Care Home: Stennards (Fb)

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What the care home does well On our visit four people and a visitor said,, " the food is excellent"; "lots to do in the home and we go out - four times a week for some"; "I like to help the staff"; "I`m happy with my room"; " the manager and staff couldn`t do more, always let me know if mum`s ill". Staff told us that the manager puts in "150 per cent", they have good training, work as a team and enjoy coming to work. "We know people well; many have lived here a long time." People are having the help they need to manage increasingly complex physical and mental health conditions and dementia. The support, stimulation and care provided by staff respects independence, individuality and provides daily choice. Since the last inspection the home have sustained excellence and high satisfaction levels, and people have a meaningful quality of life. Three outcomes for people have improved. Staff are qualified, consistent and available to people when needed. Safeguarding is taken seriously. The complaints procedure is used to promote people`s rights and actions taken can benefit everyone in the home. The manager and owners conduct audits and staff appraisals, seek and respond to people`s views and requests, and update staff practice and training. There have been no safeguarding concerns, and the home usually keeps the Commission well informed. It is comfortable, modern, very clean and people have privacy and dignity. It is well run and well maintained. Management know what they want to continue to improve. What has improved since the last inspection? A suggestions box and stakeholder survey were introduced to gain more views. In 2009 people were consulted about the home`s written information and changes made will make a new service user guide easier to read. People wanted more exercise sessions after the home arranged these, so musical instruments, games and equipment were purchased for staff who now provide additional sessions. Inter-home outings take place. The provider funds attendance at a local day centre once a week, and a school choir visits the home so they are part of the local community. A contracted musical entertainer plays 50`s - 70`s style music. Last year a sunflower was planted for each service user to look after. Most staff completed NVQ 2 care qualifications. The manager completed NVQ4 and a senior is now enrolled. Some staff completed NCFE Level 2 Dementia distance learning through Solihull College; the manager is undertaking Level 3. The manager attended council workshops on the Mental Capacity Act and Deprivation of Liberty Safeguards, briefed staff and introduced a new assessment tool to avoid unnecessary restrictions on people`s lives. Staff also had training in nutrition and skin care. The Manager of Stennards (Fb) is now also the Area Manager for Stennards; care home managers meet for support. Best practice was researched to update care planning assessment tools, infection controls, health and safety. As a result people have more thorough screening and specialist health advice about diabetes, mobility, falls prevention and nutrition. Staff were trained by health professionals to monitor blood sugar levels. Extra infection controls were put in place to prevent swine flu and influenza. Record keeping and systems such as admission are checked by the owners. The owners now log quality and safety checks and actions taken, and oversee care regulation compliance. The manager audits incidents and acts on patterns to prevent injuries. An Environmental Health inspection made no requirements about food hygiene and their recommendations were acted upon - new format (HACCP) for kitchen records and kitchen refurbishment. To comply with the 5-yearly electrical installation inspection 2008, flush lights were fitted in 2009. The roof was maintained and sewerage pipes to a toilet; a new boiler and a wetroom were installed. Perimeter fencing and patio furniture were replaced in 2008. There is ongoing refurbishment and re-decoration of the home and people`s rooms, and people are consulted about colour schemes and furnishings. What the care home could do better: People and families need accurate information about specialist care, fees and staff to make decisions about the home`s suitability. AQAAs could have said more about the development and approach of specialist care since registration changed in 2008. People`s needs are now more complex, and there are gaps in policies, systems, staff knowledge, skills and appraisal. Further safeguards are needed to promote mental and physical health, and people`s rights which Stennards (Fb) are in the process of updating. Action was taken and planned by the manager on our visit, to improve safeguards for individuals. A small amount of medication was not fully accounted for so we could not confirm that it is given as prescribed. A computer would help the manager keep up to date as laws and care regulations are changing next year. The home will need to assess their compliance and re-register online. Key inspection report Care homes for older people Name: Address: Stennards (Fb) 123 Frankley Beeches Road Northfield Birmingham West Midlands B31 5LN     The quality rating for this care home is:   three star excellent 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: Tina Smith     Date: 1 5 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 31 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 