This is to ensure that a person’s changing needs are assessed and met. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 11 The acting manager reports through the AQAA, submitted as part of the information for the inspection: ‘All residents have up to date care plans reflecting their needs, and are outcome focused’. We looked at the care plans of four people. We found some extremely detailed information which would fully inform staff how best to meet that particular need. Examples include: communication where the person has eyesight difficulties and catheter care. One care plan contained detailed and current information on how to manage the person’s diabetic condition and the member of staff responsible for their overall care (their key worker) had a good knowledge of their needs and had been trained in diabetes care by the home. However, in the care record of a person recently admitted to the home it states in the person’s ‘handling’ assessment that they are at ‘high risk’. The home’s records show that over a period of six weeks the person did have four falls but no falls risk assessment was evident in the care plan; not prompted as part of the monthly review of accidents or routine care plan review following those falls. The plan of how to best prevent and ‘manage’ falls was not up to date, which is necessary to inform staff. We found that other changes in people’s needs were not reflected in their care plan, nor risk assessed with measures put in place to reduce any risk. This includes helping the person to move safely and prevention of pressure sores. One person, following readmission to the home from hospital, had not had their needs reassessed or their plan of care reviewed. The home had not considered they might be at increased risk from pressure sores and when we visited they had developed them. The key worker for the person told us they had not had time to review and update the person’s plan. The management of the home told us they were unaware that the risk from pressure sores should be assessed, although fourteen staff had received training in tissue viability (how to prevent pressure sores) in June 2009. Records indicate that four days after staff identified the pressure sore a specialist mattress, required as necessary by visiting district nurses, had not been provided although another (but less substantial) mattress had been used. In the previous report it was recommended that information in care plans set out in detail the action which needs to be taken by care staff to ensure that all aspects of people’s health care needs are met. This is not met. We made an alert to the local authority safeguarding team based on our concerns surrounding the care of one person at the home who had developed pressure damage. We felt that the full facts should be considered under the safeguarding process where all agencies involved in the care, not only the homes, would be considered. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 12 Seven people who use the service told us they always receive the care and support they need and three told us they usually do, and nine people who use the service told us that they always get the medical care they need and one told us they usually do. A relative of a very frail person at the home told us she is very satisfied with the care provided and we were told through survey: ‘The staff are very good with my father. He always expresses his pleasure at the attentiveness’ and ‘There are caring, loving and supportive staff’. People appeared to have their personal care needs well met. Two health and social care professionals linked to the service who returned surveys told us: “The care service always seek advice and act on it to meet people’s health care needs and improve their well-being” and “The care service always respect people’s privacy and dignity”. We saw staff engaging with people with concern, respect and kindness. One staff told us through survey: “We provide a good service, even though we are more of a nursing home than a residential home, which at times is hard work, but very rewarding.” Staff who administer medicines have completed a distance learning course on the ‘Safe Handling of Medicines’. We saw that medicines are handled safely on behalf of people who cannot do so themselves with clear records, safe storage and a professional approach. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are generally supported to lead fulfilled lives but this could be further improved. EVIDENCE: In surveys received toward the inspection seven people who use the service told us the home always arranges activities they can take part in if they want, two told us it usually does and one said it sometimes does. One person said they were never asked. Comments include: ‘More trips out (would be better)as only a few can go out at a time’ and ‘Staff unable to give quality time to individuals – even for a short time’. A visitor told us: “They (staff) haven’t been able to chat with dad quite as much”. We looked at four care plans in detail. Each had detailed personal histories giving the home information toward the care planning of people’s individual and diverse needs. This, however, did not appear to be people’s experience. Records of social activities from July to October 2009 were inspected for two of St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 14 the people. One person’s activity record reported that they had gone on a trip to a local attraction in July and declined a religious service at the home in September. For both, all additional ‘activities’ were recorded as either family visits or having a ‘chat’ with staff. We spoke with the manager about activities and daily life at the home. She told us that they were trying to recruit an activities worker. She described some trips away from the home, citing a butterfly farm and Exmouth railway – “the residents decide”. We were told there are also ‘ad hoc’ activities, some people go to the day centre (within the building) there are regular visits by a PAT dog, the men get together for sports events on the television and visitors who provide religious services. We were told that at resident’s meetings people will soon be planning the decorations they will be make toward Christmas. We heard people laughing with staff and good hearted ‘banter’ and people benefit from various places they can meet and socialise with each other and visitors. We saw some enjoying the sun on the ‘patio’ by the entrance. In the previous two inspection reports there was a recommendation to the home that, to ensure people’s preference and expectation regarding activities are met, the home continues to develop meaningful and stimulating activities and outings for people. Also, staff should ensure that all people