Care Home: The Limes

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What the care home does well Staff interaction with people living in the home was friendly and kindly and staff were respectful of peoples` wishes and privacy. For one person with specific health care needs staff were very clear that they needed to be very flexible to respond to the needs of this person and had an understanding of the needs of people cared for. People spoken to were happy with the service and enjoyed the trips out and the activities provided. People were positive about the meals provided and knew what choice was available for lunch that day. Lunch looked appetising and portions were suitable for the people in the home. People were offered a choice of drinks.The providers and staff are committed to the well being of people in the home and people receive support from health professionals when needed. People have detailed life histories recorded to support their social care needs. Staff are kept informed with regular handover meetings at the beginning of each shift. We looked at accident reports and found that these are recorded and action taken. We looked at the medication arrangements and found that a suitable system is in place and storage is secure, including controlled drugs. Recording and administration of medicines is mostly satisfactory. We looked at the rotas and found that for the two and half weeks before the inspection there had been sufficient staff on duty to meet peoples` needs and the stated staffing levels on all but one occasion. Care staff are supported by the deputy manager, and part time cleaner, cook and activities organisor. We looked at three staff files. All the required recruitment checks had been made and an interview record is kept. The home now asks for a full employment history to be declared. The provider told us that all staff have received an appraisal since the last inspection. The provider told us that they send out an annual survey to people living in the home to gather their views about the service. The provider told us that the requirements of the fire and rescue service have been complied with. We viewed the fire records and could see that the fire alarm system is checked weekly as required. What the care home could do better: We examined the care records for three people. The home holds a range of information for people but the process is not managed in a person-centred or organised way. Care plans are in place but the plans, reviews, risk assessments and daily records do not tie in together and are contradictory in parts. Care need assessments and plans need more detail to ensure they reflect individual needs and effectively and consistently guide staff. Where possible people should be given the opportunity to be involved in planning their care and agree to the plan. The home cares for people with dementia but the care plans did not reflect how peoples` mental health affected their daily lives and there was no clear person-centred guidance for staff on how people should be supported and monitored. Some examples of these findings are; One person had very specific needs and the home was liaising with a specialist health care team. We examined the care records for this person and this lacked a clear plan of care to guide staff in important areas for this person, such as their specific wishes, pain management, nutrition and mood and behaviour. There was no evidence that the views of the person had been sought. Another person had diabetes but the care plan did not detail how this affected the person, their nutritional requirements or what action staff should take should they become hypo or hyperglycaemic. One person had a conditionthat affects their sight but the effects of this was not detailed and there was no plan in place to inform and guide staff. Another person had a medical condition that exhibits particular signs and symptoms and needs a specific diet. There was no care plan relating to this and it was not reflected in the nutrition assessment. Without clear plans of care it is not possible to review the effectiveness of the care provided and to ensure that staff are consistently providing care and in the way that the person prefers. There is no systematic audit of care plans which would enable the provider and senior staff to review the recording systems, ensure assessments were fully completed and up to date, check resident involvement and ensure that the care plans contained the necessary detail. It was noted that in a considerable number of accidents recorded staff had assisted people from the floor. There is no meaningful audit of accidents so trends and patterns cannot be systematically analysed so that action can be taken to address these. This is recommended as is the recommendation that consideration is given to the purchase of a mobile hoist as peoples` dependency increases. Also staff have not received any up to date practical moving and handling training and assessment, training is done through watching a DVD, so this poses a potential risk to people living in the home and staff. We looked at the lunchtime meal. We saw that no improvement had been made to improve the dining experience for people with regard to the layout of tables. Staff presence in the dining room was not constant. We looked at medication management. We found that variable doses are not recorded when administered, this means the the amount of medication administered is not known and these medicines may not be administered safely. There is no system to follow up when medicines ares regularly refused so that a GP can review this. We found a large number of hand transcribed