31 Information about the care home Name of care home: Address: Stennards (Fb) 123 Frankley Beeches Road Northfield Birmingham West Midlands B31 5LN 01214775573 01216057799 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Dawn Lee-Harris,Mr Peter David Lee-Harris care home 18 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 18. The registered person may provide the following category of service only PC care Home Only To service users of the following gender Either Whose primary care needs on admission to the home are within the following categories Older people (OP) 18 Mental Disorder (MD) 18 Dementia (DE) 18 Date of last inspection Brief description of the care home Stennards (Fb) is in a residential area, near shops, public transport and has car parking. Personal care is provided for up to 18 older people, with specialist care for mental disorder and dementia. There are ten single and four double bedrooms on two floors, accessed by two stair lifts. Eight have ensuite facilities; others have wash hand Care Homes for Older People Page 4 of 31 18 18 0 Over 65 0 0 18 Brief description of the care home basins. Toilets are near bedrooms and communal areas - a lounge, dining room, two conservatories and an enclosed garden. There are assisted bathrooms and showers. On our visit a draft service user guide was not yet published; we advise asking management about fees. Care Homes for Older People Page 5 of 31 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: three star excellent 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: The home was last inspected on 15/02/07 when four requirements were made; the quality rating was excellent. Since then the provider applied and the Commission agreed registration of specialist care for dementia and mental disorder. On this visit an inspector visited the home between 10:00 am and 8:00 pm. They did not know we were coming. We looked around, observed a meal and checked the medication system. There were 16 people in the home and one in hospital. We spoke with six people, a visitor, staff on duty, examined three peoples care and health records and the complaints log. We saw records about staff, the running of the home and other regulator reports. Policies and procedures were discussed about risk assessment, medication, Deprivation of Liberty Safeguards, complaints and safeguarding. Prior to the inspection the manager sent us an Annual Quality Assurance Assessment Care Homes for Older People Page 6 of 31 (AQAA), with information about the home, what has improved and is planned for the future. Their self assessment shows continuous improvement. Information from the AQAA and other sources was used when forming judgments on the quality of the service. The home notified us about events that affect people, and we received two reports from other sources. We discussed our findings with the manager and an owner, present for much of our visit. Three previous requirements were met and one was replaced. No immediate requirements were made as people were well cared for and action was taken or planned on matters we raised. Further requirements and recommendations are at the end of this report. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? A suggestions box and stakeholder survey were introduced to gain more views. In 2009 people were consulted about the homes written information and changes made will make a new service user guide easier to read. People wanted more exercise sessions after the home arranged these, so musical instruments, games and equipment were purchased for staff who now provide additional sessions. Inter-home outings take place. The provider funds attendance at a local day centre once a week, and a school choir visits the home so they are part of the local community. A contracted musical entertainer plays 50s - 70s style music. Last year a sunflower was planted for each service user to look after. Most staff completed NVQ 2 care qualifications. The manager completed NVQ4 and a senior is now enrolled. Some staff completed NCFE Level 2 Dementia distance learning through Solihull College; the manager is undertaking Level 3. The manager attended council workshops on the Mental Capacity Act and Deprivation of Liberty Safeguards, briefed staff and introduced a new assessment tool to avoid unnecessary restrictions on peoples lives. Staff also had training in nutrition and skin care. The Manager of Stennards (Fb) is now also the Area Manager for Stennards; care home managers meet for support. Best practice was researched to update care planning assessment tools, infection controls, health and safety. As a result people have more thorough screening and specialist health advice about diabetes, mobility, falls prevention and nutrition. Staff were trained by health professionals to monitor blood sugar levels. Extra infection controls were put in place to prevent swine flu and influenza. Record keeping and systems such as admission are checked by the owners. The owners now log quality and Care Homes for Older People Page 8 of 31 safety checks and actions taken, and oversee care regulation compliance. The manager audits incidents and acts on patterns to prevent injuries. An Environmental Health inspection made no requirements about food hygiene and their recommendations were acted upon - new format (HACCP) for kitchen records and kitchen refurbishment. To comply with the 5-yearly electrical installation inspection 2008, flush lights were fitted in 2009. The roof was maintained and sewerage pipes to a toilet; a new boiler and a wetroom were installed. Perimeter fencing and patio furniture were replaced in 2008. There is ongoing refurbishment and re-decoration of the home and peoples rooms, and people are consulted about colour schemes and furnishings. