Care Home: The Mount

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What the care home does well The acting manager had a proactive approach in that she had started to audit records and the environment taking action where necessary and where she had the authority to make improvements. We received some positive comments from people living at the home which included, "the staff are kind and helpful " and "they help as much as they can." The staff on duty were genuinely caring and friendly and made conversation with people living at the home. We saw staff talking to people and offering choices and assistance at a level and pace that they needed. Relatives told us they felt welcomed when they visited and comments included, "very welcoming, we are always offered a drink." People looked well cared for, with clothing appropriate to the weather and according to their preference. What has improved since the last inspection? The management arrangements were more consistent and any events affecting people living at the home were notified to us. Medication practices were considerably improved. Care records were improved to be more detailed with clearer guidance so that staff could meet people`s need more effectively, though some further improvements were needed. There were some improvements to the cleanliness of the premises. There was a documented audit of the environment with an action plan. Though this was mainly reactive because timescales were dependant on decisions made by the company director. Following requirements for appropriate staffing arrangements and complaints about staffing levels, the management had improved employment checks, numbers, skills and knowledge of staff to meet the needs of the people living at the home. Some quality assurance audits had improved so that failings could be recognised and actions taken to improve the service. What the care home could do better: Care plans needed further development, to include all assessed needs, and show that each person and where appropriate their representative is involved and in agreement. Access to specialist medical advice and support needs to be improved. Some aspects of medication practices needed further improvement to make medication administration as safe as possible.The people responsible for decision making in the organisation must make sure swift action is taken to progress the maintenance of the whole premises to acceptable standards. All equipment, such as hoists and lifts must be serviced and maintained to demonstrate compliance with legislation to safeguard the health and safety of all persons at the home. Key inspection report Care homes for older people Name: Address: The Mount 226 Brettell Lane Amblecote Stourbridge West Midlands DY8 4BQ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jean Edwards     Date: 1 3 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 36 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: The Mount 226 Brettell Lane Amblecote Stourbridge West Midlands DY8 4BQ 01384265955 F/P01384265955 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Jenny Joy Green care home 18 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 18 The registered person may provide the following category of service only: 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 any other category (OP) 18 Date of last inspection Brief description of the care home The Mount is registered to provide 24-hour care and support for 18 people over the age of 65. It does not provide nursing care. The property is a large 2 storey detached house situated on Brettell Lane, Amblecote and is easily accessible by public transport. The home has been extended to include a previously detached bungalow. There are gardens to the front and rear and car parking facilities to the side of the house. There are 16 single and 1 double rooms with the majority having en-suite toilet and hand wash basin facilities. Shared space comprises of a dining room, lounge and conservatory. A smaller lounge is also available and may be used when people living at Care Homes for Older People Page 4 of 36 Over 65 18 0 2 3 0 6 2 0 0 9 Brief description of the care home the home have visitors. Access to the first floor is via a lift or main stairway. The home has an assisted bath located on the 1st floor a shower room and a walk-in shower on the ground floor. Care Homes for Older People Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We, the Care Quality Commission (CQC), undertook an unannounced key inspection visit over two days. This meant that the home had not been given prior notice of the inspection visit. We monitored the compliance with all Key National Minimum Standards and requirements for improvements made at the random inspection visit in June 2009. The range of inspection methods to obtain evidence and make judgements included, assessments of records, and discussions with the acting manager and staff on duty during the visit. We also talked to visitors and people living at the home, and we made observations of people without verbal communication skills. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the Commission. We looked at a number of records and documents. The acting manager submitted the homes Annual Quality Assurance Assessment (AQAA) as requested prior to this inspection visit. We looked around the premises, looking at communal areas of the home, the Care Homes for Older People Page 6 of 36 bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. The provider had not published the range of fees. People are advised to contact the home for up to date information about the fees charged. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? What they could do better: Care plans needed further development, to include all assessed needs, and show that each person and where appropriate their representative is involved and in agreement. Access to specialist medical advice and support needs to be improved. Some aspects of medication practices needed further improvement to make medication administration as safe as possible. Care Homes for Older People Page 8 of 36 The people responsible for decision making in the organisation must make sure swift action is taken to progress the maintenance of the whole premises to acceptable standards. All equipment, such as hoists and lifts must be serviced and maintained to demonstrate compliance with legislation to safeguard the health and safety of all persons at the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 36 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The statement of purpose and service user guide did not provide full, accurate and up to date information about the home. People living at the home did not have up to date contracts terms and conditions of occupancy. This has the effect that people and their advocates do not have good information regarding their rights and entitlements, and how care will be provided. Evidence: We looked at a copy of the homes statement of purpose, which had not been updated to meet a recommendation at the last key inspection in June 2008. Although the service user guide was available when we conducted a random inspection on 23 June 2009, there were no copies of this document available at the home at this inspection visit. We were not shown any evidence that the documents could be provided in alternative formats for people unable to read or understand written information. There were a number of omissions in the statement of purpose on display such as the homes admission criteria, number and qualifications of the manager and staff or fire Care Homes for Older People Page 11 of 36 Evidence: precautions. All documents should provide accurate, easy to understand information about the home. There was no information about the range of fees. The arrangements and fee information should be included in the service user guide. This document should offer people full information about the service to help them make decisions about the choice of home. There had been no new admissions to the home since June 2009. The sample of case files of two people living at the home showed that each person had been provided with a contract and statement of terms and conditions. However the contracts were in different styles and had not been revised and updated. Both versions contained ambiguous terms, which might be considered unfair, such as an expectation that relatives should escort people to appointments outside the home with health professionals or pay an additional, unspecified amount for a staff escort. These documents should be easy to read and understand. There should be details about what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the person living at the home. From the information provided at the home we saw that the majority of people were funded through the Local Authorities. We saw that some people were charged a third party top up fee but this was not specified in the information about the home or in the sample of contracts of residence viewed. We saw evidence that the acting manager kept each persons health and care needs under review and made referrals for reassessments to appropriate healthcare professionals. There were examples of medication reviews and additional support from a physiotherapist and an occupational therapist for advice and support with mobility for two people. The examination of a sample of care records showed that there was assessment information, which recorded individual preferences such as rising, retiring, preferred activities, likes and dislikes. This meant that staff had good information about each persons needs and preferences about how they wished their care to be provided. Care Homes for Older People Page 12 of 36 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are care plans and risk assessments, which are adequate to identify peoples needs and provide staff with guidance. There are generally assurances that individual needs will be met for each person. The arrangements for administration of medication do not entirely ensure people receive their medicines as prescribed by their doctor, which may pose risks to their health and well being at times. People are treated with respect and their privacy and dignity is maintained. Evidence: We looked at a sample of care records of people living at the home. The acting manager had continued with improvements, which were at an early stage of implementation at the random inspection in June 2009. Information had been reviewed and used to formulate more person centred plans to meet each persons needs. There was a more consistent approach to the way the healthcare screening tools, risk assessments and care plans were implemented, monitored and maintained. Care Homes for Older People Page 13 of 36 Evidence: This meant that people living at the home could feel more assured that their care needs were known about, understood and would be met. An examples was, an improved care plan for a persons communication needs, where it was recorded that they refused to wear their hearing aid. There were good instructions to staff as to how to speak, face-to-face at a level and pace the person could understand, and it was also recorded that this person could lip read to some extent. The acting manager had introduced a key worker system to improve individualised care and support. Each person had a record called this is my life, which were generally well completed with life history information, and preferred names. There were also social profiles, giving additional information about personal preferences such as bedtime routines and preference, likes newspaper in the morning. We confirmed these were made available. People had generally good access to health care services to meet their assessed needs. The home used the services of a contracted GP, though we were told that people could choose their own GP within the limits of geographical borders. We saw that people had access to dentists, opticians, chiropodists and other community services such as speech and language therapists and occupational therapists. There were people who had recently received assessments and support from the occupational