have access to activities, whether on a one to one basis or in a group. Whilst some trips are arranged people’s individual social needs are not adequately met at this time. The home reports to us, through the AQAA, one aim is to improve life for people at the home by an: ‘Increase in the number of residents meetings, days out and more activities’. We spoke with one visitor to the home. She told us she is able to visit at any time, there are no visiting restrictions and she is always made welcome. Five people who use the service told us through survey that they always like the meals at the home, three said they usually do and two said they sometimes do. One person we met said: “The food is very good on the whole. Sufficient”. Lunch was taken with people on Rosella unit. Three people ate at the dining table, which was laid pleasantly with a dining cloth and table decoration. Two staff were assisting people with lunch. Four of the people on the unit needed staff to assist them with both eating and drinking and four people took their lunch in their rooms. Staff assisted people in an unhurried and sympathetic manner and lunch was a social occasion with conversation maintained between everybody in the dining room. People who were eating a soft diet had the meal presented in manner that mirrored an ordinary meal and not a specialist diet, making the meal as normal as possible. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 15 We saw good records are kept of people’s diet, especially where there might be concerns. People were asked, when they arrived for breakfast, what they would like and we saw that vegetables were served at table, providing more choice. Where people choose to have alcohol this is made available to them. We talked to people about how they influence what happens to them and what choices they are able to make each day. One person asked whether he can rise and retire to bed when he wishes, told us: “I would like to get up between eight and half past. Normally it is later but today it was earlier”. We confirmed that people are asked what they want to eat and, although encouraged to eat healthily, staff understood that people have the right to choose some things which might not be good for them in large quantity, for example, cake and alcohol. We were told of meetings and gatherings where people choose what outings they might like and planning the decorations they will be make toward Christmas. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is working toward further improvement of the handling of complaints and the safeguarding of vulnerable adults. EVIDENCE: The home reports: ‘All complaints are recorded and responded within the Devon County Council policy and procedures’. Each person using the service told us there is somebody they can speak to informally if not happy and eight of the ten people told us they know how to make a formal complaint. In the last 12 months we received one complaint directly about the service and wrote to Devon County Council asking them to investigate. When we received no reply we wrote again and received a response. Following this we received an action plan, based on an investigation into the complaint, to improve outcomes for people living at the service. Actions from the plan have been completed and the person who made the complaint is now satisfied with how concerns are dealt with at the home. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 17 The home reports that the service will be improved when staff understand complaints /concerns and the importance of putting in place procedures to ensure that there is not a repeat of a complaint. However, they say staff are more aware of the need to accept complaints and not to react in a defensive way. We received a concern about one person who uses the service, raised by a temporary worker at the home, who believed a person may have been financially abused by a person they knew. When the home was made aware of the concern they responded robustly and did what they could to investigate and protect the person. Each staff who responded to survey told us that they know what to do if someone has concerns about the home. Three staff spoken with said they had completed training in safeguarding adults and knew about how to ‘Whistle Blow,’ if they need to raise a concern outside of the home. However, our findings indicate that the home does not have a sufficiently robust approach to promoting health and well-being in that specialist equipment has not been ‘chased up’ when needed. One person we met told us she felt very safe at the home and a visitor told us: “Dad knew he was safe here. Staff have gone out of their way to be there and helpful. I can‘t speak too highly of them”. Health and social care professionals who returned surveys told us that the home always responds appropriately if any concerns are raised via the community health and social care professionals who visit the service. We looked at where restrictive practice, such as the use of lap belts, is used, whether consent is obtained and a risk assessment is completed. The one person we met who had a lap belt had no consent recorded and no assessment of risk from its use. Therefore this previous recommendation is not met and we are requiring that risk assessment is undertaken. (See the Outcome called Management). St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 & 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home environment meets the needs of most people who use the service but could be further improved for their comfort and well-being. EVIDENCE: St Lawrence is a purpose built care home over three floors, which are accessed by passenger lift or stairs. The communal accommodation includes a dining room and sitting room on each floor. There are sufficient toilets and bathroom to meet people’s needs. The general environment appears comfortable although some areas, such as the dinning rooms would benefit from re-decoration. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 19 As mentioned in the previous inspection report, the intermediate care and short stay unit located on the ground floor was not in use. There are continuing plans to move the dementia unit to this area of the home to reduce isolation and enable people to access other areas of the home more readily including the garden. These changes are now imminent. Several individual bedrooms were visited, with people’s permission, during our visit. All rooms are single occupancy. We found bedrooms were clean and fresh and had been personalised with various items, such as furniture, pictures, photos etc. People we met told us they had what they needed and were happy with the private accommodation. New furniture and a sun canopy have been purchased for the garden. We saw a number of people enjoying the front garden in the afternoon sun. As mentioned in the previous inspection report, there are plans to develop an enclosed part of the garden for people to enjoy. We were told that this is still in the planning stage. We saw that the home had assisted baths, patient hoists and a stand aid to aid the transfer and comfort of people with reduced mobility. The manager told us that the home shares one of its hoists with the day care service offered in the building and that the service would benefit from there being an additional hoist so that resources were not too spread out. One member of staff told us: “We have to wait for specialist equipment. It can be a long wait”. This wait for equipment may have been a contributory factor to pressure damage. (Also see the Outcome called Health and Personal Care and Complaints and Protection). Seven people who use the service told us told us that the home is always fresh and clean and three said it usually is. A visitor told us: “The cleanliness is sometimes good and sometimes not”. When we visited we found Nightingale and Rosella units had a bad odour in the corridor areas but Bluebell unit was fresh. There are good hand washing facilities, in bedrooms and bathrooms, and liquid soap and paper towels are freely available to promote good infection control practice. The laundry contains the necessary equipment to meet the needs of the home and staff receive training in infection control. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive a service from a staff which is keen to do a good job, properly recruited and trained but staffing numbers/deployment are negatively affecting the care and support they receive. EVIDENCE: There were twenty people resident at the home when we visited and the home reports that nine need two or more staff to help with their care, eighteen need help with dressing and undressing and all need help with washing and bathing. The staff rota now record which staff are on duty at any time including the hours worked by the manager. The acting manager reported that care staff daily numbers were as a minimum, five in the morning, four in the afternoon and two waking night staff. She added that she has flexibility to increase staffing if dependency levels increase and that minimum staffing levels are to increase when the home occupancy level increases. We were told that there is 58 hours per week care staff vacancies and that applicants have been interviewed for these posts St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 21 and offer letters of employment have been sent out. The home reports that the retention of staff is good. Two staff told us through survey that there are usually enough staff to meet the individual needs of all the people who use the service; four said there sometimes are and two said there never are. One added: “Not often enough staff these days”. Many people who use the service mentioned low staffing numbers. Comments include: • • • ‘I want them to get me out of the dining room quicker after meals’. ‘I think they could do with more staff.’ ‘Staff are unable to give quality time to individuals – even for a short time. Toileting etc, is a problem with the only one staff member… There is insufficient help available to encourage eating at mealtimes and food is often just left, especially important with visual problems. The problem appears to be understaffing which causes unnecessary pressure on existing staff who do their best.’ A recommendation, that consistent staffing levels be maintained particularly on Rosella unit to ensure people’s needs are met safely and in a timely way, was made following the last two inspection reports. We found one staff caring for three bed bound, frail people on the unit and there were two people with dementia who were more mobile. One person was looking for attention and trying to interact with staff. We were told, and saw, that a ‘floating’ staff was available during the time of most ‘physical task’ need. Both staff were attentive to the lady seeking attention as they moved from room to room providing personal care to those in bed or clearing the kitchen after breakfast. We asked those two staff about the staffing numbers and deployment and were told: “People aren’t going without, but we have less time with them. It’s a bit like a conveyor belt now we can’t use agency staff”. One staff on the unit told us they did not have time to review a care plan where the person’s needs had changed. Domestic staff told us they are two domestics short, which leaves two weekends which would not be covered. One is covered by ‘goodwill’ and the forth weekend is not covered and so no cleaning takes place. We were also told that sometimes a kitchen assistant is on the staffing rota to cook and, lacking confidence, changes the menu to meals she prefers to prepare. We were also told that domestic staff are used to provide care when care numbers are low which then affects the cleaning routine. They said: “It’s hard going at the moment”. The home reports that its plan for the future is to increase the number of relief staff available for the home. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 22 All staff who responded thorough survey told us that their employer carried out checks, such as CRB, before they started work. Information was made available regarding the last two people to be employed at the home. This showed us that recruitment checks are carried out to ensure staff are safe to work with vulnerable adults. Two staff told us through survey that their induction covered everything they needed to know to do the job well very well, four said mostly and two said partly. Staff who responded through survey told us that their training needs were mostly being met but training in health care and medication could be improved. We were shown the home’s training plan, which indicates that staff are encouraged to undertake National Vocational Qualifications (NVQ) in care, an indicator of staff competence. Two staff are in the process of completing the NVQ Assessor’s award. Other training in place includes: caring for people with dementia, first aid, tissue viability (prevention of pressure sores) and safeguarding vulnerable adults from abuse. A training session on infection control was scheduled for the 13th October and moving and handling update on 11th November. Two assistant managers are booked for training about the Mental Capacity Act. We were advised that staff had benefited from distance learning training in the subjects of palliative care and dementia and this approach to training will soon include the Mental Capacity Act and deprivation of liberty safeguards. The home reports that it could improve through encouraging further specialist training. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36 36 & 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is an enthusiasm to provide a good service and the management to achieve it but still work to do. EVIDENCE: As reported in previous reports on St. Lawrence, the home has been without a permanent manager since May 2007. Since that time there has been a succession of temporary managers. The most recent acting manager had been in post for three months at the time of this key inspection but she had not yet applied to be registered with the Commission. This means that we were unable St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 24 to determine if she is fit to be in charge because checks to ensure their fitness have not been completed. The acting manager told us that she does have previous experience of managing a registered care service as a Registered Manager. She holds the Registered Manager’s Award and a Certificate in Management Studies which are indicators that she is competent in the role. One staff told us: “I now have no concerns about the home as things have changed considerably. My manager is very approachable, professional and is certainly turning the home around but all this takes time. I am very happy with how the home is now progressing under new management”. We looked at how well the provider monitors the quality of the service at St. Lawrence. We saw a comments book in the foyer. The last comment was written in July 2009 and although complimentary about the care delivered by staff at the home concern was expressed about perceived shortage of staffing in providing suitable and plentiful activities at the home. The acting manager told us that internal surveys are being renamed to reflect staff management changes at the home before being distributed to people who use the service and their families. Thus surveys sent on behalf of the provider (the local authority) have not yet been distributed during 2009. We looked at the records from the provider’s unannounced visits to the home, which should be toward making a judgement as to whether the standard of service provided is satisfactory. The documents were linked (and therefore we presume to be judged against) the National Minimum Standards. We were shown evidence of how issues raised have been monitored. However, we found that accidents within the home are either not audited, so that concerns can be identified and therefore addressed, or they are audited but nothing done to address any risk. (See also the Outcome Health and Personal Care). One staff told us through survey that their manager often gives them enough support and they meet to discuss how they are working; five staff told us they sometimes get that support and meetings; one said they never do. One told us about the new manager. However, the acting manager has recently developed a tracking tool for staff monthly supervision, commencing from September 2009. Formal supervision of staff is delegated between the three assistant managers and the acting home manager. In discussion with four staff it was reported that some staff have received supervision within the last month and others had not. However, staff said if they had a problem or a concern that they could take this directly to the home’s management. We saw that staff meetings were scheduled in the week commencing the 20th October 2009 and a notice to this St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 25 effect was displayed in staff areas. The acting manager said she plans to have staff meetings every six weeks, if possible. We inspected monies held at the home on behalf of people using the service. Cash held in the home was securely stored and records tallied with cash held, although the total amount of cash held on behalf of people remains ‘pooled.’ The last key inspection of the service recommended for transparency that people’s monies be separated. Two staff signatures were recorded when money left the home and people had signed, where able, when their personal allowances were received into the home. The local authority conducts its own internal audits into the handling of finances by the home of people who live there. This was last undertaken in October 2008 and is an annual exercise. We are also aware of how a previous acting manager, and the provider, took steps to ensure the safety of one person’s finances where it was believed this might be subject to abuse (from outside the home). Staff receive all required health and safety training, the home is maintained to a safe standard and we saw no environmental or practice health and safety concerns during the inspection visit. St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 2 X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 X 2 St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 27 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 (2) Requirement The assessment of people’s needs must be kept under review and revised when circumstances may have changed, such as readmission to the home. This is to ensure their needs will be understood, the home can meet those needs and a plan can be produced to inform staff what they must do. Care plans must reflect the current needs of people and include risk assessment relating to pressure sore and falls prevention. The home must have a more robust approach to ensuring equipment, necessary to promote and maintain health, is available when needed. Consistent staffing levels must be maintained to ensure the well-being of people at the home is promoted. Where a lap belt is used for a person using a wheelchair any risk from this must be assessed. This will enable staff to reduce risk to a minimum. DS0000033100.V378117.R01.S.doc Timescale for action 31/10/09 2 OP7 15 (1) 31/10/09 3 OP8 12 (1) 31/10/09 4 OP27 18 (1) 30/11/09 5 OP38 13 (4) 30/11/09 St Lawrence Version 5.3 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations To ensure people’s preference and expectation regarding activities are met, it is recommended that you continue to develop meaningful and stimulating activities and outings for people. Staff should ensure that all people have access to activities, whether on a one to one basis or in a group. (Carried over in part from previous two inspections) To ensure that improvements continue and people receive the care they need, it is recommended that arrangements be made to ensure that the home has a permanent manager who is registered with the Commission. (Carried over from previous two inspections) 2 OP31 St Lawrence DS0000033100.V378117.R01.S.doc Version 5.3 Page 29 Care Quality Commission Care Quality Commission South West Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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