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 31 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 31 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 visit, have a pre-admission assessment and a welcome pack which may not answer all questions about the home. Information from professionals helps the home decide whether needs can be met with community health care support, if necessary. Evidence: As there was a registration change, this year we wanted to see if people had accurate information. A corporate service user guide is being drafted, which will have an updated statement of purpose about the service. After consulting people this will be in large print so it will be easier to read. Currently the manager gives a welcome pack to prospective families. This explains the process of admission in Plain English and provides some information about the home. We were told that the guide will have information specifically on Stennards (Fb) about specialist care, fees, facilities, staff qualifications and training. Staff certificates are on display in the home. We looked at the records of two people, one who came to the home in the past few Care Homes for Older People Page 11 of 31 Evidence: months and another living in the home for several years. Pre-admission assessments were undertaken during the new persons visit to the home which identified needs and preferences. Information was gathered from professionals about physical and mental health conditions, needs and mental capacity before a decision was made by the home that these could be met. We were told about consultations with primary care health services and families, as well as any funding authorities when end of life care and illness needed consideration to determine where needs were best met. During the past year one person was admitted for end of life care, and two people moved to nursing homes. This shows us that the home understands the limits of their service. For the person newly admitted there were more thorough assessments after admission, but some records were blank and unsigned - a personal profile, consent form and general terms and conditions, although a Power of Attorney was involved. A formal review was held at the end of a trial period with the person, family and the social worker so that a decision to stay was considered together, a check was made about needs and support, and changes were agreed. A great deal was known about the person living longer in the home. Their care and medication was reviewed regularly by professionals and the home. Care Homes for Older People Page 12 of 31 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. People have the support they want to promote independence and have good access to health care. Care planning about interlinked and associated risks, medication policy and systems could improve to further promote physical and mental health and peoples rights. Evidence: Care plans are usually agreed with people and are based upon assessments of needs and risks. Strengths are the homes improved assessments, detailed guidance for staff, and achievements in helping people to manage complex conditions with choice, dignity and quality of life. These outweigh developmental weaknesses we also report on below. The manager already had appointments to consult doctors and will follow up matters we raised about individuals, so we had no concerns. Everyone was well groomed and bathe or shower as often as they want. Three records showed that people take part in their care so that independence and dignity is promoted. There is good social stimulation to retain memory, intellect, physical abilities and emotional wellbeing. This resulted in someone recovering from a stroke Care Homes for Older People Page 13 of 31 Evidence: having support adjusted as they regained abilities to dress, wash, mobilize and communicate. Staff had detailed guidance and assisted with a picture board, photo menu, verbal and physio exercises. People and a visitor said that they were well fed, recovered their confidence after falls and hospital stays, and staff are nearby when needed. Diabetes plans and plans to manage swallowing difficulties and malnutrition were thorough, with mealtime guidance to minimise stress; health checks, regular weighing and blood sugar monitoring. The home often meets with speech and language therapy, dieticians and consultants. We were notified about a few falls, one resulting in a fracture. The home is trying out Primary Care Trust screening tools in addition to their own to improve their system of identifying and minimising key risks to physical health. New tools were more reliable when consistently scored, but also need to consider risk of falling out of bed, and one person needed follow up. Care plans show access to local falls clinics, appropriate footwear and foot care, sensory aids, commodes and support with mobility. Interlinking risk assessments could further protect health. For example, a persons mobility deteriorated and pressure relieving aids, turn charts and monitoring of hydration were not sought when risk was at its highest level. And someone admitted with a pressure sore was not determined to be at high risk of