Care Home: The Limes

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What the care home does well There are good pre-admission assessments ensuring peoples needs are fully known and can be met. People visit the home wherever possible prior to admission so that they can make a judgment about the suitability of the home for them. This also allows a more detailed assessment of the persons needs. There is a relaxed atmosphere. Visitors say they are welcomed and feel comfortable in the home. Many visitors were seen arriving during the inspection, several are daily and some very regular visitors. The home is maintained to a high standard, with a programme of redecoration, refurbishment and improvement. There are a number of lounges and recessed areas where people can sit together in small groups or alone if they wish. There is a recessed area on the first floor that is quiet and comfortable where people can sit or receive visitors in private if they do not wish to use their bedrooms. Bedrooms seen were well decorated and furnished and personalised to reflect individuality. There appears to be an open, ongoing dialogue with the owners of the home. They visit regularly, hold regular meetings with the homes Managers and Regional Manager and have a formal agenda and recorded minutes. The impressions is of good transparent and easily accessible management. What has improved since the last inspection? Changes made to reorganise the communal lounge and dining areas have improved the inclusion of people in the daily running of the home and provided greater stimulation. Staff are able to monitor people more closely. There has been a new approach to providing activities with the appointment of a new Activity Coordinator. A better assessment of peoples social, emotional and recreational needs has provided the basis for a wider range of activities to meet those needs. As well as small group activities, more individual 1:1 input is now provided for people unable or unwilling to engage in a group. This change is new but the signs are very positive. Management, staff and providers are keen to promote and support the changes. Some improvements have been made in the recording of medication administration, although other shortfalls have been identified as a result of this inspection. The Medication systems is now audited on a regular basis by the Manager, ensuring that standards, accuracy and safety are maintained. What the care home could do better: Footplates must always be used on wheelchairs when transporting people in the home. This will ensure their safety. The medication trolley must be removed from the storage area adjacent to the toilet area. This will reduce the risk of potential cross-infection. The care planning format is being replaced and will include more detailed plans on a person centered basis relating to health and personal care needs. This will give staff the necessary information to meet peoples assessed needs. People in the home, their relatives or representatives where appropriate, should be involved in compiling care plans and be part of the review and changes to update them. The home need to improve the lines of communication with relatives involving them and informing them of progress being made. Participation and involvement is part of the care process. This will also allow them the opportunity to raise any concerns they may have. Medication required to be stored as controlled drugs, must be secured in the controlled drugs cabinet. There must be clear instructions for staff applying prescribed creams. They must have clear instructions about the creams to be administered, when, where and how often they should be applied. Staff should sign to confirm creams have been administered. This does not have to be on the MAR sheets but can be a record kept in bedrooms where creams are stored if that is more convenient. Key inspection report Care homes for older people Name: Address: The Limes Glebedale Road Fenton Stoke-on-trent Staffordshire ST4 3AP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Peter Dawson     Date: 1 6 0 3 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 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: The Limes Glebedale Road Fenton Stoke-on-trent Staffordshire ST4 3AP 01782844855 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Limes Fenton Ltd Name of registered manager (if applicable) Mrs Terrina Ann Willshaw Type of registration: Number of places registered: care home 41 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 41 The registered person may provide the following category of service only: Care Home Only (Code PC); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 17 Old age, not falling within any other category (OP) 41 Physical disability (PD) 10 Date of last inspection Brief description of the care home The Limes residential home is located in Fenton, Stoke-on-Trent, close to local facilities and in walking distance of shops and the local library. The Home provides care and accommodation for up to 41 older people some of whom may have dementia or a Care Homes for Older People Page 4 of 30 0 7 0 4 2 0 0 9 17 0 10 Over 65 0 41 0 Brief description of the care home physical disability. The home has both single en-suite and double bedrooms. The communal areas included a very pleasant conservatory and a number of lounge/seating areas on both the ground and first floors. The Home had a main dining room and other mixed sitting and dining areas. The car park is situated to the rear of the property and has adequate parking space for staff and visitors. There is a small area of garden to the rear of the property. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection of this service was on 7th April 2009. The quality rating awarded was 1 Star - Adequate This Key inspection was carried out by one inspector on one day from 08:30 - 18:30. The inspection assessed compliance with the National Minimum Standards for Older People. The inspection was unannounced so neither the home nor the provider knew we were coming. The Registered Manager was present throughout the inspection and we were joined later by the Regional Manager and the two Directors. We were able to feedback to them all at the conclusion of the inspection. The inspection included a review of information given in the Annual Quality Assurance Assessment (AQAA), this is a legally required document and provides information about current service provision in the home. It also provides us with some statistical information. Care Homes for Older People Page 6 of 30 During the inspection we followed the experiences of some people living in the home. We looked at their care records, where possible had conversations with them and their families and we observed how they interacted with staff and how their needs were being met. We spoke with 10 people using the service and 3 people (relatives) visiting them. We spoke with staff on duty throughout the day, they all expressed a positive commitment to people using the service. We had access to all records in the home including: care plans, risk assessments, staff rotas, staff files, medication records, complaints records and other documents relating to the inspection process. We inspected the communal areas of the home and a small sample of bedrooms. Care Homes for Older People Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: Footplates must always be used on wheelchairs when transporting people in the home. This will ensure their safety. Care Homes for Older People Page 8 of 30 The medication trolley must be removed from the storage area adjacent to the toilet area. This will reduce the risk of potential cross-infection. The care planning format is being replaced and will include more detailed plans on a person centered basis relating to health and personal care needs. This will give staff the necessary information to meet peoples assessed needs. People in the home, their relatives or representatives where appropriate, should be involved in compiling care plans and be part of the review and changes to update them. The home need to improve the lines of communication with relatives involving them and informing them of progress being made. Participation and involvement is part of the care process. This will also allow them the opportunity to raise any concerns they may have. Medication required to be stored as controlled drugs, must be secured in the controlled drugs cabinet. There must be clear instructions for staff applying prescribed creams. They must have clear instructions about the creams to be administered, when, where and how often they should be applied. Staff should sign to confirm creams have been administered. This does not have to be on the MAR sheets but can be a record kept in bedrooms where creams are stored if that is more convenient. 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 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Adequate information about the home, together with good pre-admission visits and assessments ensure successful placements. Evidence: Information about the home is readily available in the reception area, in the form of the Statement of Purpose and Service Users guide. These have been updated since the last inspection and reviewed against the homes commitment to diversity, valuing people and ensuring equality of opportunity. The information is comprehensive allowing people to make a judgment about the suitability of the service for them. An assessment is carried out by senior staff when admissions are being considered. People are either seen in their current environment or spend some time in the home on a day visit, allowing a more pertinent assessment of the service by the person and also by staff at the home. The pre-admission documentation has been further enhanced to give more in depth information. This includes a more lifestyle-based Care Homes for Older People Page 11 of 30 Evidence: social history. A multi-agency assessment is carried out, usually for people funded by the local authority. This is obtained prior to admission and together with the homes own assessment provides the basis for the initial care plan. People funded by the local authority have a written contract provided by them. Those funding their own care have a contract provided by the home. These were not seen on this inspection, however all people have a short Terms & Conditions document summarising the rights of both parties. There is a 6 week settling in period after which a meeting is arranged to include the person using the service, relatives, social worker and home staff. Permanent residence, if agreed is usually confirmed at that meeting. During the settling in period we feel that improved communication with family and others is necessary to ensure any initial concerns or problems are identified, discussed and resolved. An example of this is given in the next outcome area of this report. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements made to care planning information and medication practices will ensure peoples health and personal care needs are met. Evidence: Care plans are based upon assessed needs. Improvements to care planning information were previously needed. It was identified at the last inspection that improvements had been made although there were still some identified shortfalls. On this visit we looked at 4 care plans for people recently admitted and some resident for some time. We found some shortfalls in the information about personal care needs highlighted in questions raised when we spoke to visitors. They included questions about retiring times, oral care and aspects of personal care including a lack of regular shaving. Unfortunately the care planning information did not identify and provide answers to the questons. This was due in part to the care planning format that did not identify these aspects of care. The system is not person centred. The home is presently in the process of replacing the care planning format. This is Care Homes for Older People Page 13 of 30 Evidence: being piloted in another home in the group and should address many of these issues identified. Some aspects of care planning information were good. We saw pertinent information about medical diagnoses and aspects of health care including nutritional assessments and needs, waterlow assessments to identify risk of pressure damage. We looked at the care and records of a person who has been on and End of Life Pathway and found that good care with support from the nursing service had resulted in an unexpected recovery. A specialist bed had been provided, the person also turned in bed 2 hourly throughout the 24 hour period and a food and fluid intake chart, all well documented and charting the progress being made. Pressure areas had healed and clearly good care had been the basis of improvements in the persons condition. The wish of the person