Care Home: Staverton House

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What the care home does well A clear admission process is in place, which enables people to be assured that their needs will be met within the home. Care plans are detailed, up to date and reflect people`s needs, therefore enabling staff to have clear information when supporting people. Personal profiles are person centred and contain useful information about people. People have access to a range of complementary therapies as part of the fee for living at the home. Such therapies include massage, reiki and tai-chi. Staff regularly liaise with health care services enabling people`s health care needs to be met. Medication administration systems are well managed which minimises the risk of people receiving their medication inappropriately. Regular checks such as ensuring people`s rooms are cleaned to a satisfactory standard on a daily basis, form part of the home`s quality assurance system. The safe keeping of people`s personal monies is orderly managed to minimise the risk of financial abuse. An organised recruitment procedure is in place so that people are safeguarded from staff who are unsuitable to work with vulnerable people. What has improved since the last inspection? There has been a new manager and a deputy manager with a professional background in supporting people with dementia, has been appointed. The home is now fully staffed and all systems such as staff training, supervision and staff meetings have become established. Care plans have been added to, which has ensured staff have better information when supporting people. Risk assessments are in the process of being reviewed. An activity organiser has been appointed for 20 hours a week. What the care home could do better: Care planning is of a good standard yet work in relation to exploring people`s life histories and how issues may affect people`s day to day lives, should be considered. Care plans could be more person-centred with more information about important aspects of people`s lives and their goals and aspirations. In the event of a person being resistant with maintaining their personal hygiene needs, an agreed care plan should be agreed with the involvement of other key professionals and family members. This procedure should also be implemented with behaviours that challenge, which a person may present. Staff should receive specific training in managing people`s resistance and behaviours that challenge in order to effectively meet people`s needs and maintain their dignity.While there is a programme of regular staff training, topics related to supporting people with a dementia, should be further developed. This should include greater involvement from specialists who are involved in dementia care. A full investigation into the current level of accidents within the home should be undertaken. Potential contributory factors such as staffing levels should be considered as part of the investigation. While fire safety is generally of a good standard, the testing of the fire alarms systems should be consistently undertaken on a weekly basis. Documentation could be improved upon to show that all staff attend a regular fire drill. Key inspection report Care homes for older people Name: Address: Staverton House 51a Staverton Trowbridge Wiltshire BA14 6NX     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Alison Duffy     Date: 2 0 1 0 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 34 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Staverton House 51a Staverton Trowbridge Wiltshire BA14 6NX 01225782019 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): info@equality-care.co.uk Equality Care Ltd Name of registered manager (if applicable) Mrs Sarah Norvill Type of registration: Number of places registered: care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users that can be accommodated is 20. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia (Code DE) maximum of 20 places Mental disorder, excluding learning disability or dementia (Code MD) - maximum of 5 places Date of last inspection Brief description of the care home Staverton House is a residential care home registered to care for 20 older people with dementia or associated conditions. Nursing or intermediate care is not provided. The home was purpose built and opened on the 30th July 2007. Care Homes for Older People Page 4 of 34 Over 65 0 0 20 5 Brief description of the care home The home is owned and managed by Equality Care Limited. In addition to Staverton House, the organisation has two other residential care homes. The director is Ms Lucy Wilcox. The registered manager is Mrs Sarah Norvill. Mrs Norvill was registered with us in May 2009. The home is located in Staverton, a village near Trowbridge and Bradford on Avon. It was built in the grounds of another of the organisations care homes. The home is divided into pods and covers two floors. Both floors have peoples bedrooms, bathing facilities, a dining room and lounge areas. A passenger lift gives level access. People have a spacious single bedroom with an en-suite. This consists of a walk in shower, a toilet and hand wash basin. The home was designed with consideration to peoples needs. Colours are used as a tool to aid orientation. All exit doors are linked to the call bell system, so people are not at risk through leaving the building unattended. Fees for living within the home are between 790.00 and 820.00 pounds a week dependent on individual need. Care Homes for Older People Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: Before visiting Staverton House, we sent the home an Annual Quality Assurance Assessment (AQAA) to complete. The AQAA is the homes own assessment of how they are performing. The AQAA tells us about what has happened during the last year and about the homes plans for the future. The AQAA was returned on time and was fully completed. We sent surveys, for people to complete if they wanted to. We also sent the home surveys to be distributed to staff and health/social care professionals. This enabled us to get peoples views about their experiences of the home. We received surveys from four people using the service, six members of staff and four health/social care professionals. We looked at all the information that we had received about the home since the last inspection. This helped us to decide what we should focus on during an unannounced Care Homes for Older People Page 6 of 34 