further deterioration. Practice was more up to date than care plans, and some sores had been prevented, were healing or under medical investigation. The manager and owner agreed that preventative measures need to be timely. Policy guidance and monitoring could achieve a consistent approach. Access is good to a range of physical and mental health services, dentists, chiropodists, opticians. Health appointments were kept, well recorded and escorts arranged. Good daily records and charts are evaluated by the manager and health advice is sought. Staff do not yet have enough knowledge about dementia and mental health. Everyone is treated as an individual and preferences are respected even if unwise. Some mental capacity and best interest assessments needed more depth. Assessments of mental health needs did not result in care plan strategies agreed with people to respond to signs of deterioration in schizophrenia or depression and to prevent associated risks, such as self neglect and self harm. However, health advice was sought for drug side effects, frequent refusals of food and/or medication, and significant weight loss, providing a safety net for physical health. Two peoples weights Care Homes for Older People Page 14 of 31 Evidence: have now stabilised. At the last inspection medication protocols were needed. On this visit we saw three protocols for when required medicines. The brief protocols were written/signed by doctors with the purpose of the prescription and maximum doses. The circumstance and process for care staff deciding them was missing and staff did not record the dose administered. Stocks did not all tally and the medication could not be accounted for as given appropriately. Two drugs were regularly administered or offered, rather than occasionally. The prescriber was not informed so that toxic combinations and drug dependency risks can be avoided. One drug was prescribed to protect other people from verbal aggression and threatening behaviour, which means it is a chemical restraint. We were told that this was given frequently because the person told staff that they felt better when they had this medication. Medication prescribed for one purpose should not be used for another without medical assessment. Monitoring and evaluation of health is effective at the home when there are aims in care plans, such as optimum blood sugar levels, or to gain x pounds. Aims and regular evaluation should also be applied to behaviour plans and medication protocols. Protocols for low mood and pain relief should be very different from protocols for when required restraint, but they were the same. Staff did not have clear, lawfully written and agreed guidance for restraint as a last resort. The behaviour plan did not identify de-escalation techniques to be tried first by staff with the skills to apply them. This is a shared responsibility by the professionals and the home, who sought their advice. A review of staff knowledge and skills is needed, along with policies about restraint, challenging behaviour and handling aggression that the home complies with the Mental Capacity Act about peoples rights and about their roles. Medication security and storage systems are good apart from no disposals to account for two minor discrepancies, and checking shelf life as one pharmacy label obscured the use-by date. Medication records had a few unusual notations and gaps rather than codes on the bottom of the MAR- their meaning could not be explained. The manager audits medication but there are no records of findings and actions taken. Medication errors were said to be rare, discussed in staff supervision but there was no record of health advice sought for the person, the frequency of errors or how staff were updated about medication. So we cannot confirm that the medication system fully protects health and promotes rights. The medication policy, and a formal system to determine staff knowledge and competence in this area needs development. Care Homes for Older People Page 15 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are treated as individuals, lead flexible lifestyles, and can take part in activities in the home and community. Everyone likes the food and has support at mealtimes. Dietary needs and most preferences are catered apart from cultural alternatives. Evidence: Records show that people get up for the day at different times, and choose when they go to bed. The Commission received a concern that people were dressed for bed too early, but at 8 PM some people were changed and others were not, all watching TV with staff. People and a visitor told us that the staff make them very welcome, and ring if the person is unwell. Staff help people to write to their friends and family, and have time to converse with people. The TV was on in the lounge when we arrived but was not on all day. People read, did puzzle books and watched a large screen TV, some slept in the morning. Some go out to day centres, social clubs, a stroke club or on outings with family and friends. The home funds attendance at a local day centre that provides transport for people who want to attend. Two staff specialize in certain activities. Interhome outings, entertainers and celebrations in the home and community take place. People said a quiz was recently held which they enjoyed. Religious needs are met, for instance one Care Homes for Older People Page 16 of 31 Evidence: person attends church on occasion with family and staff read passages from the bible