Care Home: The Limes Rest Homes

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What the care home does well People and relatives gave The Limes high praise in every regard: "they look after all my needs…I am very happy… they are always there for you"; " extra attention to those who have difficulty eating"; "families are always welcome and they have time to listen"; "X loves the food…I think the Limes has a personal touch"; "…x…is in safe hands; "patience and genuine caring attitude of all the staff"; "extras to enhance the lives of the residents - days out, pub lunches, seasonal parties and celebrations…which can make the difference between a life and just an existence; "the home is always kept very clean and tidy"; "improvements to the fabric of the building…motivation appears to be the wellbeing of the residents." Our findings echo the views above. The Expert by Experience was very impressed with The Limes and their staff, "glad to have had the opportunity to see a home that stood out from others in my experience of services for older people." The Limes is " …safe and suitable for the residents…has a warm and friendly atmosphere… and excellent hygiene…staff interact excellently with the residents… proactive to [individual] needs." The Limes provides a professional dementia care service and explains this in public information in appropriate formats. Well maintained facilities provide privacy, security but also freedom of movement. A safe medication system and best practice has been sustained. Risk management and partnership working with health improved. People`s health conditions and wellbeing improved. End of life care is planned in advance. The home confirms quality and safety for itself, robustly, so that health, rights and dignity are protected. Concerns, complaints and safeguarding are taken very seriously and acted upon so that people have protection and legal safeguards when necessary. People have fun in the home, go out with individual support and have excellent relationships with skilled staff. They retain their mental and physical agility and control of their lives for as long as possible. Diversity is well planned for. Staff have excellent training and supervision. Management are highly motivated, creative and lead an effective team approach to benefit people. The views of people, families, professionals and staff inform learning and service development, as well as research. The home is very well run. What has improved since the last inspection? The medication procedure and system was overhauled, staff were re-trained and competence established, achieved through a new pharmacy contract and external consultants. Medication protocols and improved guidance for staff was agreed with health professionals so that staff knew signs to watch for. Best practice standards have been maintained by frequent internal audits. A Primary Care Trust liaison nurse prescriber worked with the home and primary care services to improve end of life and hospital discharge care planning, falls prevention, infection screening and plans that control the spread The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.2 of illness. Networks improved so that people have good support from mental health services and medication is only provided for as long as it is necessary so that people can continue a good quality of life. Additional training, improved behaviour plans and organisational changes have resulted in a reduction of agitation and people`s emotional wellbeing improved. The home researched best practice in dementia care and nutrition and made changes to the environment to benefit people in a variety of ways. Colour schemes and signs help people to find their way around independently. Freedom of movement improved. The garden now has ramped access and a new decked patio. The conservatory is now used for meals in addition to the dining room, which has made mealtimes more conducive to eating well. An activity coordinator now supplements existing activities by staff, a volunteer and contracted specialists so that people have a wider range of activities, exercise and individual outings to meet their preferences. Memories are retained through reminiscence and orientation activities. A new activity room was created with multi-sensory facilities to both calm and stimulate people. Work experience is now provided to local secondary school young people, which keeps people in touch with other generations and promotes care as a career. The home now has a Home Office licence but has not needed to recruit staff from abroad because of sufficient choice through further links with local employment services. The management team is stronger: professional, confident and accountable. What the care home could do better: Management addressed minor queries we raised during the inspection, and provided us with a further report within 48 hours of our visit. One ambiguous reference was followed up, although there were other robust staff recruitment checks to keep people safe. National guidance was obtained to improve hot water checks that prevent scalds, and to update plans about swine flu. Responsibility was assigned to lead a team approach to improving the home`s health and safety risk assessment. Advice will be taken to introduce body mass index measurement to improve health monitoring. The building poses constraints. Management know what they want to improve. They are continuing to research best practice building design and services for dementia care and have further plans to benefit people. Key inspection report CARE HOMES FOR OLDER PEOPLE The Limes Rest Homes 75-79 Cartland Road Stirchley Birmingham West Midlands B30 2SD Lead Inspector Tina Smith Key Unannounced Inspection 23rd September 2009 09:10 DS0000062017.V377776.R01.S.do c Version 5.3 Page 1 This report is a review of the 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. 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. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.2 Page 2 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 The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Rest Homes Address 75-79 Cartland Road Stirchley Birmingham West Midlands B30 2SD 0121 443 1789 0121 443 3332 anita@FirstCareServices.