Care Home: The Gables Nursing Home

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What the care home does well The home provides nursing care for up to 56 older people. Currently there are 32 residents in the home, of which 12 have mental health needs of the older person. Residents and their visitors spoken with said: "I am very happy with the care, they look after (the resident) well, they see to (the resident`s) needs straight away". "Since we have returned to The Gables we have a lot of new staff who are friendly and caring; and friends and family can come any time of the day or evening". "I am pleased with the care given, (resident) seems very comfortable and we are kept informed with progress by the staff, we have attended the resident and relative meetings and on one occasion I had a concern and was able to talk to the manager about it, and it was sorted out to our satisfaction". The home employs an activities coordinator on a full time basis who has involved residents in a range of innovative activities and has discussed their interests with them. Residents said that they were "delighted and really enjoy them", whilst staff spoke of how much more alert some residents seemed since these commenced. The home has been refurbished over the past year and new furniture has been provided. There is ample communal space consisting of lounges and dining rooms and residents can access a well maintained garden area. All areas of the home were clean and rooms personalised with residents possessions. The home provides a varied menu which enables residents to have choices at each meal. The majority of residents said that they enjoyed the food and that snacks and beverages were available at any time. It was noted that fresh fruit was available in the lounges and dining rooms and this was being offered to residents throughout the day. What has improved since the last inspection? Improvement has taken place across all areas of the home in the past few months. All the requirements, with the exception of one requirement not complied with in full, made at the last key inspection have been met. The standard of care planning has generally improved and although care plans seen required evidence that they have been formed in consultation with the resident or their representative and require to be more person centred, care plans show that resident`s needs have been assessed and the required care documented. The home has continued to increase its staffing levels and the manager said that staffing levels will continue to be assessed in line with the needs of the residents and not only by the number of residents in the home. All staff now receive formal supervision which ensures that residents receive their care in line with the home`s policy. Arrangements are in place to ensure that Regulation 26 visits take place (visits and reports about the services offered by the home, undertaken by either the provider or their representative, which are required by regulation to take place on a monthly basis). Routines at the home are sufficiently flexible to enable residents to choose their daily routines and how they wish to spend their day. What the care home could do better: Some concerns have been raised by the commission with management regarding staff`s understanding of dementia care. Although most staff have attended a short day course on dementia, further training is needed to ensure that staff know how to meet resident`s needs. The home is currently trying to recruit registered mental health nurses who are fully trained in dementia care and other care staff with experience and knowledge of these resident`s needs. There are also concerns that whilst the staff have undertaken some training in end of life care, this is insufficient for the needs of registered nurses at the home. The manager is aware of this and has stated her intention of addressing this matter. A previous requirement have been made around care planning, whilst the majority of this requirement has been met, there is no evidence that residents or their representatives have been consulted about their care plans. The manager was informed that the commission may take further action. A previous requirement relating to medication had not been satisfactorily complied with and the manager was informed that the commission may now take further action. The home had three adult safeguarding issues since the last inspection relating to poor care which have been substantiated. Action has been taken to address errors and the home must continue to improve and monitor, through its own quality assurance, the standard of care provided to protect those living there. The dignity of residents was seen not to be wholly upheld, with residents seen wearing `bib` type protectors whilst having meals; and those people having their meals in their rooms not being provided with salt and pepper. Enforcement action has been taken against the home by the West Sussex Fire and Rescue Service. The outcome of this will be considered by the Care Quality Commission. Requirements made at this inspection include a requirement around care planning, employment of suitably qualified staff, dignity of residents and medication. Key inspection report Care homes for older people Name: Address: The Gables Nursing Home 56 Ifield Green Crawley West Sussex RH11 0NU     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Elizabeth Dudley     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 36 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: The Gables Nursing Home 56 Ifield Green Crawley West Sussex RH11 0NU 01293552022 01293528001 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Excel Care Homes Ltd care home 56 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 56. The registered person may provide the following categories of service only: Care home with Nursing - (N) to service uers of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - (OP) Dementia (DE) Learning Disability (LD) 1 Date of last inspection Brief description of the care home The Gables Care Home is registered to provide personal and nursing care for fifty-six residents. Excel Care Homes Limited privately owns the service and the Responsible Individual on behalf of the company is Mr K Indra. The home is located in Ifield Green, which is on the outskirts of Crawley. There