to them. A local school choir attends the home. Peoples favourite activity involved musical instruments and games, such as skittles, offering gentle exercise which took place on our visit. Staff were good at getting people to take part and keeping people interested. We complimented this because people were so vibrant in the afternoon. One person took part for the first time since admission. People and staff told us of meaningful daily living tasks they like to help with, such as folding serviettes, polishing cutlery, helping to make a jelly. There are orientation, discussion and reminiscence activities which promote memory and intellect retention. This is best practice for 11 people in the home we were told had dementia. People with mental health conditions benefit from the social stimulation on offer, as do people with cognitive and communication impairments. Everyone chooses whether to take part, some choose to spend a lot of time in their room or in conservatories. The owners log shows that people are consulted about activities and the menu, and changes are made. The menus showed nutritional balance, choice of 2-3 dishes at each meal and was well liked by people. At tea each person had something different there was wide variety of hot and cold food and generous portions. All staff prepare food and have food safety training; the manager does the food shopping. There was sufficient staff to provide the support needed by some people at mealtimes. Staff knew and catered for dietary needs including low fat, diabetic and soft diets, and food fortification. Food intake records were well designed with codes, comments about portion size, menus, choices. Everyone ate well on our visit, even someone who had been refusing food. However none of the choices provided cultural alternatives matching everyone in the home. We spoke to a person whose family appear to regularly bring meals for them, but a formal arrangement and offer of recompense was not in their care records to demonstrate that equality and diversity is provided for. Care Homes for Older People Page 17 of 31 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. Complaints are taken seriously. Action is timely and can benefit the entire home. People feel safe and there have been no safeguarding concerns. Policies and systems need further safeguards of peoples rights. Evidence: Although the AQAA told us there were no complaints, we found five were investigated in 2009. These were taken seriously; actions were prompt, well within the 28 day timescale of their procedure and get at root causes. This sometimes benefitted everyone in the home or resulted in an apology and rectification. However they do not result in a written response to the complainant. One complaint was found not to have resulted from actions by the home and it was not clear whether the complainant was notified or accepted the outcome of an investigation by the manager. Complaints concerned missing and misplaced clothing, laundry, hair care, and a two day delay in responding to a request to alter a persons room. We fedback that this is a robust complaints log, but the AQAA was not accurate. Two concerns were reported to the Commission by statutory agencies and individuals since the last inspection. In 2008 there was a concern about standards of care which was disproved. In 2009 there was a concern just before the inspection, about which we found no evidence that raised any concerns on our visit about stimulation, respecting individual choice or supervision of people by staff. Most wings lead through the lounge, so staff passed by every few minutes while they assisted people to get up Care Homes for Older People Page 18 of 31 Evidence: in the morning. After dinner there were two staff in the kitchen washing up and a third worker in the lounge with people. In the evening people and staff watched TV together. Four people told us that they felt safe and well respected in the home. There have been no safeguarding concerns since the last inspection. New staff have robust recruitment checks. All staff have training to recognise and report abuse and poor practice, and understand the company code of conduct. One worker described poor practice as shouting, rushing, pushing, which shows understanding of what is expected of them. The safeguarding procedure is linked to the local council protocol. A poster reminds people, visitors and staff to use the complaints procedure to promote rights. It says Stennards have a no blame policy for staff who want to report matters. Staff said they can report any concern to the manager or owner and know they will be taken seriously too. The noticeboard has an array of important safeguarding procedures about missing persons, swine flu and accidents. This shows that key procedures to ensure people are safe and health is protected are readily accessible. Making notifications to the Commission is integrated into the homes systems and policies. The home tried to obtain an up to date Regulation 37 form and guidance from the Commissions website, which was not functioning as it should so we sent it to them. We are usually kept well informed by the home, but were not informed about a restraint protocol and we have not been notified of any medication errors. The home is registered to provide care for people who may not be able to make specific decisions for themselves all of the time due to the nature of their conditions, some of which may be progressive. The home are expected to