and her family to remain at The Limes were being supported. Some information in the care plans seen needed updating/change. A person previously insulin dependent but refused this for sometime was still referred to as insulin dependent throughout the information seen. This person refused blood sugar level and other tests, although this had been recorded and a plan to monitor the change was in place. The relative of this person who visits daily, was spoken with during the inspection and expressed satisfaction with the care of her mother at The Limes over the past 2 years. We saw Mental Capacity Act assessments in place for all. It was interesting to see in relation to a recently admitted person that the multi-agency assessment had stated the person did not have capacity. The homes own assessment, with the benefit of 24 hour care, indicated that the person had capacity to make decisions. Unfortunately the multi agency assessment about capacity had been copied into the care plan giving both views. We saw that people were weighed regularly and several weighed weekly where there were concerns about weight loss. We saw minimal weight loss recorded in the care plan of the person with diabetes mentioned above, but there had been a referral to the dietician because of changes in eating habits. Risk assessments were in place for moving and handling and falls and other daily risks. Care plans and risk assessments were generally reviewed on a monthly basis within the home. Care Homes for Older People Page 14 of 30 Evidence: Overall, we found that some further improvements in the quality of care plans had been made. Further improvements are somewhat restricted by the care planning format that is due to change to a more person-centred individual plan. Daily notes recording the support given and wellbeing of the person were adequate. Some recording by night care workers was minimal, comments included slept well and no problems this could be improved. A visiting relative said she had informed staff 2 days prior to the inspection that her recently admitted relative was constipated - a pre-existing condition. The relative had requested medication to resolve this problem. When visiting during the inspection the relative was told that this had not been given but would be given upon his return from the outing with his family. There was no record in the daily notes 2 days previously of the request/concern or evidence of any follow-up. We identified that the person does have a prescribed laxative to be given as required, but unfortunately the MAR (Medication Administration Record) sheet did not clearly record this being given in the instance outlined. We looked at the medication system in place. We found that there were no gaps on MAR sheets - identified in the last report. There was an audit trail in records to check medication in stock at any point in the medication cycle with a reducing count of all medication administered. We were told that all prescribed creams are kept in peoples bedrooms for ease of use, the MAR charts not signed. Records can be kept in bedrooms also but need to be prescriptive about which cream is administered, when, where and how often. Some people have several prescribed creams and their individual use must be detailed. We did see that eye drops opened had not been dated when opened (limited life of 1 month from opening). This applied to only 1 item and we were told that all eye drops are disposed of at the end of the monthly medication cycle. All medication returned to the pharmacy is listed and countersigned by the pharmacy. We noted that night sedation classed as a controlled drug for storage purposes was not stored in the controlled drugs cabinet. This should be done. The home have 3 medication trolleys one was stored in a cupboard only accessed through a toilet area. This must be re-sited to reduce potential contamination/infection from this high risk area. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have opportunities to make choices about their life. A new approach to activities is improving quality of life for people. Improving communication with relatives will also bring improved quality of life. Evidence: At the time of the last inspection we had some concerns about the range of activities available for people, particularly those with dementia care needs. Since that inspection there has been some re-arrangement of the lounge/dining areas. This means that people are now more involved in the daily events in the home. Some previously sat in the more remote communal areas and lacked ongoing stimulation and supervision. During this inspection we found quite a vibrant atmosphere with many visitors arriving throughout the day. They engaged with many people, other than those they specifically had visited. The 3 lounge areas, conservatory and main dining area are located fairly centrally on the ground floor with small break-out areas where people can sit and have meals. Several are inter-linked and mobility within the groups is easy. Since the last inspection a new Activity Coordinator has been appointed. She has been Care Homes for Older People Page 16 of 30 Evidence: in post for 4 months working 15 hours per week. She has established activity records for each person based upon social history and records of interests, hobbies and skills. Records show each persons involvement in activities in the home. The range of activities is tailored to the needs of the individual. She has moved from group activities to small group and individual activities - an example being her input into a person being cared for in bed by means of 1:1 discussion and engagement and stimulation both verbally and visually. We saw a small group of people involved in a quiz others involved in reminiscence based interactions. This is a very positive move, the Activities Coordinator is highly motivated and very keen to extend the range of activities both internally and externally. Activities are now geared particularly towards people with dementia care needs. Additional hours are needed and the providers who are pleased with the results are considering additional hours for this purpose. We spoke with 3 visiting relatives on the day of the inspection. They all said that they were made to feel welcome and felt comfortable and free to move around in the home. Some positive comments were made about the service, but some matters were raised that need to be pursued by the home. The