is a car park to the front of the home. A local shop, post office and pub are close by. Bus services are available close to the home and Crawley town centre and other amenities are approximately 10 minutes drive away. The home consists of a two-storey building, the majority of the resident s rooms are situated on the ground floor, and those rooms Care Homes for Older People Page 4 of 36 0 0 Over 65 0 0 Brief description of the care home on the first floor are accessible by a passenger lift. An enclosed garden is in the centre of the premises; residents rooms surround this. A pleasant garden with a lawn, shrubs and flowers is to the front of the premises. The fees currently being charged by the home are £558.30 to £968.30 per week. This does not include extra services such as chiropody and hairdressing and details of the charges for these can be obtained from the home. Care Homes for Older People Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This key unannounced inspection was undertaken on 15th January 2010 from 07:15 to 16:00 by two inspectors; the lead inspector and a specialist pharmacy inspector, and was facilitated by the appointed manager of the home. No Annual Quality Assurance Assessment (AQAA) was requested on this inspection due to it being the second key inspection this year. The AQAA is a document required by regulation, in which the provider or manager sets out what has happened during the previous 12 months, including any improvements made and their plans for the next 12 months. A random inspection also took place on the 3rd November 2009 to check compliance with statutory requirement notices imposed by the Care Quality Commission to address previous requirements not complied with. The home has not been admitting residents since the last key inspection. Care Homes for Older People Page 6 of 36 Methods used to reach the judgements made in this report included examination of documentation such as care plans, medication documents, staff training and personnel files and other documentation required for the smooth running of the home and wellbeing of the residents. All residents living in The Gables were seen and spoken with during the day, and in depth conversations were held with six residents and four visitors about life in the home and how it was meeting their expectations. Seven members of staff were also involved in the inspection and their views have been used towards forming the judgements. All areas of the home were seen, including residents private accommodation. Prior to the inspection the Care Quality Commission sent out questionnaires to ten residents, ten members of staff and four health and social care professionals. Responses to questionnaires were received from six residents or their representatives and two health and social care professionals. No staff have responded at the current time. The information gained from these surveys has been used in assessing the services provided by the home. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? Improvement has taken place across all areas of the home in the past few months. All the requirements, with the exception of one requirement not complied with in full, made at the last key inspection have been met. The standard of care planning has generally improved and although care plans seen required evidence that they have been formed in consultation with the resident or their representative and require to be more person centred, care plans show that residents needs have been assessed and the required care documented. The home has continued to increase its staffing levels and the manager said that staffing levels will continue to be assessed in line with the needs of the residents and not only by the number of residents in the home. All staff now receive formal supervision which ensures that residents receive their care in line with the homes policy. Arrangements are in place to ensure that Regulation 26 visits take place (visits and reports about the services offered by the home, undertaken by either the provider or their representative, which are required by regulation to take place on a monthly basis). Care Homes for Older People Page 8 of 36 Routines at the home are sufficiently flexible to enable residents to choose their daily routines and how they wish to spend their day. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 36 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient information is available to enable prospective residents to make a decision about whether the home can meet their needs. The admission process was not able to be assessed at this inspection Evidence: Both the Statement of Purpose and Service User Guide have been fully reviewed and are generally compliant with regulation. Minor amendments were discussed with the manager. The Service User Guide has been produced in a format suitable for the use of the people living in the home and gives information on how to access the services offered by the home. All residents, irrespective of how they are funded, receive a copy of the homes Terms and Conditions of Residence following their admission to the home. Care Homes for Older People Page 11 of 36 Evidence: The home has not admitted any new residents since the last inspection therefore the standard of preadmission assessments, which are formed when the manager assesses prospective residents to ensure the home can meet their needs, was unable to be assessed. This will be addressed at the next inspection. The manager stated that any prospective resident will receive a full preadmission assessment undertaken by herself or a senior member of nursing staff, to ensure that the home can meet their needs. She said that prospective residents and their representatives could visit the home and meet the residents and all prospective residents will receive written confirmation about whether the home will be able to meet their needs and admit them to the home. The home admits residents for permanent and respite care but not for intermediate care Care Homes for Older People Page 12 of 36 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of care planning needs further attention to thoroughly identify the needs and wishes of the residents along with a record of outcomes of any care given, including for as required medication. Risk assessments for nursing