visit to the home. This visit took place on the 16th October 2009 and the 20th October 2009. Mrs Norvill was available throughout and received feedback at the end of the inspection. During our visit, we toured the accommodation and met with people who use the service. Due to some peoples communication needs, we were not able to gain detailed verbal feedback about the service they received. We spoke to staff members on duty and observed how they interacted with people. We saw people having lunch. We looked at care-planning information, staff training records and recruitment documentation. We also looked at documentation in relation to health and safety and complaints. The last key inspection of this service took place on the 28th November 2007. All key standards were assessed on this inspection. Observation, discussions and viewing of documentation gave evidence, which showed whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the experiences of people using the service. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? What they could do better: Care planning is of a good standard yet work in relation to exploring peoples life histories and how issues may affect peoples day to day lives, should be considered. Care plans could be more person-centred with more information about important aspects of peoples lives and their goals and aspirations. In the event of a person being resistant with maintaining their personal hygiene needs, an agreed care plan should be agreed with the involvement of other key professionals and family members. This procedure should also be implemented with behaviours that challenge, which a person may present. Staff should receive specific training in managing peoples resistance and behaviours that challenge in order to effectively meet peoples needs and maintain their dignity. Care Homes for Older People Page 8 of 34 While there is a programme of regular staff training, topics related to supporting people with a dementia, should be further developed. This should include greater involvement from specialists who are involved in dementia care. A full investigation into the current level of accidents within the home should be undertaken. Potential contributory factors such as staffing levels should be considered as part of the investigation. While fire safety is generally of a good standard, the testing of the fire alarms systems should be consistently undertaken on a weekly basis. Documentation could be improved upon to show that all staff attend a regular fire drill. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 34 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 34 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. People are assessed before being offered a service, so are assured that their needs will be met. Evidence: At the time of the last inspection, the home was new and had recently been registered with us. It was not fully occupied or fully staffed. Mrs Norvill told us that each admission was carefully planned. Time was given between each placement so that people could settle before the next person arrived. She said that any disruption was always kept to an absolute minimum so that people did not become anxious. She said all admissions had been successful and the home now had a waiting list. Mrs Norvill told us that she generally completed all assessments in order to ensure Staverton House was suitable for people. If a person had very specialist dementia care needs or they had a very unusual type of dementia, Mrs Norvill said she would involve the deputy manager in the assessment process. This was because the deputy Care Homes for Older People Page 11 of 34 Evidence: manager was a registered psychiatric nurse and therefore had specialist expertise and experience. Mrs Norvill told us that she or the deputy manager would visit people in their own home or in an environment such as a hospital or another care home. She said she also liaised with peoples families and other involved personnel such as home carers and/or the persons GP or their Community Psychiatric Nurse. This was so that she could gain as much information about the person as possible to ensure the home could meet their needs. Within the AQAA, it was stated full assessment prior to admission to ensure that we can meet residents current and future needs and trial periods/respite stays were things the home did well. It said a personal profile questionnaire was undertaken to enable staff to know what particular likes, dislikes and hobbies the new person had. In relation to what the home did well, the AQAA stated, allowing the resident to bring own furniture (where practical) and belongings to customise their room thus enabling a seamless transition from old life to the new. Within their surveys, three health care professionals said that the homes assessment arrangements ensured that accurate information was gathered and the right service was planned for people. One health care professional said a respite service would be good. We looked at the assessment documentation of two new people to the service. We saw that the assessment format contained basic information about peoples needs. Such information included wears spectacles, fully continent if regular toileting is maintained and needs assistance from one member of staff to maintain their personal hygiene. We saw that this information was expanded upon in more detail within the care plan. One assessment identified that the person could be paranoid. It did not expand upon the circumstances of the persons paranoia or potential triggers. The assessment highlighted short term memory loss yet it did not identify how this affected the persons life on a day to day basis. We advised that such information be identified in order for staff to have the knowledge to support people effectively. We saw that one person had a hospital discharge letter on their file, as part of the assessment process. As stated within the AQAA, family members had also completed a personal profile. This was very person centred and identified key issues such as any subjects the person did not like talking about. Whether people wanted to actively practice their religion was identified within the information. Care Homes for Older People Page 12 of 34 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning is of a good standard which ensures staff have clear information so they can meet peoples needs effectively. People have good access to health care provision. Peoples