have a thorough understanding of their legal duties, including skills to assess and review mental capacity and Deprivation of Liberty Safeguards (DOLS), and to protect peoples rights, health, safety and welfare under various laws. Information on advocacy services was on display, and the manager knew how to arrange statutory advocates. This shows us that people can have access to independent support for serious decisions. The homes records show that consent is usually sought from people and representatives about decisions on admission and daily about care, stimulation, medication and health treatment appointments. Refusals are accepted but concerns about physical and mental health are followed up with health specialists, which exercises a duty of care. Care plans guide staff on decisions they may need to take for people with incapacity, such as choosing appropriate clothing for the weather. The manager had training about DOLS and introduced a form Care Homes for Older People Page 19 of 31 Evidence: about mental capacity and to try and avoid any undue restrictions on peoples lives, which is good practice. No DOLS authorisations were made or requested from the council. An assumption was made by the home that as a person could decide about food that they could decide about medication. However a behaviour management plan was not signed by the person or interested parties, and did not show how least restriction would be applied to a medication protocol for restraint. There was no assessment of incapacity to justify the necessity for restraint in their best interests by multi-agency decision makers, and with least restriction. We question the necessity for restraint in circumstances where there were few incidents and staff successfully intervened to prevent harm. The need for a DOLS authorisation was not re-considered in light of restraint in place, or other safeguards of the persons rights in accordance with the Mental Capacity Act. Use of restraint was not logged as an incident or analysed on each occasion to protect the person from untoward restraint, which is abuse and can be a crime, and it had not been reviewed since June 2009. Some staff but not all had training about challenging behaviour and managing aggression in the past. Laws have changed. Further understanding about restraint and DOLS is necessary - behaviour plans and protocols for restraint must be lawful and give staff sufficient instruction to safeguard the persons rights even when safeguarding others in the home. On most occasions the Commission would report a concern of abuse to the council about this. The person however felt better with this medication and had various medication changes under psychiatric review and a preplanned multi-professional meeting was taking place in a few days. There is balance between risk-taking and risk management for people, however policy and system gaps need to be filled to make sure duties are exercised appropriately to safeguard vulnerable people and their rights. Care Homes for Older People Page 20 of 31 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was warm, safe and well maintained with high standards of hygiene and comfort. Rooms are personalized with a good standard of facilities and furnishings, but there are no lockable facilities for valuables. People have privacy if they request a bedroom door lock, key, a privacy screen in shared rooms and provide their own padlock for valuables. Evidence: Stennards (Fb) is in a residential area and was well designed by the owners. The home has wings and people did not appear to have difficulty finding their way around, although varied colour schemes might help. Each bedroom is different in design. People bring their own possessions and aids, and some use their rooms more than others. Privacy is maintained by locks on bedroom doors if requested, and toilet doors. We asked why there were no privacy screens in shared rooms, and were told that no one requested one. Care records do not show whether people were ever asked or whether this is reviewed. We came across a screen in regular use outside of someones room, as they want to prop the door open. The person appeared very isolated by this arrangement, but was happy with their care. There are lockable drawers in bedrooms for valuables, if people provide their own padlock. Nothing is going missing. A persons inventory was written on a serviette in one record. The front door is locked to prevent intruders and safeguards people from wandering. Care Homes for Older People Page 21 of 31 Evidence: Window restrictors upstairs prevents falls. Some people need an escort when they go out or to use the stairlifts. Two wheelchairs are maintained for general use. People have sufficient toilet raisers and commodes, and they are disinfected in a sluice in the laundry. During our visit an owner returned a broken aid and collected a new one, showing us that they go that extra mile to ensure peoples needs are met. There is open access to conservatories. The larger, unheated conservatory is used as a smoking room by one person. We were told that this was risk assessed and that people in the dining room are protected from smoke by a door closer; they wanted to provide smoking facilities that offer shelter from the weather. However most people cannot use this conservatory without risk from smoke or gain access to the garden without going through this conservatory and we recommend freedom of movement is reviewed. There were no requirements