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) First Care Services Ltd Miss Jennie Roberts Care Home 28 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (28) of places The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. Old Age not falling within ant other category - Code LD (maximum number of places 28). Dementia over 50 years of age - Code DE (maximum number of places 28) The maximum number of service users who can be accommodated is 28. 6th February 2009 2. Date of last inspection Brief Description of the Service: The Limes has been run by First Care Services Ltd since 2004. Three houses are joined together on a residential street near local shops, parks and bus routes to Birmingham. There is a front ramp for wheelchairs. Car parking, an enclosed garden, smoking area and training room are at the back. On the ground floor there are four lounges, including one for quiet space, dining room, activity room, conservatory, senior staff and district nurse offices, kitchen, and a hairdressing room leads to the laundry. The management office is on the top floor. Twenty single and four twin-bedded rooms, some en-suite and one with a shower, are on the ground and first floors with access by either a passenger lift or stair lift. A gate or keypad protects people from steep stairs. Assisted baths, showers and toilets are on both floors. Bedrooms have a two-way call system so that people and staff can talk. Some doors are alarmed so that staff can rapidly assist people at risk of confusion or falls at night. Weekly fees start at £398 for a shared room, £408 for a single room, according to care needs and facilities, and any top up fees would be between £20 and £50 per week. The home employs a physiotherapist and has a communal daily newspaper for which there is no charge. Extra charges apply to toiletries, hairdressing, chiropody, private newspapers, transport to hospital or appointments, private phones and Sky TV. This information applied at the time of our visit; up to date information should be requested from the service. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means that the people who use this service experience excellent quality outcomes. Prior to our visit, the home sent us their Annual Quality Assurance Assessment (AQAA), with information about running the home, what has improved and is planned for the future. Their self assessment shows critical analysis and striving for excellence to benefit people. Information from this and from other sources was also used when forming judgments on the quality of the service. We received 23 out of 30 surveys from people, relatives and staff. The home sends us notifications about legally required events, and we receive reports from other sources. The last key inspection was on 25/09/08, when The Limes lost a good quality rating because of a depleted management team and a problem they had already begun to address with their medication system. The home took rapid and thorough action and kept us well informed of progress. We made two unannounced visits in January and February 2009 by Pharmacy and Regulation Inspectors, and confirmed compliance within the timescales we set for two statutory notices. Action by the home exceeded our expectations; nine requirements and recommendations were met. We did not inspect one remaining requirement from the last key inspection. One inspector visited the home on 23/09/09 for nine hours, joined by an Expert by Experience from Age Concern/Help the Aged for three hours. The home was not informed before our visit. Experts have experience of care services or caring roles. They provide us with reports of their observations and their views of peoples outcomes after discussions with people and others in the home. The Expert and Inspector separately looked around the home, observed mealtimes and medication administration. We spoke with many people, two relatives, five staff and a visiting health professional. The inspector saw three peoples care and health records. Records were also checked about: staffing and training, medication, maintenance, complaints, incidents, health and safety risk assessments. We saw the homes public information, certificates, and quality assurance audits and records of the views of people, relatives and professionals. Policies and procedures were seen or discussed about mental capacity and Deprivation of Liberty Safeguards, infection control, sexuality and human resources. We discussed our findings with the manager, deputy and owner who were present throughout our visit. No requirements or recommendations were made as people were safe, well cared for. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.2 Page 6 What the service does well: People and relatives gave The Limes high praise in every regard: they look after all my needs…I am very happy… they are always there for you; extra attention to those who have difficulty eating; families are always welcome and they have time to listen; X loves the food…I think the Limes has a personal touch; …x…is in safe hands; patience and genuine caring attitude of all the staff; extras to enhance the lives of the residents - days out, pub lunches, seasonal parties and celebrations…which can make the difference between a life and just an existence; the home is always kept very clean and tidy; improvements to the fabric of the building…motivation appears to be the wellbeing of the residents. Our findings echo the views above. The Expert by Experience was very impressed with The Limes and their staff, glad to have had the opportunity to see a home that stood out from others in my experience of services for older people. The Limes is …safe and suitable for the residents…has a warm and friendly atmosphere… and excellent hygiene…staff interact excellently with the residents… proactive to [individual] needs. The Limes provides a professional dementia care service and explains this in public information in appropriate formats. Well maintained facilities provide privacy, security but also freedom of movement. A safe medication system and best practice has been sustained. Risk management and partnership working with health improved. Peoples health conditions and wellbeing improved. End of life care is planned in advance. The home confirms quality and safety for itself, robustly, so that health, rights and dignity are protected. Concerns, complaints and safeguarding are taken very seriously and acted upon so that people have protection and legal safeguards when necessary. People have fun in the home, go out