rights to privacy, dignity and respect are generally promoted yet staff need more support to maintain some peoples personal hygiene needs. Medication administration systems were well managed. Evidence: Mrs Norvill told us that since the last inspection, all care plans have been developed so that they include more detail about peoples individual needs. This was identified in the AQAA, whereby it stated they [the care plans] are now fuller, clearer and easier to follow. The AQAA confirmed that people were involved in the development of their care plan. The care plans we looked at were very detailed and person centred. They gave specific information about peoples needs, their preferred daily routines and what they enjoyed or disliked. There was information showing that people had been involved in the development of their plan, if they were able. Peoples families had also provided staff Care Homes for Older People Page 13 of 34 Evidence: with information about the person. The plans had been regularly reviewed and updated as peoples needs changed. Ways in which people could maintain their independence and be involved in decision making were clearly stated in their care plan. For example, one care plan stated that staff were to use prompts. This included for example, showing a person a hairbrush whilst asking would you like me to brush your hair. We saw that attention to detail was evident within care plans. One persons plan identified a personal care routine, which included ask XX if she would like some perfume. We saw within one persons care plan that they often repeatedly asked questions. The intervention was staff to answer, as many times as is needed. One person communicated to staff through writing. We saw that staff gave the person time to do this. One person told us that they did not like the company of lots of people. They told us they liked sitting on their own and they would not worry if they were to die tomorrow. They said they had been content with their life but there was a time when you had to call it a day. We saw that their finger nails were in need of a trim. We looked at the persons care plan and each aspect we noted was identified. A management plan was in place regarding the persons finger nails, as having them cut caused significant anxiety. We saw within one persons care plan that at times, they would lie on the floor in the corridor and would refuse staff assistance to get up. The care plan stated that encouragement should be used. However, if it was clear the person was not going to respond and they were becoming agitated, staff should make them comfortable, where they were. This involved giving the person a pillow and if required, a blanket. While noting that this was a positive approach, allowing the person to lie on the floor in a public area, was not promoting their dignity. We advised that strategies to address this behaviour be discussed with the persons care manager. Similarly, we saw that two people had food debris on their clothing. One person was supported to change immediately after their meal. Staff told us that the other person was very resistive to any form of support with their personal care. Staff said that they needed to wait their moment before support could be offered. This resistance and its management were identified on the persons care plan. Another person had food debris on their face. Staff offered the person a wipe and encouraged them to wipe their face. The person put the wipe in their pocket. Staff got another wipe and repeated the encouragement. We saw that the interaction was respectful and was not in any way confrontational. However, it was not fully productive, as the person still had food debris on their face. We felt this did not promote the persons dignity. Staff told us that managing assistance was a difficult area, which required patience and Care Homes for Older People Page 14 of 34 Evidence: perseverance. They said they regularly went back to people or asked another staff member to offer assistance. Staff told us they had completed some training in managing challenging behaviour. However, as stated above, greater consultation with the persons care manager is required. This would enable discussion about ways to manage the persons resistance. It would also ensure that the persons dignity was maintained, their needs were met and their placement was suitable. In their surveys people told us with staff support, that they received the care and support they required. A health care professional told us, in relation to what the home does well ensure to the best of their ability that their residents individual needs are met and they are happy. A staff member told us the home does well with communication skills, looking after residents as individuals and overall teamwork. Another staff member said the home meets the residents individual needs. The residents are very well cared for. A health care professional said specialise in the specific needs of dementia - give respect to the residents. Another health care professional told us in relation to what the home does well, provide good person centred care. Report any concerns about residents to our team so we can reassess. Good relationship with families. Attends CPA meetings. Takes note of advice given. The AQAA stated that people have regular reviews with other health care professionals. It stated weve established a high standard of communication with outside professionals especially with the mental health team. Mrs Norvill and staff told us that the local district nursing service was excellent. They said they got good support from all involved health/social care professionals. Mrs Norvill said this enabled peoples health care needs to be met effectively without delay. Within each persons file, there was a record of any medical intervention or appointments the person had attended. During our visit, one person received a visit from the District Nurse. They had a blood test taken in the lounge with other people around. While acknowledging that the person was asked if they were happy for the procedure to be undertaken where they were, they were not encouraged to move to a more discreet area such as their bedroom. We saw in one persons care plan that their blood glucose levels to ensure their well being were clearly stated. Another care plan detailed the potential signs and symptoms of a urinary tract infection, which the person was prone to. Within daily records there was good follow