entries, including Oramorph, with no signatures or dates and where paracetamol is to be given `as required` there was no rationale for administration nor a safe maximum dose to be given recorded. This means that in some situations medication is not managed safely. There is not a system of medication audit which, if implemented, would identify these issues so that action can be taken to rectify poor practice. The home has a staff training file but there is not a system where training gaps and needs can quickly be identified. It is recommended that a training matrix be developed which will inform the audit systems. There is not yet a formal system of regular supervision for staff, the provider informed us that this is to be implemented now appraisals have been completed. We looked at the fire records. The last fire drill was carried out in October 2009. The home is a complex building and fire drills should be carried out a regular intervals to ensure the safety of people at the home should there be a fire. The quality assurance system is limited and there are no formal audit systems. The providers do not complete Regulation 26 reports as they do not consider these necessary as they are at the home five days a week. The home must develop a system of audit and a more comprehensive quality assurance approach to ensure ongoing monitoring of the quality of the service so this requirement will remain. Random inspection report Care homes for older people Name: Address: The Limes 41/45 Church Street Bridgwater Somerset TA6 5AT one star adequate service 16/11/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme 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 review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Sue Burn Date: 2 0 0 5 2 0 1 0 Information about the care home Name of care home: Address: The Limes 41/45 Church Street Bridgwater Somerset TA6 5AT 01278422535 Telephone number: Fax number: Email address: Provider web address: angelbre2003@yahoo.co.uk Name of registered provider(s): Name of registered manager (if applicable) Ms Paulene Coles Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Brian Thomas care home 26 Number of places (if applicable): Under 65 Over 65 5 21 dementia old age, not falling within any other category Conditions of registration: 0 0 An additional bathroom equipped with assisted bathing facilities will be installed within 10 months from Date of Registration Registered for 21 persons in category OP and 5 persons in category DE(E) The large pond in the rear garden is protected in a manner which prevent accidents to vulnerable service users, within 8 weeks of Date of Registration Date of last inspection Brief description of the care home The Limes is located in a quiet but central part of Bridgwater. It is currently registered with us to provide personal care to up to 28 people over the age of 65, this includes 5 Care Homes for Older People Page 2 of 13 1 6 1 1 2 0 0 9 Brief description of the care home people who have a dementia. The home is not registered to provide nursing care. Accommodation is arranged on 4 floors, with lift access to all floors. All communal areas are on the lower floors. The registered provider is Mr Brian Thomas. The home is furnished in a comfortable domestic style. There are twenty-four single bedrooms and two double rooms. Twenty-three of the bedrooms have en suite facilities. Care Homes for Older People Page 3 of 13 What we found: The inspection was carried out by one inspector, however the term we is used throughout the report. This is because the report, and the judgments within it, are on behalf of the Care Quality Commission (CQC). This focused inspection was carried out to follow up compliance with specific requirements from the last key inspection and anonymous concerns raised with us regarding the adequacy of staffing levels. The quality rating at the last key inspection in November 2009 was one star, which means that people using the service experience adequate quality outcomes. We reviewed the last key inspection report, information sent to us, spoke to staff and people living in the home and examined records. Mrs Hazel Thomas, one of the homes owners and the deputy manager were present throughout the inspection visit. The registered provider is Mr Brian Thomas. At the time of the inspection there were 19 people living at the home. Since the last inspection the registered manager had left in December 2009 and the manager recruited to replace her had also left on 15 May 2010. Mrs Thomas told us that she and the deputy manager would manage the home until a suitable manager could be recruited. The outcome areas reviewed at this inspection were those relating to health and personal care, aspects of daily life and social activities, staffing and some areas of management and administration. At the last inspection nine requirements and three good practice recommendations were made. Six of the requirements and two recommendations were checked at this inspection. We did not inspect requirements relating to social activities, environmental refurbishment or financial transactions so these requirements remain but the provider may have taken action to address them. One requirement and one recommendation had been fully complied with. The requirements in this report have been made to reflect the findings of this inspection. At the end of the inspection we gave feedback to Mrs Thomas and the deputy manager. What the care home does well: Staff interaction with people living in the home was friendly and kindly and staff were respectful of peoples wishes and privacy. For one person with specific health care needs staff were very clear that they