with individual support and have excellent relationships with skilled staff. They retain their mental and physical agility and control of their lives for as long as possible. Diversity is well planned for. Staff have excellent training and supervision. Management are highly motivated, creative and lead an effective team approach to benefit people. The views of people, families, professionals and staff inform learning and service development, as well as research. The home is very well run. What has improved since the last inspection? The medication procedure and system was overhauled, staff were re-trained and competence established, achieved through a new pharmacy contract and external consultants. Medication protocols and improved guidance for staff was agreed with health professionals so that staff knew signs to watch for. Best practice standards have been maintained by frequent internal audits. A Primary Care Trust liaison nurse prescriber worked with the home and primary care services to improve end of life and hospital discharge care planning, falls prevention, infection screening and plans that control the spread The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.2 Page 7 of illness. Networks improved so that people have good support from mental health services and medication is only provided for as long as it is necessary so that people can continue a good quality of life. Additional training, improved behaviour plans and organisational changes have resulted in a reduction of agitation and peoples emotional wellbeing improved. The home researched best practice in dementia care and nutrition and made changes to the environment to benefit people in a variety of ways. Colour schemes and signs help people to find their way around independently. Freedom of movement improved. The garden now has ramped access and a new decked patio. The conservatory is now used for meals in addition to the dining room, which has made mealtimes more conducive to eating well. An activity coordinator now supplements existing activities by staff, a volunteer and contracted specialists so that people have a wider range of activities, exercise and individual outings to meet their preferences. Memories are retained through reminiscence and orientation activities. A new activity room was created with multi-sensory facilities to both calm and stimulate people. Work experience is now provided to local secondary school young people, which keeps people in touch with other generations and promotes care as a career. The home now has a Home Office licence but has not needed to recruit staff from abroad because of sufficient choice through further links with local employment services. The management team is stronger: professional, confident and accountable. 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. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1 and 3: People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the information they, and those who represent them need to decide if The Limes is suitable. There is a thorough pre-admission assessment and sensitive process to help people settle in, that meets their needs. EVIDENCE: Seven people told us in surveys that they had enough information and a contract, and relatives said that there had been positive changes. We wanted to see whether peoples experience of the pre-admission process continued to answer all their questions. On our visit there were 25 people in the home, two people in hospital and one vacancy. We discussed four new admissions and studied the experience of two people admitted to the home within the last four The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 10 months, one who was funding their own care. The Expert by Experience found that people and relatives were happy with the care and welcoming atmosphere of the home. The home refined their approach to dementia care and added a new section explaining this in their public information, which shows that they considered consumer needs. Information is more accessible with summarised precautions and the complaints process in Plain English, using large print and photos. People told us that the service was explained to them by staff and social care professionals. There is accurate detail about services, fees, terms and conditions. A map ensures that the home can be easily found; the staff chart has been simplified and explains how to distinguish staff. The only inaccuracy is that the management office has moved within the building. The statement of purpose and service user guide explain that The Limes provides services for people over the age of 50 who are frail, physically dependent or have dementia including those who have behaviour which could be seen as challenging behaviour or who have other functional mental health problems. Intermediate care services are not provided. The assessment and care planning process is well explained for planned and emergency admissions. Resources available to help families learn more about dementia and links with the Alzheimers Society are also useful new additions. Pre-admission assessments by trained staff took place in the most appropriate place, i.e. in hospital or in peoples homes. Information was gathered from social services and health. People and families visited the home, several times in one instance. Everything was in place to meet their needs before moving in. Staff knew peoples routines and preferences to help them settle in. Families were advised how they could help so that disorientation was brief. Care planning decisions are made together, in accordance with the persons ability to make their own informed choices. Both people had trial periods to decide about staying. One person had a review, and the other is due shortly. A new form records the views of families. Advocacy services are displayed so that people can have independent support about serious decisions. For example, one person temporarily in the home does not have dementia but wants to stay because the home has improved their health and made them feel secure. Social services agreed after an advocate helped the person to try another service, which did not suit them as well as The Limes. The home told us how they achieved sensitive end of life care with treatment arranged from community health services for another person. This is not always possible and the manager requested multi-agency re-assessment and a family meeting to decide whether The Limes can continue to meet the needs of a person in hospital needing nursing care. This shows that they understand their boundaries. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7-11: People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health and personal care is unique to individuals; met with dignity and in privacy. Healthy living is promoted; people retain their abilities for as long as possible, or a good quality of life. Access to health services is good. Medication is safely managed for health and wellbeing, only for as long as is necessary. EVIDENCE: Our last key inspection found outcomes for peoples health reduced from good to adequate as a result of the homes medication system and limited support to the home by health services. The Limes was already trying to improve and the Primary Care Trust had just started to assist them. At that time people had few falls and no pressure sores but we were aware that some conditions were progressive. Our visits in January and February 2009 confirmed that The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 12 changes the home told us about were robust and strides were made by embedding best practice. The home keeps us informed so we were aware of three falls resulting in fractures, four people with pressure sores before and after admission, and one contagious infection caught in hospital. On this visit we checked risk management for three people and enquired about two people from our previous visits. Staff had a higher level of training to learn more about dementia, palliative and pressure area care, and to manage conflict and behaviour. People have good support from primary care and mental health services. There were many examples of improved health and wellbeing, respectful individualised personal care, people maintaining their physical and mental agility. We heard about end of life care planning where needs and wishes were expressed and met; care and treatment decisions were made in advance with the family and doctor. The Expert by Experience said, residents requiring assistance were helped in a caring dignified way… efforts are made to satisfy [their] individual needs... two visiting relatives… were very pleased with the level of care. We had 13 surveys from people and relatives with similar satisfaction. Care records show that people choose the gender of staff, preferred rising and bedtimes, what people are able to do by themselves and detail support, aids and equipment. For example, some people are prompted when shaving, washing or dressing, helped with buttons, zippers or oral hygiene. On our visit people were appropriately dressed for the weather, their own clothing in the right order, tidy appearance and had good personal hygiene. Someones mobility fluctuated. Their care plan changed to provide instructions to support use of their frame, a handling belt or hoist including the correct sling size on days they are unable to walk or weightbear, so that staff could respond flexibly. One person was being nursed in bed. Accurate risk assessments and care plans prevent and manage falls, pressure sores and malnutrition. These are interlinked and regularly reviewed. Changes in mobility, skin integrity or food or fluid intake trigger referrals at early points to doctors for nutritional supplements, district nurses and specialists such as dentists, dieticians, continence advisers and falls clinics, and the homes physiotherapist reviews mobility and exercise. We saw up to date daily records and charts, outcomes of health appointments. Health checks, flu vaccinations, eyesight, dental care and chiropody were up to date. A visiting district nurse provided pressure relieving equipment and said staff always follow our advice about personal care and turning in bed and keep good records; pressure sores are healing and conditions such as cellulitis and diabetes are managed well. One person was admitted for a short stay at the request of health as their sores had not been healing at home. The Expert told us that staff were attentive to peoples body language and prompted use of the toilet sensitively, also that staff responded to confused agitation immediately in an appropriate fashion to restore calm and alleviate The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 13 the distress of two people. The Expert was impressed by how peoples nutritional needs were met. This confirmed our own observations. Care plans have objectives agreed and evaluated in respect of the effect on people and their conditions in a sophisticated, professional manner. We saw detailed nutritional plans and behaviour plans with triggers. Staff have clear guidance about communication to promote cooperation and people making daily choices, and clear instructions about decisions staff may need to make. Multi-agency teams make best interest decisions with people and their representatives. The owner involved external consultants to revise procedures, overhauled the medication system and practice, brought forward a new pharmacy contract and sent us detailed reports about progress. There is a new medication storage system and more trolleys, pre-printed records, and a new controlled drugs register. Consultants re-trained all staff to their roles, tested and observed staff competence. Since then the manager and owner continue to frequently observe staff and audit the whole system so that The Limes confirms it self that peoples health is fully monitored and protected. Our visits confirmed that best practice was sustained. Audits now evidence timely action, records show robust temperature controls so that medication remains stable, and everyones medication and administration records are checked. There is now a link between audits, staff supervision and learning in staff meetings so that practice continues to develop. The Expert by Experience reported, some of the residents declined their medication and they were gently [persuaded] to take their tablets. This is because staff know people well and can explain in a way they understand, what the medication is used to treat. Excellent guidance has been produced with health specialists so that staff know the way it affects people and what to do if there are concerns about side effects. People can refuse medication. There are individual protocols for occasional use medication, agreed and signed by doctors. Homely remedies are also checked and are usually prescribed. On our visit no one was assessed to be able to safely self manage medication or they had asked the home to do this. The manager proactively asks for medication reviews by specialists, which has strengthened relationships with mental health services. Since the last inspection there were no incidents of people upsetting or pushing each other. We asked about one person previously experiencing agitation and aggression resulting in frequent incidents and hospital admission. We were told that their mental wellbeing improved with therapy; after reviews they are no longer prescribed psychiatric medication and remain calm and content. This approach provides excellent outcomes for peoples health, wellbeing and quality of life, in line with national best practice strategies about dementia care. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12-15: People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People remain in control of their lives, relationships and hobbies, or decisions are made in their best interests in keeping with their religion and lifestyles. People have support to eat well, exercise, and for individual or group activities and outings and maintain contact with the community. EVIDENCE: The home sustained and improved good outcomes for people in this area since the last key inspection. People make daily decisions and have flexible care. Staff work with people, their family, friends and advocates to learn about the person, their likes and dislikes and plan services together in keeping with their individual lifestyles and routines. Life story books, photos and mementoes are used in reminiscence and orientation activities, as well as smells, objects and multi-sensory stimulation. These help people to retain their short and long term memories. Exercise and a nutritious diet promote healthy living and The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 15 physical agility. Diversity is well catered for, including sensory needs such as a hearing loop to enhance sound for hearing aid users, and a large print library. The Expert by Experience said, staff are friendly and interact excellently with the residents…music is playing in the background…I observed a young male carer and it was obvious that his presence…added a healthy balance to the staffing arrangements…The home has a designated activities organiser and efforts are made to provide a relevant programme of activities…displayed in the activity room…and to satisfy individual needs… one [person] spends a lot of time knitting and another keeps their musical instruments in the activities room. A visiting relative said, it is a load off my mind to know my mother is treated with kindness and respect. Care records show, preferred ways in which masculinity and femininity, dignity, cultural and religious needs are met. The sexuality policy was revised, but this was not as well developed as it could be in care plans. People have individual stimulation plans, for instance needs for exercise are met by walks, activities guided by the physiotherapist, or the skilled music and movement facilitator we saw and spoke to on our visit. People told us how much fun they have in these sessions with interesting objects they manoeuvred - they were lively even after dinner, which is unusual in care homes, and one visitor found this session a good time to see their relative at their best. The activities coordinator said that they visit people in their rooms for activities and take people on individual outings such as personal shopping. This supplements activities by staff and a volunteer, or external facilitators. At night there are large screen films and celebrations that families particularly valued - adding that extra touch. In one care record a person with depression and a tendency to become withdrawn has an objective to increase social interaction and they have individual support from staff to take part in activities. People go out to worship or there are visiting clergy. Families are frequently in the home or people have help to keep in touch with access to a private telephone through staff. Mealtimes are a social occasion. The home have reduced noise so that people can talk and others have less distractions by using the conservatory as well as the dining room and staggering mealtimes. People can eat when they want. Some people ate in their rooms or a lounge on our visit. The Expert saw a menu of the day with two choices and staff ensured people needing diabetic alternatives had them. There was a copious supply of cranberry juice at mealtime instead of the usual orangeade. We checked and found one person is no longer prescribed medication affected by cranberry juice. The AQAA told us that focussing on fluid intake has reduced urinary track infections. Sufficient food is prepared so that people make choices for each course. Pictures or photos of food could enhance decision making. People ate well; the food was tasty and we complimented the cook. Menus show that there is a The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 16 balanced, healthy diet with roughage, oily fish, fresh fruit and vegetables and alcohol is available for celebrations. People are consulted about the menus so they include their favourite foods and local specialities. People prone to self neglect or at risk of malnutrition have food and fluid intake charts. Nutrition plans show dietary needs and preferred portion sizes, which the cook and staff were aware of. Some people had plate guards to help them eat independently. There was sufficient staff to feed or prompt those who needed help, sensitively fed and unrushed. Staff noticed two people not eating their chosen meal and offered additional choices until they found something the person fancied. We discussed one person who appears to need review as they became distracted when staff brought another course at the wrong time and they ate little. Others ate well. Most people are regularly weighed. We queried someone who had lost 4.5 kg in 4 months and could not be weighed in bed. The home had raised concern with the District Nurse who thought the cause was the hot weather. We discussed using body mass index instead of weighing and managers will ask District Nurses to advise them on a system so that health can be more accurately monitored. Food is fortified and nutritional supplements are sought and used when necessary. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16-18: People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home responds to concerns, complaints or needs for protection in a timely way so that people are safe but can still take risks. Their civil and human rights are promoted. Local protocols are used to safeguard people with incapacity when necessary, and in accordance with new legal duties. EVIDENCE: People can have confidence that complaints and concerns are taken seriously at The Limes. They have an established history of acting effectively in a timely way, promoting civil rights such as voting and opening ones own mail, and protecting people with other agencies when necessary. The Commission is kept well informed. People know who to speak to if they are unhappy or have a concern; most but not all know how to make a complaint, as surveys told us. Relatives said that there is an appropriate response to any concern. We wanted to see how the home sustained good outcomes for people, and how new legal duties have been put into effect. We made recommendations about this at their last key inspection. On our visit we found best practice in use at The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 18 The Limes, particularly for people with fluctuating or loss of capacity to make their own decisions and people who may have difficulty expressing their views. An updated complaints procedure, summarised in the service user guide, is regularly mentioned at resident meetings. Accurate contact details allow a concern to be reported inside or outside of the home. The home works with statutory advocates, in accordance with mental capacity law so that people can have independent support to express their views. Everyone in the home has had contact with relatives or advocates during the past year. There was one complaint resolved within the timescale with satisfaction although not upheld, which we reviewed in the homes log. This means that the procedure is accessible to people, and that it is used. Complaints and incidents are also checked at First Care visits and used for learning and development of the service. This means that the experience of people and families is reflected upon, and influences how the service is run. The home continues to use their safeguarding policies and adult protection procedure responsibly and make reports in accordance with council protocol and national guidance. The home told us about one report to a government list of someone dismissed, but when we checked this did not concern abuse of people using the service. The Limes had to take action with the police to protect someone with incapacity during an incident involving a visitor. Their actions ensure that the person and the home have ongoing protection pending resolution of a complex matter through multi-agency safeguarding processes. Managers have a good understanding of human and civil rights and legal duties, and updated policies, procedures and audits. Records show that mental capacity and communication modes are assessed and reviewed. Peoples nominated representatives, powers of attorney and advocates are consulted and best interest decisions are recorded and signed. Staff have clear instructions about seeking consent and offering choice, as well as recognising decisions staff may need to make daily. There are invoiced accounts for personal allowance expenditure which relatives told us are appropriate, and people store very small amounts of money themselves. Conditions of employment and the code of conduct preclude staff involvement in peoples financial affairs or benefiting from wills. We noticed a marked decrease in agitation and a calmer atmosphere so we asked how this was achieved. Staff had training in conflict resolution and to manage aggression. Care plans now include triggers and a wider array of least restrictive strategies so that self harming, agitated or aggressive behaviour is managed by reassurance and distraction at early points to prevent a situation worsening. Changes now prevent frustration, for example bottlenecks in doorways were eliminated and people are no longer complaining of others pushing them. Freedom of movement within the home and grounds was improved, as well as more outings. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 19 People are supported to take risks when assessed to be safe and which also respect the rights of others living in the home. Managers asked us to review recent safeguarding minutes and an emergency Deprivation of Liberty Safeguard authorisation which the home drafted but held in obeyance after seeking council advice. They will be following this up with an application to the council supervisory body on our advice as they appear to have been given incorrect information in a complex matter. This shows us that the home understand and know how to use new legal duties to protect peoples rights when it is necessary in law to apply restrictions for personal safety. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19, 20, 24-26: People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises and grounds are comfortable, clean, and safe. The atmosphere is welcoming and calm. The layout, signage and decoration helps people to find their way around and move about freely. People personalise their rooms. Equipment and facilities are appropriate for sensory and dementia care needs. EVIDENCE: The Limes is in a residential area and is only distinguishable as a care home by a discrete sign and ramp for wheelchair access. People live in safe and comfortable surroundings. The front door is locked so that people have protection from the busy road, but there is free access to the enclosed garden, which is now signposted. Since the last inspection, changes have been made The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 21 to benefit people by moving management offices upstairs and removing gates, except those assessed to be needed to protect people from two steep staircases. Communal rooms as well as bedrooms and toilets now have different colour schemes so that people can find their way around independently, and people chose the colours. This is best practice for a dementia care environment. Freedom of movement has improved, and an activities room was created. District nurses now have an office, which they said