up of any aspect of ill health. For example, there was documentation about a persons rash and the prescribed intervention. It was clearly stated when the persons skin condition improved. Staff had recorded any mark or bruise identified on a person. However, Care Homes for Older People Page 15 of 34 Evidence: there was no description, which included the size or colour of the mark or potential reasons for its occurrence. This information would be useful to monitor the healing process and also to limit further occurrences of the injury. We saw that peoples risk of developing a pressure sore and their risk of falling had been assessed. There was clear information about the areas of the person that were prone to pressure damage. Mrs Norvill told us that a new tool had been introduced to assess each persons risk of malnutrition. Manual handling assessments also formed part of the persons care plan. All assessments had been regularly reviewed and updated. Records showed that people were regularly weighed. Staff told us that a person would have a food and/or fluid chart, to monitor their intake if they were not eating or drinking properly. Within care plans, we saw that people were to be asked between meals, if they were hungry. If so, snacks were to be offered. The cook and other staff told us about how people used up a high level of calories due to their level of walking around. They said it was essential for them to have a high calorie, nutritious diet to ensure their wellbeing. Mrs Norvill told us the assessments in place which identified risks to people in their every day lives were in the process of being further developed. We agreed that they needed to be more detailed and specific to the individual. For example, an assessment about using the garden stated residents to be encouraged to use hats and sunscreen if it is sunny and sit under umbrella. While the assessment was based on good practice, it did not relate to those people who liked to walk with a purpose or perhaps resisted such intervention. We spoke to the deputy manager about the administration of peoples medication. She told us that a clear assessment process was undertaken before a staff member was able to administer medication. She said that new staff received medication training and shadowed a more experienced member of staff. They then completed the medication administration with supervision and their competency was assessed. If deemed competent, they were able to continue on their own. The deputy manager told us that staffs competency with medication was regularly assessed. They were often monitored when administering medication. Staff confirmed this. We saw that the medication was orderly stored. Each medication was clearly documented when received into the home. All medication administration records had been signed appropriately when medication had been given. All hand written medication instructions had been countersigned by another member of staff. This ensured that errors were not made when documenting the prescribing details. New records to demonstrate the application of topical creams were in place. At the last inspection, we recommended that any medication with a short shelf life was dated when opened. This Care Homes for Older People Page 16 of 34 Evidence: had been addressed. Medication which was prescribed to be taken as required was identified on the persons care plan. Within one plan it stated that the person would generally tell staff if they were constipated. We advised that other ways of knowing this information, should be considered. The deputy manager told us that staff did not administer medication at mealtimes due to the distraction it caused people. We saw that throughout our visit, people were treated with respect and their privacy was generally maintained. Within the complaint log, we saw that a person had gone into another persons room. We asked staff about this. They told us that this behaviour was difficult to stop completely. They said that some people locked their bedroom door when they were not in the room. They said they tried to ensure they knew where people were at all times. However, when supporting people with personal care, this was not always possible. We advised that this are should be further monitored to ensure peoples privacy was not intruded upon. We saw one staff member knock on a persons door and wait until the person opened the door before they entered. The staff member told the person who they were and the reason for disturbing them. Care Homes for Older People Page 17 of 34 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social activity provision has increased due to the appointment of a designated member of staff. People are encouraged to maintain important relationships and make decisions within their daily lives. Meal provision is of a good standard and is enjoyed by people. Evidence: Since the last inspection an activity organiser had been employed for twenty hours a week. They said they organised group activities such as a reading group and also undertook individual work with people. They said that often due to some peoples needs and level of concentration, one to one work was generally more productive. They said that some people seemed to enjoy musical activities and sit and be fit. They also enjoyed animals and a number of dogs, trained for therapeutic use, were brought to the home on a regular basis. There was also a gardening group. Some people enjoyed growing and tending vegetables, which were then cooked in the home. The activity organiser told us that activities such as bingo were not undertaken, as they had proved unsuccessful and had caused some people anxiety. Mrs Norvill said she met with the activity organiser on a weekly basis to monitor social activity provided. We saw there was a record of peoples involvement in each activity and whether it was successful or not. Care Homes for Older People Page 18 of 34 Evidence: One person told us about the homes cat, which appeared to give them great pleasure. They said they helped feed it. The home also had rabbits, which staff said some people found therapeutic to hold. One person told us they liked to see the rabbits jump around. Within a survey, a relative said, in relation to what the home could do better provide more entertainment or stimulation via out of house professionals visiting. A staff member told us in their survey the home could have some sort of their own transport e.g. minibus to take more residents