equipment are not always sufficiently in depth to ensure all risks are managed to ensure residents safety and wellbeing. Residents requiring mental health care, dementia care and end of life care may not always have all their needs met. Some areas around administration of medication need further attention to ensure the safety and wellbeing of residents. Evidence: There have been substantial improvements in the quality of the care planning affecting the care of residents in the home. Care Homes for Older People Page 13 of 36 Evidence: A sample of six care plans was examined. All care plans had planning in place to address the health, psychological and social needs of the residents. End of Life care had not been planned for in the majority of care plans. Care planning included continence care, nutritional care, wound care and mental health needs. Each care plan had specific day and night care plans. Staff should ensure that residents preferences continue to be included in the day and night care planning. Mental capacity assessment is not carried out routinely on all residents. With the exception of one of the six care plans examined, all had been reviewed on a regular basis, these did not all show that the findings of review were incorporated into the main care planning, and it was noted that changes to the residents condition and any changes in care given to address this were recorded in the daily records and was not always transferred to the care planning. None of the care plans examined showed evidence of consultation with the resident or their representative regarding the whole of the care plan. The current care plan formatting, which is of a commercial pre-populated type, does not have a specific place where consultation can be evidenced and this has been previously discussed with the manager. This should be included for every resident. Consultation with residents and their representatives formed part of a requirement made over previous inspections; therefore the home was given warning that the commission may take further action. There was evidence of clear instructions for care staff in the majority of the care plans viewed, and care staff said that they have a handover and are encouraged to read and familiarise themselves with the individual care plans. Not all care plans were sufficiently personalised to ensure that the care given to residents suited the individuals preferences. Minor inclusions to some, (but not all), care plans were required to ensure that staff receive full information, these were namely the size of hoist slings to be used and the sizes of incontinence aids used. Risk assessments relating to the use of hoists, bedrails, pressure beds and any other equipment used by the resident were in place. However these needed to be more Care Homes for Older People Page 14 of 36 Evidence: detailed relating to the risks involved and also how the risks are to be managed i.e. one hoist assessment said risk of falling from hoist but did not give details of how this risk would be managed. Bedrail risk assessments did not address the risks involved in the use of bed rail bumpers (this was the only pre populated risk assessment, and did not include bed rail bumpers) but staff had not thought to address the risk of bed rail bumpers separately. Currently registered nurses are not meeting their responsibility of assessing the risks to the residents in their care in a robust manner, or being proactive in recognising risks. There was evidence in the care planning, and on the day of inspection, of other health care professionals including general practitioners, community psychiatric nurses and speech and language therapists being usually brought in as required. However concerns were raised with the manager that one specific resident had not had suitable interventions from mental health care professionals although this had been identified at previous inspections. Two surveys received from health care practitioners commented on the lack of communication between some staff, one saying At times the doctors visit and not all members of staff are aware of the reason for the visit. Another said: (There needs to be) A more cohesive approach with better handover of information, there tends to be a void when people go off duty and people coming on shift dont know what is happening. This was refuted by the manager. Resident and their relatives spoken with and surveys received, showed that generally they were happy with the care given to residents receiving general nursing care: The Gables gives unconditional care and attention both mentally and physically. They look after us very well, I have no complaints and can do things at the times it suits me, staff are very nice and very kind. Comments received from relatives visiting residents with mental health problems said I wish there were more staff who knew about dementia care as they only have one registered mental nurse on and she is now working elsewhere so is not here regularly, the staff dont really know about dementia people and dont know how to deal with them properly. I am happy with the basic care and (resident) is happy, but they do not really understand dementia care here, the staff dont understand what these people need. One incident taking place in the EMI unit was dealt with well by the mental health nurse and she also showed she understood the needs of the resident, consulted with the manager and appropriate arrangements were put in place, however other staff Care Homes for Older People Page 15 of 36 Evidence: appeared to unsure of what to do. Likewise the mental health care plans written by this member of staff gave clear instructions for staff and addressed the needs of the residents, but not all residents in this unit had such comprehensive care planning, especially around holistic care needs. The home employs only one mental health nurse who has speciality training in dementia and this nurse is only working part time, further mental health specialised staff are required for this unit to run in a manner which meets the needs of the residents. Concerns were raised with the manager that the knowledge of the staff was insufficient to care for older people with mental health conditions. Subsequent to the inspection the commission was informed that the manager is in the process of recruiting registered