is much appreciated. A new decked patio is in the garden which the Expert remarked on positively. There is a new cupboard to store wheelchairs and weighing equipment which removed a hazard near someones room. The home is well maintained and facilities match the needs of people using the service. There are new pictures on the walls, and notice boards were changed so that they are free of clutter and more easily read. A hearing loop was installed to improve sound for hearing aid users. Facilities and materials used to stimulate people are appropriate for sight impairment, mobility and coordination e.g. a clock with large numbers, books and games in large print or larger sizes. We queried dim lighting in one bathroom - an energy saving bulb takes time to fully alight. The Expert by Experience saw that people personalise their rooms. They choose colour schemes and flooring. People have sufficient storage for their belongings and access to aids and equipment they need for safe mobilising and manual handling. The health service provided pressure relieving aids, including a mattress. We were told that no bed rails were in use on our visit. The Expert by Experience advised that some furniture is worn and carpet in one bathroom was likely to be unhygienic and should be replaced with an easy-clean surface. This was discussed and we were told that this bathroom is seldom used but the views expressed will be considered in their rolling refurbishment programme. The home and peoples rooms smelled clean and fresh, which was complimented by the Expert by Experience and inspector. Contractor certificates checked about fire and emergency call equipment, emergency lighting, heating and gas appliances, and an assisted bath were up to date. Maintenance records about hot water were discussed with managers. The handyperson has instructions about weekly checks, and any corrective action is followed up by staff. However the system in place needs to ensure that all taps people use are tested frequently. The records we saw are in the safe range so that people are protected from scalds. Showers have thermostatic valves but records showed one - two degrees C above the safe range. Management obtained Health and Safety Executive guidance during our visit, changed instructions to the handyperson and said this would be acted upon the next day for further safeguards. We were told that no one showers independently and staff check temperatures, because at the last inspection showers were too cold. We were satisfied with these precautions. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 22 The AQAA told us about an action plan to control the spread of infection, but the contagious disease procedure had not been reviewed since 2006. Only half the staff were trained in infection control. We saw good measures in place such as paper towels, liquid soap, aprons and gloves however personal toiletries had been left in one shower room. These were removed and managers said this will be discussed in the next staff meeting. The Expert by Experience was impressed that staff encouraged use of anti-bacterial gel by visitors. People had flu injections and infection screening and care plans ensure clothing is washed separately at the right temperature when necessary. We saw COSHH chemicals safely stored, and cleaning schedules that use best practice are kept up to date. A new cleaner told us how they had been inducted, were clear on infection control measures such as colour coded mops and had all the necessary equipment. During our visit arrangements were made to train the remaining staff in infection control, and after our visit the home told us that this was brought forward to October 2009. All care and catering staff had food safety training. We had no cause to report any concerns to other regulators. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27-30: People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have assistance from competent staff who have management support and additional training so that their conditions and best practice is understood. Staff are usually available when people need support, and the recruitment process protects people. Specialist staff and volunteers provide added value. EVIDENCE: The service user guide says that although each staff member has a role, the emphasis is on teamwork, something we saw in action during our visit. This year two thirds of staff we surveyed responded, which was an improvement. They had good things to tell us about in writing and on our visit - how they work well together, how much they like their work, and how proud they are of the way they care for people. The Expert by Experience reported senior carers have served for several years and they give the home a sense of security…residents benefit from this level of continuity…a young male carer added a healthy balance to the staffing arrangements. There are two male care staff so that men have choice. The inspector spoke to two new staff that were full of enthusiasm and confidence The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 24 from good inductions and training and knowing that I can ask any question and more experienced staff will guide me. We asked management how they achieved their team approach after disappointment at the last inspection. They showed us how they use praise in staff meetings and re-vamped supervision, and they hold staff events outside of work time to celebrate achievements. People told us that they always get the care and support they need, and that staff are usually available when they are needed. Staff told us that there are always enough staff, and we confirmed by observation and rotas that there are sufficient staff at peak times. Temporary staff are not used - staff and managers cover holidays and sickness so that people have consistency. People have skilled help in an emergency as all seniors and managers are trained in resuscitation, and staff are trained in first aid awareness. During the past year four staff left. Everyone with a regular role has checks with police and government lists, including one volunteer and young people on work experience. Robust risk assessments put supervision in place so that induction and shadowing experienced staff can commence before full checks are received. We queried an ambiguous reference for one new worker, although other recruitment checks were robust. Management prepared an immediate risk assessment so that people were safe, followed this up and a third reference to confirm their satisfaction with us within 48 hours of our visit. Staff are highly valued and have excellent induction, training and opportunities for additional qualifications. An initial induction is followed by a Skills For Care induction, progressed within six months and competencies are checked. New staff impressed us with their knowledge of the homes safe working systems and approach to dementia care. Induction ensures that staff are aware of the code of conduct, policies and safe working practices for health, safety and welfare. 