over the past two inspections about the environment. The home was warm, well maintained, with ongoing redecoration and refurbishment plans. Servicing checks were up to date; AQAAs are accurate about this. Fire prevention is taken very seriously. Hot water temperatures were maintained within the safe range to prevent scalds, despite one room that people use having a Very Hot Water sign. The premises risk assessment is regularly reviewed. Hairdressing takes place in the laundry and this risk assessment should include hot water and infection control risks as a commode was waiting disinfection during our visit. Cleaning agents were locked away. There is an infection control plan. Extra precautions were in evidence as well as Health Protection Agency advice to prevent swine flu and influenza, including anti-bacterial gel for staff and visitors, and vigilant cleaning schedules. There are high standards of hygiene and people told us it is always this way. Staff said that Environmental Health visited in 2009 and made no requirements about food hygiene. Records show that food is heated to safe temperatures. Food is date labeled when opened; fridge and freezer temperatures are in safe ranges. There is separation of clean and soiled clothing in the laundry, however the manager agreed that there was no need for towels to be stored in the room with soiled laundry and removed this cross contamination risk. There have been no outbreaks of contagious illness in the home. Care Homes for Older People Page 22 of 31 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. Staff have robust checks to make sure they are safe to work in the home. Qualified staff provide consistent care and are available when people need them. There is ongoing and additional training and more is planned to deliver specialist care. Evidence: Staffing was improved since our last inspection as there are now staff for activities. We saw sufficient staff so that people had help at peak times when they wanted to get up, for meals and in the evening. Three staff are on duty until 10 pm, when there are two staff - waking and sleeping night staff. The manager is supernumerary. Temporary staff were not used and there is a low staff turnover, so there is consistency of care. There are well organised staff records, now all kept in the home. We looked at two records and saw the required recruitment checks before staff start work in the home. One worker is 17 years of age and has been working in the home since 2008 with appropriate boundaries to their role. The worker commenced at an age too young to work in care, and has a dual job description that includes care. Registered persons must be mindful of age restrictions in future. There is CQC guidance available. Staff had Skills For Care inductions completed within two months. Comprehensive inductions were noted at the last inspection. Since then most staff, 80 percent, Care Homes for Older People Page 23 of 31 Evidence: completed NVQ 2 qualifications so that they understand their care roles, which exceeds minimum standards. A Senior is enrolled for NVQ 4, and the home has sought funding for staff to progress to NVQ 3. Mandatory training is undertaken and refreshed. Carers prepare food and there are domestic staff. All staff have food safety, infection control and fire safety training. We were told that manual handling training is by video. The home does not have a hoist and staff do not have hoist training. We are unclear whether newer staff had hands-on accredited manual handling training, but there were instructions about transfers and use of peoples aids in care records. There are two levels of first aid training and we were told all staff are to be offered resuscitation training so that they have these skills in an emergency. Additional training was undertaken in the past year about nutrition and care of skin. We looked at how staff gained knowledge to deliver specialist care in the statement of purpose. A few staff are trained in Level 2 Dementia Care and the manager is progressing through Level 3. The AQAA says that in 2009 sources of funding were sought for 11 staff to attend Dementia Care training. The owner said that they are looking at learning packages about mental to find one that will meet staff needs. We suggested on-line training and consulting the Social Care For Excellence website for resources (www.scie.org.uk). The manager attended a council workshop on Deprivation of Liberty Safeguards during the past year and briefed staff to update them. Staff were clear on their keyworker roles. They said that they have enough support, constant training, and have enough information shared about people at handover meetings between shifts. Staff records show supervision is held two monthly; staff meetings are held twice a year. The manager issues notes to staff or puts them in MAR or care records or on notice boards if not personal data, so that there is an effective communication system. One worker said; in this home staff and management give 110 per cent, manager probably 150 per cent. They have commitment and worked effectively as a team, ensuring that people were not left unattended in the lounge for long on our visit. Staff, manager and the owners knew people well. A visitor and four people told us that they had good relationships with them. Care Homes for Older People Page 24 of 31 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well run, person-centred and people benefit from sustained leadership