mental health nurses with dementia care knowledge to work in the unit, and the commission awaits confirmation that these posts have now been filled. Records kept in residents rooms showing care and nursing interventions, mattress pressures and fluid charts, were satisfactorily completed and up to date. The data gained from various charts was not always being used to influence nursing decisions or inform care. i.e. fluid charts although totalled to show the intake over a day were not followed up with care planning to ensure that actions were put in place to address any deficit. Likewise revised information ie pressures of electric mattresses were not revised in the care plans therefore giving incorrect information to staff. Residents in all areas of the home looked well presented and comfortable. Subsequent to the inspection the manager informed the commission that a specific resident exhibited behaviour which disturbed other residents and could not be sat out in the main lounges, however their room was not sufficiently large enough to accommodate the specialised seating required. This resulted in the resident spending the majority of the time in bed. The home has not been proactive in addressing this and is therefore not meeting this residents needs. The pharmacist inspector visited the home on the day to assess medicine management in the service. We watched morning medicines being given. This involved two separate rounds by qualified nurses. The procedure used followed safe practice. Medicines given via a PEG tube (endogastric tube) were managed well. Staff had clear guidance on which medicines can be crushed before giving. There were unlabelled creams for use after washing in several residents rooms. Care Homes for Older People Page 16 of 36 Evidence: Creams for external use must be labelled and used for the same person to reduce risk of cross infection. On the MAR charts it was noted that when creams are used the record is made with a tick. This does not indicate who applied the cream or who ensured that the cream was applied. Nursing Staff should take accountability for their work and this must be indicated by records including their initials. This includes initialling the medicines record when they have delegated a task such as care staff applying cream after a wash. It was also noted that when medicines were prescribed as a variable dose the actual amount given was not always recorded. Staff must complete records and ensure that they are accurate to give a clear picture of medicine had. All medicine administration records (MAR) charts were examined. The files included information such as sample signatures, photos, and a short profile on the resident e.g. swallowing problems etc. Care plans were seen for prescribed medicine for individuals, to be taken only when needed. These did not cover sufficient detail to give staff guidance on when to give this medicine for consistency. When asked, the manager showed us a sample template done for staff indicating the level of detail to go into the care plan but care staff had not followed her template. The home has introduced additional documentation to record when a medicine is given only if required. This record is not always filled in by nursing staff. This was identified at a previous inspection and has not been addressed fully. There should be a clear audit of the decision making and the outcome achieved for giving medicine that are prescribed to be given only when needed. For one resident we saw a specific medicine in the trolley which was not on the MAR chart, although in the care plan for this resident there was a record of the condition the person was suffering from which would require this medicine (only when needed). We checked the previous cycle of Medicine Administration Record chart and this medicine was not on the chart. The need for this medicine must be reviewed by the doctor and if prescribed to be included on the MAR chart so staff are aware that it is prescribed. A Controlled Drugs check showed on two pages a balance after destroying that medicine. The balance left should read zero. Nursing staff must have clear understanding on how to record information in the Controlled drugs register. The home has no end of life care planning, residents wishes for resuscitation or preferred place for end of life care, and little evidence of discussion about this with Care Homes for Older People Page 17 of 36 Evidence: residents. Staff have recently received some training for end of life care but this specific training is not sufficiently detailed enough for registered nurses. The manager said that she will not admit residents specifically requiring end of life care until training is in place. However existing residents may require the nurses to have this knowledge and to be able to put this care in place without undue reliance on health care professionals from the community. Therefore end of life care planning should be commenced. Care Homes for Older People Page 18 of 36 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are able to enjoy a variety of activities which are planned around the individuals interests. Routines around the home are sufficiently flexible to enable residents to arrange their day according to their preferences. Staff were not always being proactive in considering residents dignity regarding some aspects of care in the home. The home provides a varied and nutritious menu and the majority of the residents said that they enjoyed the meals provided. Evidence: The employment of a full time activities coordinator over the past few months has resulted in the compilation of an activities programme offering a range of activities including art, cookery, crafts, gardening, music, quizzes and other games. The coordinator has been assessing residents individual interests, forming social care Care Homes for Older People Page 19 of 36 Evidence: plans and keeping full records of their participation. Some one to one sessions take place with people unable to leave their rooms, and this was evidenced in their care plans, however with only one activities coordinator this aspect of interaction was taking place infrequently. Discussions were held at the random inspection with the provider regarding this and the possibility of training and involving care staff in activities. Concerns were raised