79 of staff have at least NVQ 2 qualifications, which exceeds minimum standards. The deputy and senior staff are progressing NVQ 4 qualifications. During the past year staff have undertaken and refreshed most mandatory training, and started Level 3 dementia care training by college distance learning. Additional training has changed ways of working. Regular staff meetings and supervision take place, where knowledge and observations of practice and audits are reviewed, and there is continued learning and problem solving. This shows us that staff development is continuous. This was confirmed by a variety of sources on our visit. People and relatives are in competent, safe and responsible hands. Staff have excellent relationships with people. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31-33, 35-38: People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well run, using best practice systems for health and safety and to maintain high quality standards. The service continues to learn and develop from the views of people, representatives and professionals as well as their own research, networks and strategies. EVIDENCE: The manager has long experience in care, the appropriate managers award and is registered by the Commission. They are working on an NVQ4 The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 26 qualification in management and leadership. The manager is supported by a deputy responsible for the supervision of staff and keeps the training plan up to date. The owner is regularly in the home, meets regularly with the manager and conducts unannounced visits and audits. This management team is confident, highly motivated and leads a person-centred team approach and new ways of working. Supervision and appraisal improved. Staff told us that management are always on hand and helpful, and that emergencies are well managed. Management do research on best practice and arrange additional training whenever it is needed from external providers so that staff gain new knowledge and new skills to meet the needs of the service specified in the statement of purpose. It was clear to us that this learning was used to review and develop the homes approach to dementia care, falls prevention, nutrition, pressure area care, infection control and behaviour management. Revised policies, procedures, risk assessments and systems reflect national best practice. Training and external consultancy was used in a timely way to meet all the requirements and recommendations we made at our last inspection. Appropriate certificates were on display in the home. Peoples outcomes have improved, and relatives have noticed the effects of changes that have added quality of life benefits for people. Everyone finds the management team approachable and responsive. The quality assurance system seeks views of people, relatives and professionals by questionnaires and in meetings, and as a result provided more outings and use of community facilities. There are further plans to improve the design and layout of the home, and to add a raised allotment for people to grow their own vegetables and scented flowers. Incidents, complaints and audits of health and safety are analysed and used to continue learning and service development. The home no longer provides safekeeping of personal allowances, following break-ins. Instead they invoice for necessary personal expenditure, and families told us that this is helpful. During our visit the owner obtained advice from the Health Protection agency and wrote a swine flu contingency plan to ensure service continuity which was made known to staff. Their cleaning schedules already matched government guidance to prevent infection. We also found management to be responsive. The smooth running of the home is ensured by maintenance and refurbishment, and systems for safe working practices. We were told that there were no outstanding requirements from other regulators. The home achieved a 4H award for good food hygiene and food safety from the council environmental health. The homes risk asst was updated since the last inspection. We discussed improving its critique and quality, clearly identifying the risk, and dates the existing actions were progressed and completed. Lead responsibility for improving this was promptly assigned. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 27 Robust interlinked systems ensure high standards are self-sustained. The Expert by Experience was very impressed with The Limes and their staff, glad to have had the opportunity to see a home that stood out from others in their experience of services for older people. The Limes may further benefit by seeking external confirmation of quality, such as ISO 9001. Human resource processes ensure safe and consistent staffing. The diversified recruitment strategy provides choice of staff and volunteers to match to peoples needs. It has not been necessary to use their Home Office licence due to new links with local employment services. Relationships with schools were further developed, and the home now provides young people on the King Edwards Award with supervised work experience. This ensures the home has an active role in the community, care is promoted as a career, and people benefit from intergenerational contact. The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 4 18 4 4 4 X X X 3 4 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 4 4 4 3 The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 29 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Limes Rest Homes DS0000062017.V377776.R01.S.doc Version 5.3 Page 30 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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. 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