out at one time. We saw that staff engaged well with people. Staff spent time sitting down with people for a chat. One staff member talked about the content of the newspaper. Following discussion with a person about local villages, a staff member looked for a book within the library about the local area. They said that people were involved in various activities. Some people just liked to watch what was going on around them. During our visit, there were generally old war time songs playing in the lounge. We said that staff should not assume this music was enjoyed and other eras and types of music should be considered. Mrs Norvill told us that other forms of music were available yet this was peoples choice on the day. At one point, the television was on with the sound turned down. The music was also playing. This could be confusing for some people and therefore the music centre and television should not be on at the same time, in the same room. As part of the fee for living at the home, people could have a massage or a manicure, if they wished. A qualified therapist visited the home to provide these services. We saw that some people had a hand massage, which appeared to be enjoyed. Staff told us that two hairdressers visited on a regular basis. People were also able to visit their own choice of hairdresser if they wanted to. One person told us I have my hair done here. They always do it very nicely. Staff told us that the mobile library visited on a regular basis. Mrs Norvill told us that some people were supported to go out within the local community, if they wanted to. This included going into the local town for shopping or to the local garden centre. Mrs Norvill told us that one person went out with staff to get the cat food. Some people go out with their family. Mrs Norvill told us that some group outings had been arranged yet due to peoples needs, it was found more one to one activities were beneficial. She said that calendar events were generally celebrated within the home. A bonfire party was in the process of being organised although Halloween was not going to be celebrated due to peoples needs. Care Homes for Older People Page 19 of 34 Evidence: Within their surveys, health care professionals told us that people were supported to live the life they chose, wherever possible. Staff told us that people were able to make their own choices as far as possible. They said that some people did not sleep well at night so needed to sleep on in the morning. We saw within care plans that people were to be offered a hot drink during the night if they could not sleep. As identified within an earlier part of this report, we talked to Mrs Norvill about further developing work with people to complete their life story. Such work would promote positive quality outcomes for people and further enhance their wellbeing. People told us that they liked the food. When we arrived on the first morning, one person was in the lounge eating a poached egg on toast. They said it was very good. Another person had a bowl of cereal. One person was walking around eating some porridge. At lunch time the meal looked appetising and was well presented and colourful. There was homemade soup followed by a choice of two main meals and a pudding. The cook told us that high priority was given to food. They said the menus were devised to ensure a high nutritional intake but also for people to enjoy what they were eating. They talked about the need to tempt some people to eat and to ensure people had sufficient food. This was especially so when some people did not like sitting to the table to eat for long periods. We saw that staff monitored the food intake of those people who left the table before finishing their meal. They said they would encourage the person back to the table or alternatively would take the persons food to them. They said some people benefited from finger food, which they could eat while they were walking. The cook told us that vegetarian food was being introduced to the menu. They said that high nutritional foods such as beans were also included. The cook told us that the majority of the food was home cooked. They said if people did not like the choice available, an alternative would always be offered. They told us of a range of alternatives, which could be offered to a person who was unwell. We saw that the cook served the meals to people in the dining room. This enabled them to gain feedback and see what food was being enjoyed. In order to help people make a selection, they were asked which food choice they wanted and were also shown the alternative. People could therefore visually choose what they wanted to eat. Mrs Norvill told us that all food was sourced locally so it was of a good quality. She said the menus were changed with the seasons to take into account seasonal produce. Care Homes for Older People Page 20 of 34 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. Concerns are taken seriously and are resolved as quickly as possible. Clear systems are in place to minimise the risk of people experiencing abuse. Evidence: Staff told us that they would try to address any issue of concern, which a person told them about. They said they would also inform a manager so that the matter could be dealt with at that level. Mrs Norvill told us that she aimed to adopt an open approach to complaints. She said she had spoken to the staff team about responding to any concern in a positive manner. She said she viewed complaints as a means to improve the service. Within a survey, a staff member told us any problems are sorted out quickly and in an efficient way. All staff told us in their survey, that they knew what to do if they received a complaint about the service. A record of complaints was maintained. This included formal complaints and concerns which were raised on a day to day basis. We saw that any concern raised had been discussed and addressed. For example, one relative raised concern about the laundry. Records showed that an apology was given. The relative was informed that staff would be told to be more mindful in the future. In another instance, we saw that one person had said their sandwich was too dry. An apology was made, their complaint was Care Homes for Older People Page 21 of 34 Evidence: substantiated and an alternative was offered. In order to monitor complaints, we said that the investigation should be recorded more fully. This would enable any trends in provision to be more clearly