relatives of a person admitted 6 weeks prior to the inspection raised some concerns about a range of issues involving: dental and chiropody appointments, missing clothing and hearing aid, lack of shaving and inaction about constipation. They said that they had not been involved in establishing and reviewing the ongoing care plan. We discussed these issues with the home and it was agreed that people using the service and their relatives should be involved in establishing and reviewing care plans. It was also clear that there had not been ongoing consultation and involvement during the settling in period for this person. Clearly established lines of communication and explanation would have resolved many of the issues raised and changes could have been made to improve the service for this person. He has pride in his appearance and actions to ensure he maintains his preferred standards are vital to his ongoing wellbeing and self worth. This was discussed at feedback at the end of the inspection and the home will take steps to ensure involvement of relatives in care planning and establish regular opportunities for discussions with families, particularly in the initial settling-in period. We spoke with many people about the food provided at The Limes. They were all highly satisfied with the quality, quantity and choice of food. The mid day meal is 3 courses and there is a choice of main dish. We saw drinks and snacks readily served in the lounge areas throughout the day. We saw finger food available at lunch and at Care Homes for Older People Page 17 of 30 Evidence: other times for people unable to eat conventional meals, or for those on the move. Care Homes for Older People Page 18 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be sure they are listened to and their complaints taken seriously and investigated. Safeguarding procedures and training have highlighted for staff the importance of early referrals for investigation. Evidence: The complaints procedure is displayed in the home for people using the service and visitors. There is also a copy with the Service Users Guide, also available in the reception area. We saw that the home have received 4 complaints since the last inspection. All were dealt with swiftly and investigated immediately. Two were upheld, but all were responded to in writing within the required 28 days. Where complaints were founded the home quickly apologised to people in writing and outlined the actions they were taking to avoid repetition in the future. No complaints about the home have been received by us since the last inspection. Two safeguarding referrals have been made since the last inspection. One related to marks found on a person returning home after respite care. This was investigated under Safeguarding procedures and it was not ultimately possible to establish the actual cause or circumstances surrounding the allegation. Care Homes for Older People Page 19 of 30 Evidence: The other referral to safeguarding resulted in injury to a person following a disagreement between 2 people using the service. This referral was made 2 weeks following the incident and should have been made at the time. The home acknowledge this and have taken steps to ensure all staff have current information about the procedures to be followed in future if this occurs (the incident happened at weekend). All staff have been provided with training relating to the Protection of Vulnerable Adults. Care Homes for Older People Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is spacious, clean and pleasant providing a homely place for people to live. There is good ongoing maintenance of the building. Evidence: The home is clean and well decorated, presenting a homely, comfortable place. Visitors commented upon the homely feel to the home. Since the last inspection there has been ongoing maintenance and redecoration including new soft furnishings and carpets in some communal and bedroom areas. Additional air freshing units have been installed and liquid soap and paper towel dispensers installed in all the en-suite rooms. As a result of recommendations at the last inspection the main dining area has been relocated and other areas made into small lounge/dining areas. The AQAA states: this has had a positive reaction from our residents and ensure all residents integrate well and become more involved in the day to day activities. New signage has been provided for all toilet and bathroom areas to assist people with cognitive impairments. There is a patio area to the rear of the property and a pleasant separate lawned area. Unfortunately this area is not secure, meaning that people would have to be escorted by staff at all times, although the area would provide a place for people to sit and Care Homes for Older People Page 21 of 30 Evidence: move at will if it were secure. We looked at the main communal areas and a small sample of bedrooms. Bedrooms were adequately furnished and reflected the individuality of the people with many items personalising those seen. We did notice that some chairs in the lounge areas looked tired and need replacing. This would improve presentation and comfort. We brought this to the attention of the providers during feedback following the inspection. There are wide corridors allowing good mobility and wheelchair use. Aids and adaptations in toilet and bathroom areas promote independence for people using the service. Care Homes for Older People Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels must be continually appraised to ensure peoples needs continue to be met. More robust recruitment procedures will provide total protection for people using the service. Evidence: There are 5 care staff on duty during the day and 3 care staff on duty at night for 38 people living in the home. This is the minimum staffing level required to operate the home and meet to needs of people living there. Dependency levels obviously change and we were told that some people were currently being re-assessed to determine if they needed higher levels of care, such as may be provided in nursing care. It is a matter for the home to state whether the needs of those people can be met in this setting. There was an example of a person being cared for in bed with quite high dependency needs with input from the nursing service. The home were continuing to meet this persons needs, although the views of the District Nursing Service may be different. The family certainly