and oversight of health, safety and quality. Further training, policy development and monitoring of updated systems is planned. Evidence: We checked the training certificates of the manager to confirm that a previous requirement was met. The manager has NVQ4 qualifications and the Registered Managers Award. They have been at the home since it opened in 1995, and are registered by the Commission. Managers of Stennards care homes now meet to support each other and the manager of Stennards (Fb) acts as the Area Manager for the company to raise standards. This year the manager updated their knowledge on a range of best practice matters to benefit peoples health, welfare and rights. Policies and procedures were reviewed in light of changing laws and legal duties. The AQAA was generally accurate and showed some analysis but could have told us more about their development of specialist Care Homes for Older People Page 25 of 31 Evidence: services. Value for money is understood in relation to local comparisons. People manage small amounts of money independently and/or families and Powers of Attorney assist with their financial affairs. The home checks that Powers of Attorney are registered with the Public Guardian, which is good practice to safeguard people. The home provides a written statement and receipts if they make purchases from their float for peoples needs but they do not handle or provide safekeeping for peoples money. There is a code of conduct and staff are prevented from involvement in peoples financial affairs or benefiting from wills. The care planning system is evolving and needs policies underpinning risk management of health, safety and welfare. Environmental safety is robust - the home is well maintained and smoothly run. There are meetings for service users and staff twice a year. This year a stakeholder quality assurance survey was introduced and a suggestion box to gain more views to develop the service. The owners visit daily and log monthly checks on peoples wellbeing, activities, record keeping and maintenance. The manager conducts regular audits. Supervision of staff takes place bi-monthly and there are annual appraisal of work performance, but these do not include a formal system of confirming ongoing medication competence. Management know what they want to improve, and expressed intention to address policy and system gaps. The home generally keeps the Commission well informed but needs to notify us fully, in accordance with current guidance. The manager would benefit from a computer and internet access to keep up to date on new care regulations and re-registration taking place during the next year. There is a proven track record of sustaining excellent outcomes for people and continuous improvement. Care Homes for Older People Page 26 of 31 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 27 of 31 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 9 13 13(2): Medication policies must be reviewed to ensure that protocols for when required medication and chemical restraint fully protect people and reflect good practice. Staff must be trained to adhere to them. The health and rights of people must be protected by the homes medication system. 15/02/2010 2 9 13 13(2): Medication administration records (MAR) must be accurate to account for medicines received into the home, administered and disposed of. Discrepancies need to be followed up effectively and in a timely way. People must have medication as prescribed for their health. 15/02/2010 Care Homes for Older People Page 28 of 31 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 18 13 13(7): Restraint needs to be 15/02/2010 logged and analysed to ensure safe protocols and procedures were followed. The Commission must also be notified. Peoples rights and safety must be promoted and protected. 4 30 18 Reg 18(1)(a): Training of staff and managers, appropriate to roles, must match the needs of people and the service specified in the statement of purpose. This is to ensure peoples needs are recognised and met. 15/04/2010 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 8 Behavioural strategies, when warranted in best interests or with consent, should detail least restrictive contingencies, be regularly reviewed and evaluated. To meet mental health needs, strategies to minimise associated risks should be reflected in care plans agreed with people and professionals. Cultural alternatives should be available at each meal in accordance with peoples preferences. Arrangements with families to provide regular catering should be formalised and recompense offered to demonstrate equality and diversity of provision. 2 8 3 15 Care Homes for Older People Page 29 of 31 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 4 5 18 24 The Mental Capacity Act code of practice chapter on restraint should be consulted when reviewing policies. Privacy screens in shared rooms would enable people to choose each day whether to use them. If requested for other purposes, care plans should reflect informed decisions were made. An over-arching policy should ensure consistent, robust and inter-linked risk assessment of nutrition, pressure sores and falls so that health is promoted. A review of the homes risk assessment should ensure freedom of movement within the home and grounds with protection from smoke. 6 33 7 38 Care Homes for Older People Page 30 of 31 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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