identified. There was a complaints procedure in the entrance area of the home. Staff told us that some people relied on others such as family members, to raise a concern on their behalf. At the last inspection, we recommended that a user-friendly complaint procedure be developed. This would enable people to give their views more readily. We did not see that this had been addressed. Staff told us that they had undertaken training in safeguarding vulnerable people. We saw that this had been undertaken within a number of staff meetings. Mrs Norvill told us that staff had received external training in safeguarding at the local Vulnerable Adults Unit. We asked some staff about what they would do if they received an allegation or suspicion of abuse. They said they would report the issue to management and also make a safeguarding referral. They were aware of the local safeguarding unit and its role. Staff told us that they had a copy of the local adult protection procedures No Secrets. Since the last inspection, the home had appropriately made safeguarding alerts in relation to behaviours that challenge. Within one persons care plan we saw that they often gave people a gentle tap, as a way of saying hello. Staff confirmed this. While acknowledging that this was a way the person possibly communicated, such expression should be discouraged. Ways of managing the behaviour should be discussed with the persons placing authority. Care Homes for Older People Page 22 of 34 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. People benefit from an environment which meets their needs and is furnished to a good standard. Some aspects of cleaning could be improved upon. Evidence: People had a single bedroom with an en-suite facility on the ground or first floor. People were able to use the passenger lift as required yet the stairs had a key fob system to ensure peoples safety. Rooms which were not intended for peoples use such as the cleaning store were painted the same as the walls, so they were disguised. The bathroom doors were painted yellow and had a picture of a bath on them to help people orientate themselves. Toilet seats were red so that they could be clearly seen. We saw the layout of the home enabled people to walk around freely. The rooms were in pods so that if people continued to walk in the same direction, they would return to their original starting point. Mrs Norvill told us that this had been paramount in enabling some peoples anxiety to be reduced. There was a well furnished, spacious communal lounge and separate dining room on the ground floor. There was also an additional dining room and adjoining lounge on the first floor. Staff said that this room was not often used unless people had visitors or an activity was taking place. They said this was historical as when the home opened initially, the small number of people living at the home, always ate their meals downstairs. Staff said there were plans to serve meals in the upstairs dining room Care Homes for Older People Page 23 of 34 Evidence: although this had not as yet taken place. There were patio doors from the main lounge which opened onto a well maintained, enclosed garden. We saw that some people regularly walked out into the garden without staff support. Some people sat in the summer house before returning inside. We saw that peoples rooms were personalised to varying degrees. One person showed us a number of photographs of their family members they had on their wall. All rooms had telephone sockets, Internet access and television aerial points. There were light switches at waist height. All exit doors other than the patio doors were fitted with an alarm. The alarm triggered the call bell system, if activated in order to safeguard people from going out alone. The ancillary manager told us that cleaning schedules were kept up to date and regularly monitored. This was confirmed within the AQAA. Staff signed to state they had undertaken various tasks. Spot checks were undertaken to ensure an adequate standard was maintained. Staff said that an industrial carpet cleaner had recently been purchased. The ancillary manager told us that the machine was easy to use and had significantly improved the appearance of some carpets, which required regular shampooing. We saw that the home was cleaned to a good standard yet greater attention was required with the edges of tables and the arms of chairs. Many had food debris on them. We did not look at the laundry systems on this occasion. Staff told us that there was a laundry assistant and that the systems were working well. We saw that there had been a complaint about the laundry including items going missing and items which had shrunk. Staff had been reminded to be more mindful and the person had been reimbursed for their ruined clothing. Care Homes for Older People Page 24 of 34 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. People benefit from a staff team who are well supported, trained and supervised. People are protected by a robust recruitment procedure. Evidence: A member of staff told us that there were generally four care staff and the deputy manager or manager on duty during the day. In addition to the care staff team there were catering and housekeeping staff, a laundry assistant, an activities organiser and a maintenance/gardener. We saw that the staffing roster confirmed this. At night there were two waking night staff and a staff member who provided sleeping in cover. An on call management system was available at all times. Within the AQAA, we saw that general assistants had been employed to assist care staff with serving meals and morning coffee and with preparing supper and snacks. This enabled care staff to spend more time undertaking caring responsibilities and one to one time with people. It was confirmed within the AQAA that mixed skills and age range of the staff team was something the home did well. Staff told us that staffing levels were adequate to meet peoples needs. They also confirmed this within their surveys. They said they were generally told who they were to support and monitor during their shift. They said this ensured people received the support they required and were not missed. At the last inspection we noted that staff presence on the first floor of the building was limited. During this inspection, we saw Care Homes for Older People Page 25 of 34 Evidence: that this had improved. There were staff on the ground and first floors. We saw one