therapists to improve mobility and one person had been provided with a special lamp positioned by her chair for optimum effect for her visual impairment. Another persons care plan contained good information regarding physiotherapy provided by the visiting physiotherapist. There was a daily exercise regime and staff recorded progress in daily notes. There were also diagrams of the personal exercise programme on file so that staff could offer support between the physiotherapists visits. There were improvements to risk assessments and moving and handling assessments with clearer instructions to staff specifying the level of assistance and equipment required, which meant people were transferred appropriately. We recommended the type of hoist and size of sling should also be recorded for additional safety. There were risk assessments and care plans relating to challenging behaviours and we noted that there were also care charts in place for hourly checks if the person refused to leave their bedroom during the day. We saw that staff used appropriate techniques to diffuse situations when people became anxious or agitated. Care Homes for Older People Page 14 of 36 Evidence: There were some areas, which needed further improvements such as care plans for people with dementia, which needed to be expanded to include all presenting symptoms. The information was difficult to find in some files, which were disordered. All care files should be reorganised to easily access information. Some information had been inaccurately transferred to newer formats, for example spiritual needs. In one persons profile it stated Church of England when in fact they belonged to the Spiritualist church. There were monthly care plan evaluations but many contained comments such as, no change to care plan. This did not give useful or accurate information about the person over the previous months, especially as other records showed there had been changes in the persons condition. The care plans and evaluations did not show that the person or their representative had been involved and there were no signatures to demonstrate their active involvement. Relatives and a person living at the home told us they had not been shown information or been asked to confirm their agreement. The acting manager acknowledged there were people living at the home who were capable of giving informed consent and this was an area, which needed to be improved. We noted that though there was generally good liaison with doctors, there were some areas where timely responses where not happening, such as blood tests required for a person experiencing an exacerbation in symptoms. The acting manager told us she had no idea when the practice nurse would be coming to do this procedure. There was also no indication that a referral for specialist advice had been considered despite the persons obvious new symptoms relating to rheumatoid arthritis. There was also a lack of follow up support for a person with a history of mental illness. We recommended that advice and support should be sought from Primary Care Trust (PCT) specialist services such as rheumatology, diabetes, Parkinsons and mental health teams. The acting manager gave us assurances that she would make sure reviews and follow up appointments took place. The daily records had generally improved to show how each persons care was being provided. However we discussed one record with the acting manager, where night staff had described a person as very demanding buzzed 12 times while getting other residents up, we had to tell her to buzz once and wait her turn. The acting manager agreed to investigate this with member of night staff and inform the person and us of the outcome. Care Homes for Older People Page 15 of 36 Evidence: The pharmacist inspector visited the home on 13th October 2009 to check the management and control of medicines within the home. We saw that medication was stored in a locked room upstairs. The temperature of the room was recorded daily and was within the correct storage temperature for medication. We saw that the medication refrigerator was locked and a daily record of the temperatures was within the correct storage temperature. This meant that medication was stored securely and within the recommended temperature ranges. A previous inspection had found that some medication, which requires special storage arrangements under the Misuse of Drugs (Safe Custody) Regulations 1973, was not stored according to legal requirements. At this inspection we were shown a new storage cupboard. The storage requirements for controlled drugs met the regulations. We looked at the current records for the receipt, administration and disposal of medication for people living in the home and found that overall the medication records had improved and were well recorded. The majority of the medication administration record (MAR) charts were documented by the care staff either with a signature for administration or a code was documented with a reason why medication was not given. We saw records for the disposal and return of medication to the pharmacy. The receipt of medication was usually documented but we did see two examples where this had not been done. Balances of medication were not always carried forward from an old MAR chart to a new MAR chart in particular for any liquid medicines. The date of opening of any boxed or bottles of medication was usually recorded but we did see some examples where this had not been done. We informed the manager of the particular examples where it had not always been done in order to ensure the health and well being of people who live in the home are safeguarded. We saw that the home kept a record of any medication changes or reviews made by a GP. This ensured that any medication changes were immediately available for care staff to check. We saw that some people were prescribed medicine, which was to be given on a when required or as needed basis. We saw protocols for staff to follow to ensure that the medication was given according to the prescribers instructions. We checked the