with him that people with dementia and other related conditions need substantial interaction and stimulation particularly if they are unable to leave their rooms. This has not yet been addressed. A survey received stated: The home could have more staff to spend more time with people who are unable to get out of their rooms, as the only time they see anyone is when they have care or are fed. A visitor to the home made comments in a similar vein: There are some people that you never see in the lounges and they are always alone in their rooms with the television for company. The home had Halloween and Christmas parties and has brought in carol singers and musical entertainers. Outings are being planned. At the random inspection, nursing staff expressed their satisfaction at how this programme is progressing and the benefits evident in the residents, saying that They are more alert. Residents said that they look forward to the activities sessions. I really enjoy the activities provided, there is always something interesting going on. Visitors said that they can visit at any time and are made welcome by the staff. Relatives of residents confirmed that they are kept up to date with any concerns or issues involving their resident and that residents and relatives meetings are held regularly. They said that they are invited to participate in the life of the home and can attend events held. Ministers of religion visit the home and a church service is held at intervals. The manager has information on various faiths and said she can access different ministers of religion dependant on residents requirements. Observations during the day, care plans and discussion with residents showed that the routines within the home are sufficiently flexible to enable residents to plan the day according to their wishes. Residents said: I please myself what time I get up and dressed and have a drink when I want, its up to me if I want to join in with things and if I dont want my dinner at the time, I can have it later. We have choices about Care Homes for Older People Page 20 of 36 Evidence: everything. The home provides a varied and nutritious menu which can cater for various dietary needs and residents preferences. Residents are offered two or more choices at each meal, and the chef will cook something different to the two choices on the main menus for those who want something different. Meals seen, including pureed meals, were well presented and of sufficient quantity. The majority of the residents take their meals in pleasant dining rooms but some residents prefer to have their meals in the lounges or their rooms. Tables in the dining rooms were attractively set out but it was noted that some of the trays taken to residents rooms did not have salt or pepper included. It was noted that many of the residents were provided with impermeable bib type protectors at meal times, whilst necessary to protect clothing this affects the dignity of the resident and there are other, more discreet, types of protector available. The majority of residents spoken with said that they enjoyed all the meals provided by the home. One survey received stated We could have plain English cooking including grilled fish or meat and a resident said We have too much foreign food. Examination of the menu showed that there were very few non English dishes offered and several of the residents said that they enjoyed a curry or pasta when it was offered. A relative of a resident who is not of British origin said that They dont give (resident) our kind of food because (resident) has dementia and doesnt recognise food, but (resident) enjoys our food when at home, they do provide bananas in the morning which we requested. Another relative of a resident who often joins the resident for meals said: Ive never had a bad meal here. Residents confirmed that they could have snacks or beverages when they asked for them and there were bowls of fruit in the lounges, with staff taking extra fruit round at tea time, homemade cake is also offered at tea. Care Homes for Older People Page 21 of 36 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are comfortable with making their concerns known to management and that these will be addressed in a transparent manner. Staff are aware of their responsibilities to safeguard those in their care Evidence: There is information about making complaints in both the Service User Guide and Statement of Purpose and the complaints policy is displayed in the home. However some residents spoken with, and one survey received showed that not all residents were familiar with how to make a formal complaint but would be comfortable talking with the manager or staff about any concerns they may have, and were confident that these would be addressed in an open and transparent manner. There has been one minor concern since the last inspection which the manager addressed in a satisfactory manner. There have been five adult safeguarding issues since the last key inspection Three of these regarding poor care have been substantiated, one not substantiated and one not taken forward. Care Homes for Older People Page 22 of 36 Evidence: Actions have been put in place to address the issues substantiated and to prevent their reoccurrence; and the home must continue to improve the standard of care providedand monitor this through its own quality assurance in order to protect those living in the home. The majority of staff have attended adult safeguarding training. There were previously some queries around the adult safeguarding training programme used by the home but these have now been addressed. The manager and senior staff received safeguarding training from the local authority. Staff spoken with were aware of their responsibilities towards those in their care. Care Homes for Older People Page 23 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a clean and well-maintained home. Not all rooms are of a suitable size to meet the needs of specific residents. Evidence: All areas of the home are well maintained and pleasantly decorated. Residents have access to communal accommodation which includes a lounge, dining rooms and a garden. Due to floods in 2008/09 the home now has flood defences in place and night staff and key members of staff have received the necessary training in the use of these Residents