staff member sit with a person in the upstairs corridor. They were chatting about the persons family and the local area. Throughout the inspection we saw that staff engaged well with people. They were attentive and spoke to people respectfully. People were given time and reassured as appropriate. Some people responded to banter, which showed positive relationships had been established. We saw staff support one person to the lounge. They communicated with the person throughout, saying things like where would you like to sit? How are you feeling today? How are those legs? We heard another staff member say could I offer you a sherry sir? Mrs Norvill told us that a lot of work had been done with staff regarding general communication. She said staff were encouraged to step into the persons shoes and to try to understand what the person was seeing or feeling. We saw one staff member spend time with a person, looking out of the window. They were acknowledging what the person was seeing but also talking about the leaves changing colour and the time of the year. We saw another staff member intervene quickly when a person took used cups from the washing up trolley. They were distracted well by saying shall we go and get you a nice fresh drink, what would you like? Within surveys, staff told us that their employer carried out checks such as CRB (Criminal Record Bureau) and references before they started work. We looked at the recruitment documentation of three most recently employed members of staff. The files contained the required information, which showed a robust recruitment procedure. There was a photograph, an application form and two written references. There were details of the persons medical health, which ensured they were fit to do the job. Each staff member had been checked against the Protection of Vulnerable Adults register before commencing employment. Criminal Record Bureau (CRB) certificates were in place as required. These checks ensured the staff were suitable to work with vulnerable people. We saw that any gaps in the staff members employment history had been identified and discussed. Mrs Norvill told us that the recruitment procedure was thorough as she was committed to finding the right person for the job. She said a recent appointment of a registered psychiatric nurse to the post of deputy manager had significantly helped the development of the service. Staff told us that training was given priority and there were always courses being arranged. Mrs Norvill confirmed this and said that staff were motivated and interested in learning and developing their skills. She said a high number of staff had either completed or were doing their National Vocational Qualification (NVQ.) Within the Care Homes for Older People Page 26 of 34 Evidence: AQAA it stated that the home had been re-accredited the Investors in People award. We saw that a range of training had been undertaken. Staff were up to date with fire safety, first aid, manual handling, infection control and health and safety training. We advised that topics such as manual handling could be developed more in terms of peoples specialised dementia care needs. Mrs Norvill said that two staff had completed dignity and respect training. We saw that different topics such as safeguarding, role of the care worker, the Mental Capacity Act and our inspection methodology had been discussed within regular staff meetings. Some training had been undertaken in the form of a DVD and question papers. We advised that the use of more external trainers be used to complement the in house training plan currently in place. As stated earlier in this report, we said that staff would benefit from more training in relation to peoples resistance in receiving support to maintain their personal hygiene needs. Within the AQAA, maintaining staff retention and progress with all training - in-house and external were areas the home was planning to improve upon. The AQAA also stated all staff to have dementia care training regardless of their role to include the [organisations training providers] training and Person Centre Care Training. We saw within the AQAA that it stated specialised training has taken place with regards to various topics that may affect this client group i.e. managing and preventing aggression and attachment therapies. Some staff had undertaken a leadership course. Within a survey, a staff member told us I feel that the staff have adequate training on all different levels. A health care professional told us that training for carers was what the home could do better. Another health care professional said staff are now trained to cope with more challenging behaviour (this wasnt so when the home first opened.) Care Homes for Older People Page 27 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a manager who is person centred and has a clear focus of the service to be provided. The safe keeping of peoples personal monies is well managed. Peoples wellbeing is promoted through clear health and safety systems. Evidence: Mrs Norvill was registered with us as the manager in May 2009. Previous to this she was the organisations Director of Training. For a period of time, after the previous manager left, Mrs Norvill undertook the role of acting manager. Due to unsuccessful recruitment of a suitable applicant, she said she agreed to apply to become the registered manager. Mrs Norvill told us that she has the Registered Managers Award and is part way through the NVQ level 4 in Care. She said she was looking into completing her psychiatric nurse training through distance learning, sometime in the future. Mrs Norvill told us that since being in post she had completed training in risk and outcome focused care planning, fire risk assessment, nutrition and the management of aggression and prevention. Mrs Norvill said that since starting her Care Homes for Older People Page 28 of 34 Evidence: post, the home had reached its full occupancy. She said additional staff had been recruited to meet the increased numbers of people. Systems such as care planning and staff training had also been developed. Mrs Norvill told us that she had recently attended a Dementia congress in Bournemouth and was planning to introduce what she had learnt within the home. She said she was also open to any other suggestions, which would improve the service people received. Within the AQAA, it stated that the things the home did well were open and supportive management team within