wish the person to remain in the home. The difficulty with minimum staffing levels is that if dependency levels change swiftly, options may be between reassessments or an increase in staffing levels. We discussed this with the Manager and Providers in feedback at the end of the inspection. They are aware of these issues and the fact that difficult decisions have to be made. Care Homes for Older People Page 23 of 30 Evidence: Our observations throughout the inspection day were that staff were certainly very busy. There are several wheelchair users, some people require 2 staff for personal care or to hoist, but few need individual assistance with eating. Staff were certainly meeting the needs of people we observed and reviewed in care plans. The reorganisation of the environment since the last inspection has ensured people are more involved and therefore more readily observed and supervised in the lounge areas. Staff felt previously they had little time to sit and engage with people. The change in approach to activities may have gone some way to easing that situation. The training programme for staff in the home has improved considerably over the past 2 years. The current staff training matrix evidenced that staff training has continued. Current shortfalls in training have been addressed with planned training in Infection Control, Dementia/challenging behaviours, Fire Safety and Food Hygiene - 12 staff are allocated to receive this training in the next 2 months. NVQ training for staff is ongoing and more than half the staff group have obtained at lease NVQ Level 2, the remainder being involved in ongoing NVQ courses. There has been training in the Mental Capacity Act and Deprivation of Liberty Safeguards since the last inspection and we saw good assessments completed for all people in assessing their capacity. We looked at a sample of staff files and found that all had either POVA (Protection of Vulnerable Adults) checks or CRB (Criminal Records Bureau) prior to commencing employment. We did advise where a criminal conviction is present that discussions with the person and the reasons for continued employment were recorded. One application form did not have a complete list of previous employment - important in checking any gaps in employment. Another record had two references from relatives who had previously employed her - it is important in these situations to obtain an independent character reference. Care Homes for Older People Page 24 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Ongoing improvements are being made. This will ensure people have the support to meet their needs and will keep them safe. Evidence: The Manager is a Registered Nurse and has considerable experience in providing a service for older people, having worked in the NHS and Private Care. She attends regular training to update her knowledge. The Annual Quality Assurance Assessment, required by law, was returned to us by the required date and gave a satisfactorily detailed account of the level of service being provided. Improvements have been made in activities and the stimulation of people living in the home. This is ongoing and we will look for continued progress in this area. Staffing levels were satisfactory at the time of this inspection to meet the current Care Homes for Older People Page 25 of 30 Evidence: dependency needs of people. This does need to be monitored closely as dependency levels change. The current care planning system is not person centered and the planned changes are needed to provide a more detailed and person centered plan for each person, with clear instructions for staff to meet health, personal and social care needs. The importance of good channels of communication with relatives and their involvement in care planning are highlighted in this report. Improvements are needed in this area. There is a very relaxed atmosphere in the home. We noted good engagement and relationships between people living in the home and staff. We saw sensitive handling by care staff of peoples personal needs and their responses to repetitive behaviours people presented. We saw a person with painful cellulitis of both legs being transported in a wheelchair without footrests. This is a dangerous practice and must cease. There is a quality assurance system in place that includes the survey of people who live at the home, relatives and other stakeholders. The providers monitor performance against key standards. Staff meetings and meeting for people using the service take place regularly and are recorded. We saw Regulation 26 visits by Providers or their representatives, although several were missing from the file. We understand they are emailed following the visits and should be available. The ones we saw highlighted areas for change/improvement. The Regional Manager visits regularly and provides management support to the Registered Manager. There are regular Monthly Management Meetings with an agenda and circulated minutes. The Manager and Deputy attend and also the Regional Manager and the two Directors. Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 The medication trolley must be removed from the area accessed via the toilet area This will reduce the risk of potential contamination/infection. 25/03/2010 2 38 13 Footplates must be on wheelchairs at all times when transporting people in the home. This will ensure the safety of the person in transit. 25/03/2010 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 7 People using the service should be involved in care planning, involving their relatives where appropriate. It is part of good practice and communication to involve people and their families in care planning and review. Care plans must include all personal care needs. This will ensure people have all the support they need. 2 8 Care Homes for Older People Page 28 of 30 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 3 4 9 9 Medicaton required to be stored as controlled drugs must be secured in the controlled drugs cabinet. Prescribed creams stored and used in bedrooms should be signed for when applied. Clear instructions for staff must be provided indicating the time, frequency and site of application for each cream. Continue to review staffing levels in the light of changing levels of dependency. This will ensure people needs continue to be met. 5 27 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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