accommodation consists of fifty two single and two double rooms. Although not all of the rooms have en suite facilities, the provider states that they are planning to provide these to some ground floor rooms. Some ground floor rooms in the dementia unit are not sufficiently large enough to meet the needs of specific residents. The hot water temperatures to residents outlets have been monitored on a regular Care Homes for Older People Page 24 of 36 Evidence: basis and records showed that these were within recommended parameters. Window restrictors were in place throughout the building and were patent. The EMI area is separated by a door, which is locked by keypad, although there are some residents with mental health conditions in the rooms adjacent to the unit. Discussions were held with the manager at the last inspection about the necessity of ensuring that people living within this unit had Deprivation of Liberty Safeguarding assessments if required. To an extent this has taken place, however residents must be observed when first admitted to this unit for any indication that this may not be in their best interests. The home provides a range of equipment, including nursing beds and hoists, to enable residents to maintain their independence. Some residents still have divan beds as opposed to variable height beds; this could impact on staff safety in the event of the resident requiring to be nursed in bed. The home was very clean and staff were wearing disposable aprons and gloves for care tasks and separate protective aprons when entering the kitchen. Alcohol gel is provided throughout the home. An inspection by the Environmental Health Authority took place on the 26th October 2009 and the kitchen was awarded four stars as part of the Scores on Doors initiative Infection control policies have been reviewed and infection control training is in progress for staff with 15 of the staff having attended this. Recent power cuts left the home without electricity on four occasions recently. The manager ensured that the necessary arrangements were in place for the comfort of residents and arranged to hire a generator, which arrived too late to be used. The home has addressed the power cuts with their power supplier. Whilst the CQC has no records of being informed of these power cuts the manager has produced evidence that information was sent. Care Homes for Older People Page 25 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst staffing levels have been increased, the geography of the home makes it difficult to locate staff when required and this could impact on residents care. Staff are receiving ongoing training to meet the needs of the residents in the home, however the level of training in mental health, dementia care and end of life care, is insufficient to meet residents needs. Evidence: Staffing has been increased in recent months, and now the home has sufficient staff to meet the needs of the residents currently in the home. The manager has stated that she intends to increase staffing according to the needs of the residents, as opposed to increasing them only when numbers increase. Staff spoken with, which included both day and night staff, said there were sufficient staff on duty to ensure the care of the residents in the home and they did not feel rushed or felt they had to rush care. Care was seen taking place in an unhurried manner and residents and staff appeared relaxed. There are two members of staff in the EMI unit at all times of day and night. Care Homes for Older People Page 26 of 36 Evidence: Some surveys and relatives said that there were still insufficient staff in the lounges during the day. It was observed that there was not a member of staff in the lounge at all times of the day, but this was for short periods only apart from busy times of the day such as early morning. The manager should ensure that there is a member of staff in the lounge at all times. The geography of the home means that staff are not always visible in all parts of the home; and relatives and residents stated both face to face and by survey that it is sometimes difficult to locate staff and this was apparent during this day. Induction training takes place for new staff, the home is commencing the Skills for Care recognised induction training for new members of care staff, although registered nurses continue to be inducted using the homes own induction course. A recent training matrix showed that 99 of the staff have attended mandatory training including moving and handling and fire training, actions are being taken to ensure that the 1 of staff not having received this will undertake it, or will face disciplinary action. There are still some new staff and bank staff requiring to undertake a full safeguarding training although a basic safeguarding training is included in induction. All catering staff have a current Food Hygiene Certificate and there was evidence that housekeeping staff have received training on the control of substances hazardous to health, (COSHH). Ancillary staff also receive moving and handling and fire training. A recent visit by the fire services has resulted in senior staff being required to take in depth fire training courses. There are currently 23 care staff working in the home excluding registered nurses; ten of these staff have attained the National Vocational Qualification in Care at levels 2, 3 or 4. A further 9 members of staff are currently studying for this qualification at level 3. Other training in care matters is ongoing. Some staff have attended a one day course in dementia care, the manager recognises that this is insufficient for the needs of the residents in this home and is looking for more in depth courses for staff. Staff have also undertaken a distance learning course in End of Life care, and it is necessary for the registered nurses to undertake further training as they will be leading the care. Care Homes for Older People Page 27 of 36 Evidence: Three personnel files were examined these showed evidence of robust recruitment systems with all checks as required by regulation taking place. Care Homes for Older People Page 28 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Considerable efforts have been made by the manager and improvements have taken place throughout the home in relation to improved safety and welfare