the Home and Head Quarters and small family business - supportive to all - very personal - not institutionalised. As a means to monitor the service, weekly quality assurance meetings were held. Regular audits had also been introduced. These included the housekeeper checking each room on a daily basis to ensure the standard of cleaning was satisfactory. Peoples views had been requested in relation to areas such as meal arrangements and the food provided. Mrs Norvill told us that surveys had been sent out to relatives in order to gain their views about the service. She said that a minimal number were returned. Since the last inspection, relatives meetings had been introduced. Records of the last meeting showed that a representative from the Alzheimers Society had attended. We saw that regular management meetings were held to discuss service provision. While noting that various systems were in place to monitor practice, the findings were not coordinated. It was therefore not possible to see an overview of the issues identified and how they were to be addressed. Mrs Norvill told us that she was aware the home did not have a system which gave this. She agreed it was something she needed to work on. We saw that the home held small amounts of peoples personal monies for safekeeping. We looked at the systems for managing this and checked a sample of cash amounts. The cash corresponded with the balance sheets. Generally only Mrs Norvill and the administrator had access to the storage of peoples personal monies. At the last inspection, we recommended that another member of staff countersigned each transaction related to peoples personal monies. We saw that Mrs Norvill had generally signed the records. There was no additional signature. The administrator told us that they regularly checked the monies. They said that other administrators within the organisation also audited the systems on a regular basis. There were a range of health and safety policies and procedures in place. The housekeeper told us that information regarding cleaning substances and their safe use were held in the staff room and the cleaning cupboards. Staff were up to date with their training in topics such as first aid, manual handling, food hygiene and fire safety. Care Homes for Older People Page 29 of 34 Evidence: Mrs Norvill told us that the deputy manager was a manual handling trainer so regularly undertook training in the home. There were a number of risk assessments in place yet these were in the process of being developed with more detail added. The cook told us that clear documentation to show the health and safety systems in the kitchen were maintained. They said they always used a temperature device to treat the food in the kitchen and again before it was served, to ensure it was of a safe temperature. The fire log book was generally well maintained yet there were a number of gaps in the recording of the weekly fire alarm checks. Mrs Norvill told us that this appeared to be when the staff member with this responsibility was on annual leave. She said she would address this in the future so it did not happen again. Not all staff had signed to show they had received fire instruction. Mrs Norvill told us that fire safety was always discussed in each staff meeting. She said the staff would have received the instruction yet probably did not sign the log book. We saw that regular fire drills had been undertaken. In order to show that staff had attended regular drills, we advised that the same format was used for recording fire instruction and the drills. A fire risk assessment was in place for each room. The home had a Fire and Rescue service inspection in January 2009. No issues were identified. Within a survey, a staff member told us I feel the health and safety in the home does well e.g. cross infection. We saw that there had been a high level of accidents recorded within the accident book. These generally involved people falling or being found on the floor. The records showed that the accidents had been monitored yet there had not been a decrease in the occurrences. We saw that the majority of accidents took place after 16.30. We advised that contributory factors such as staffing levels should be reviewed in terms of the number of accidents occurring. Care Homes for Older People Page 30 of 34 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 31 of 34 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 12 Peoples resistance to 30/11/2009 receiving support with maintaining their personal hygiene needs and/or any behaviours that challenge must be discussed with the persons placing authority. A plan of care must be devised and agreed with all individuals involved. So that the persons individual needs are met and their dignity is maintained. 2 26 23 Staff must ensure that they clean less visible areas such as the edges of tables and the arms of chairs. To enable people to have pleasant environment and to minimise the risk of infection. 16/11/2009 Care Homes for Older People Page 32 of 34 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 3 38 13 A review of all accidents 30/11/2009 which takes into account any contributory factors such as staffing levels must be undertaken. To minimise further accidents enabling people to be safeguarded from harm. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 3 Terms such as short term memory loss should be expanded upon to show how it affects the person in their everyday life. Any medical treatment should be undertaken in private so that the persons privacy and dignity is maintained. Any mark or bruise noted on a person should be fully documented to include its size, colour and exact location in order to effectively monitor the healing process. Staff should ensure that the television and the music centre are not playing at the same time, in the same room. Alternative strategies should be devised so that people do not communicate through giving others a gentle tap. Staff should receive additional support and training in order to be able to effectively manage peoples resistance to maintaining their personal hygiene needs. Documentation should clearly show how often each staff member is involved in a fire drill. Documentation should evidence when each member of staff has received fire instruction. 2 3 8 8 4 5 6 12 18 30 7 8 38 38 Care Homes for Older People Page 33 of 34 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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