needed to be very flexible to respond to the needs of this person and had an understanding of the needs of people cared for. People spoken to were happy with the service and enjoyed the trips out and the activities provided. People were positive about the meals provided and knew what choice was available for lunch that day. Lunch looked appetising and portions were suitable for the people in the home. People were offered a choice of drinks. Care Homes for Older People Page 4 of 13 The providers and staff are committed to the well being of people in the home and people receive support from health professionals when needed. People have detailed life histories recorded to support their social care needs. Staff are kept informed with regular handover meetings at the beginning of each shift. We looked at accident reports and found that these are recorded and action taken. We looked at the medication arrangements and found that a suitable system is in place and storage is secure, including controlled drugs. Recording and administration of medicines is mostly satisfactory. We looked at the rotas and found that for the two and half weeks before the inspection there had been sufficient staff on duty to meet peoples needs and the stated staffing levels on all but one occasion. Care staff are supported by the deputy manager, and part time cleaner, cook and activities organisor. We looked at three staff files. All the required recruitment checks had been made and an interview record is kept. The home now asks for a full employment history to be declared. The provider told us that all staff have received an appraisal since the last inspection. The provider told us that they send out an annual survey to people living in the home to gather their views about the service. The provider told us that the requirements of the fire and rescue service have been complied with. We viewed the fire records and could see that the fire alarm system is checked weekly as required. What they could do better: We examined the care records for three people. The home holds a range of information for people but the process is not managed in a person-centred or organised way. Care plans are in place but the plans, reviews, risk assessments and daily records do not tie in together and are contradictory in parts. Care need assessments and plans need more detail to ensure they reflect individual needs and effectively and consistently guide staff. Where possible people should be given the opportunity to be involved in planning their care and agree to the plan. The home cares for people with dementia but the care plans did not reflect how peoples mental health affected their daily lives and there was no clear person-centred guidance for staff on how people should be supported and monitored. Some examples of these findings are; One person had very specific needs and the home was liaising with a specialist health care team. We examined the care records for this person and this lacked a clear plan of care to guide staff in important areas for this person, such as their specific wishes, pain management, nutrition and mood and behaviour. There was no evidence that the views of the person had been sought. Another person had diabetes but the care plan did not detail how this affected the person, their nutritional requirements or what action staff should take should they become hypo or hyperglycaemic. One person had a condition Care Homes for Older People Page 5 of 13 that affects their sight but the effects of this was not detailed and there was no plan in place to inform and guide staff. Another person had a medical condition that exhibits particular signs and symptoms and needs a specific diet. There was no care plan relating to this and it was not reflected in the nutrition assessment. Without clear plans of care it is not possible to review the effectiveness of the care provided and to ensure that staff are consistently providing care and in the way that the person prefers. There is no systematic audit of care plans which would enable the provider and senior staff to review the recording systems, ensure assessments were fully completed and up to date, check resident involvement and ensure that the care plans contained the necessary detail. It was noted that in a considerable number of accidents recorded staff had assisted people from the floor. There is no meaningful audit of accidents so trends and patterns cannot be systematically analysed so that action can be taken to address these. This is recommended as is the recommendation that consideration is given to the purchase of a mobile hoist as peoples dependency increases. Also staff have not received any up to date practical moving and handling training and assessment, training is done through watching a DVD, so this poses a potential risk to people living in the home and staff. We looked at the lunchtime meal. We saw that no improvement had been made to improve the dining experience for people with regard to the layout of tables. Staff presence in the dining room was not constant. We looked at medication management. We found that variable doses are not recorded when administered, this means the the amount of medication administered is not known and these medicines may not be administered safely. There is no system to follow up when medicines ares regularly refused so that a GP can review this. We found a large number of hand transcribed entries, including Oramorph, with no signatures or dates and where paracetamol is to be given as required there was no rationale for administration nor a safe maximum dose to be given recorded. This means that in some situations medication is not managed