of the residents that live there. These must continue to improve and be monitored through the homes own quality assurance to ensure the standard of care provided, in order to protect those living in the home Concerns noted by the West Sussex Fire and Rescue Services have resulted in the fire authority undertaking enforcement action to further ensure the safety of residents. Evidence: The appointed manager has been in post for ten months, is a registered general nurse (level1) and has past experience of managing homes. She is in the process of applying for registration with the Care Quality Commission. The manager has attended training regarding Deprivation of Liberty Safeguarding (DOLS) and the Mental Capacity Act (MCA). Deprivation of Liberty Safeguarding Care Homes for Older People Page 29 of 36 Evidence: referrals have been made on two residents in recent months. The manager was reminded that the CQC requires a regulation 37 (incident report) when residents are referred to a best interests assessor. An AQAA ( Annual Quality Assurance Assessment, a document required by regulation which informs the commission about what has happened in the home in the past twelve months and what is planned for the future) was not required for this inspection as this is the second key inspection in a year. Staff, residents and relatives made positive comments about the improvements that have taken place in the past few months. The commission will expect that improvements made will be sustained and expanded upon and embedded within practice in the home, and this will be checked at further inspections. The home is sending out satisfaction surveys to residents and their representatives to gain their views on services provided by the home. Residents and representatives meetings are taking place at bi monthly intervals and minutes of these were available. Staff meetings have also been taking place and these are expected to continue on a bi monthly schedule or more often as required. The home does not become involved in residents financial matters or keep any money for residents. Regulation 26 visits and reports are now taking place (Reg26 visits and reports are required by regulation to be undertaken by the provider to ensure that the home is providing care and services).These have taken place at regular intervals and action plans were in place to address any points raised. All staff have been receiving formal supervision sessions at intervals prescribed by the National Minimum Standards. Risk assessments are in place throughout the home and those done for the home in general were robust. The fire service visited the home in January 2010 and made some requirements but the CQC is not in receipt of this report at the time of writing. The majority of staff (99 ) have now received mandatory health and safety training and there was no evidence of any health and safety breaches within the home. Some staff have still to receive safeguarding training, these are either new staff or bank staff and the manager is currently setting up training for these members of staff. Accident and incidents records were examined and the commission has received Regulation 37 reports (accident and incident reports) as applicable. Care Homes for Older People Page 30 of 36 Evidence: Recent power cuts left the home without electricity on four occasions recently. The manager ensured that the necessary arrangements were in place for the comfort of residents and arranged to hire a generator, which arrived too late to be used. The home has addressed the power cuts with their power supplier. Whilst the CQC has no records of being informed of these power cuts the manager has produced evidence that information was sent. Recent visits by the West Sussex Fire and Rescue Services has resulted in enforcement action under their legislation, the outcome of which will be considered by the commission. The provider must be proactive in ensuring the safety of the residents in the home. Care Homes for Older People Page 31 of 36 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 9 Reg 13(2) To have current medicine treatment profile for residents. Staff must follow the homes own procedures and complete records of medicines given accurately. 01/02/2010 Care Homes for Older People Page 32 of 36 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 10 That registered nurses 30/04/2010 currently employed receive specific training relative to their role in end of life care. That dementia training provided to current staff is sufficiently in depth to give them sufficient knowledge to meet the needs of service users. That registered mental health nurses, and other staff with knowledge of dementia care and the relevant experience are employed by the home to ensure that the needs of the service users are met. To enable all service users to receive the highest possible standard of care. 2 7 13 That risk assessments for 01/04/2010 the use of bed rail bumpers are put in place and that risk assessments involving equipment used in the Page 33 of 36 Care Homes for Older People 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 nursing of service users include ways in which the risk is to be managed . To ensure the safety of service users. 3 10 12 That all aspects of services offered by the home take into account the need to maintain the dignity of the service users. To ensure that service users dignity is maintained in a manner that they would expect. 4 12 16 That sufficient activities and social interaction are given to those service users who do not leave their rooms .To ensure that all service users receive the same opportunities. 5 23 23 The registered person 28/02/2010 ensures that the size of the rooms allocated are sufficient to meet the needs of the individual service user .To ensure that service users are enabled to lead a life which meets their needs. 28/02/2010 28/02/2010 Care Homes for Older People Page 34 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 6 38 13 That the provider ensures that actions are taken to comply with enforcement action regarding fire legislation .To ensure the safety of service users, staff and visitors to the home. 01/04/2010 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 Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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