safely. There is not a system of medication audit which, if implemented, would identify these issues so that action can be taken to rectify poor practice. The home has a staff training file but there is not a system where training gaps and needs can quickly be identified. It is recommended that a training matrix be developed which will inform the audit systems. There is not yet a formal system of regular supervision for staff, the provider informed us that this is to be implemented now appraisals have been completed. We looked at the fire records. The last fire drill was carried out in October 2009. The home is a complex building and fire drills should be carried out a regular intervals to ensure the safety of people at the home should there be a fire. The quality assurance system is limited and there are no formal audit systems. The providers do not complete Regulation 26 reports as they do not consider these necessary as they are at the home five days a week. The home must develop a system of audit and a more comprehensive quality assurance approach to ensure ongoing monitoring of the quality of the service so this requirement will remain. Care Homes for Older People Page 6 of 13 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 set out on page 2. Care Homes for Older People Page 7 of 13 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 The Registered Person must complete the development and improvement of each persons care plan and their risk assessments. This would ensure staff have clear and accurate information relating to each persons care needs. 16/02/2010 2 9 13 The Registered Person must 16/01/2010 ensure that each persons medication is correctly recorded and stock levels are correct. This will ensure that people are supported with their medicines in a safe and consistent way. 3 12 16 The Registered Person must ensure that the activities programme is reviewed and improved where possible. This will ensure that each person receives adequate social stimulation. 16/01/2010 4 19 23 The Registered Person must 16/02/2010 ensure the planned refurbishment of the home is completed. Care Homes for Older People Page 8 of 13 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action This would ensure the people who live at The Limes are provided with a comfortable and homely environment. 5 30 18 The Registered Person must ensure that staff complete their training programme. This would ensure staff have the knowledge and skills to support people properly. 6 32 26 The Registered Person must ensure that monthly audits of the home are carried out and a report written. This will ensure the home is effectively monitored to ensure the people who live here receive a safe and accountable service. 7 35 16 The Registered Person must 16/01/2010 review how the home records financial transcations for people and ensure the balances held for people are correct. This would help to make the system safer and may reduce the likelihood of erors being made. 8 36 18 The Registered Person must 16/01/2010 ensure each member of staff is supervised regularly. This would ensure staff are being given the support they need to provide good quality care to people who live in the Care Homes for Older People Page 9 of 13 16/03/2010 16/01/2010 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action home. Care Homes for Older People Page 10 of 13 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, 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 registered person shall 31/05/2010 make arrangements for the recording and safe administration of medicines. Where a variable dose is prescribed the actual amount given is recorded and where medication is to be given as required a reason for this is identified. This is to ensure that people receive their medication in a safe way. 2 38 13 The registered person shall 20/08/2010 make suitable arrangements to provide a safe system for moving and handling service users, through the provision of practical and up to date training. This is to ensure that service users are moved safely and staff are not put at risk of harm. Care Homes for Older People Page 11 of 13 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 9 The registered person should ensure that all hand transcribed prescriptions on the medication chart are signed by two staff and dated. A monthly medication audit should be implemented. The registered person should ensure that clear records are kept when activities are offered and declined by people who live in the home. This would help ensure that the activities programme continues to meet peoples needs. The registered person should review the current dining arrangments and how tables are laid. This may help to improve the dining experience for the people who live in the home. The registered person should consider sourcing training for a member of staff to train as a moving and handling trainer to support staff. A staff training matrix should be developed where training gaps and needs can quickly be identified. Fire drills should be held regularly to ensure staff are kept updated and new staff and any change in risk are taken account of. The registered person should consider purchasing a portable hoist or other suitable aid to assist people who may need assistance from the floor. A system of monthly audit of accidents and incidents should be maintained to ensure action can be taken where trends and patterns are identified. 2 12 3 15 4 30 5 6 30 38 7 38 8 38 Care Homes for Older People Page 12 of 13 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 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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