medication and healthcare records for one person who had been administered medication when required for behaviour management. We saw that there was a PRN protocol for staff to follow in the medication folder and also in the persons individual plan of care. However, the protocol did not include any other calming methods or Care Homes for Older People Page 16 of 36 Evidence: under what specific circumstances the medication would be required to be given to the person. We spoke to the manager who described the particular behaviour that the person showed when agitated, however this information was not written into the protocol for administration of the medication to ensure the safety of the person. We saw that staff were respectful to each person and considered their dignity when they were providing personal care. They spoke to people using terms and a pace they could understand. People looked cared for and well groomed, wearing clothing of their choice and appropriate for the weather. Each persons last wishes were well recorded, where appropriate. For example one person had stated in detail the church of their choice, their preferred music and final resting place. Care Homes for Older People Page 17 of 36 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are some activities for people, though limited access to social stimulation in the local community. People are enabled and encouraged to maintain good contact with family and friends. People can choose from a balanced and varied selection of foods that meet their preferences and nutritional needs. Evidence: The routines of the home were generally flexible to meet each persons needs. There had been improvements to record each persons choice of rising, retiring, bathing or showering. Discussions confirmed that people were generally assisted at the time of their choosing. One person told us they still had to wait at times for assistance, especially in the mornings, when they felt there were staffing shortages if staff were sick. We discussed this persons concerns, with their consent with the acting manager, who agreed to investigate further and find a satisfactory resolution. The home does not have an activities organiser and staff at the home were using their knowledge of peoples preferences to plan activities, which people might like. There were no allocated hours for activities, though staff told us they made time to lead Care Homes for Older People Page 18 of 36 Evidence: activities sessions each morning and afternoon. We were told that most people enjoyed bingo, quizzes and exercises to music. The staff provided small prizes; there was no budget for equipment for activities. There was little evidence of involvement with the wider community, such as trips or outings. However the acting manager told us that some people wanted to go to the pantomime for Christmas and she was planning to organise this. She had also organised a Christmas outing and meal at a local pub. The acting manager had conducted a survey about activity preferences and had received 15 responses. 12 people were happy with activities provided, 3 people felt there were not enough activities and comments included, would like to go for walks and more bingo and dominos with prizes. We were told that one person who wished to continue with their faith was visited by the vicar from the local church, usually most Sundays. We saw that family and friends were welcomed and we spoke to some visitors who told us they knew they could visit the home at any time. They told us that the acting manager and staff team always made time to talk to them and offer them drinks. People were encouraged to bring in their personal possessions to make their room more familiar and homely. There were no inventories of personal possessions on the sample of files examined. Inventories of each persons possessions should be recorded and should be kept up to date, signed and dated by the person or their representative and witnessed by the member of staff. The acting manager had arranged postal votes for people who had chosen to vote. There were written menus for each meal, with at least two choices. There were no other formats for people unable to understand the written information but the acting manager told us that she planned to devise and put in place pictorial menus to help people make realistic choices. We discussed nutrition with care staff and acting manager. They were generally knowledgeable about each persons nutritional needs and we were told that a choice was always offered, there were also diabetic and soft diets. We were told there was also added calorific value at mealtimes for people with poor appetite or at risk of weight loss, using cream, butter and cheese. Food records for each person had been put in place since the last inspection. A carer was working as a temporarily cook until a new cooks recruitment clearances were obtained. People told us that meals had Care Homes for Older People Page 19 of 36 Evidence: improved since the random inspection in June 2009. The main meal looked appetising and people appeared to have enjoyed their food, with little wasted. Care staff on duty made the tea, supper and drinks and snacks at all other times. Staff were aware of the needs of people who found it difficult to eat at mealtimes and they offered sensitive assistance with feeding. They were aware of the importance of offering food at the persons pace, so that they were not hurried. Efforts had been made with the dining room to make it look inviting with attractive tablecloths, table decorations, crockery and condiments. Care Homes for Older People Page 20 of 36 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can generally feel assured that any concerns and complaints are listened to with action to investigate using systems to record findings and outcomes. There are arrangements in place to safeguard people living at the home. Evidence: We looked at the homes systems to deal with complaints. We saw that there was a complaints procedure displayed in the home and available in the Service Users Guide. Some of the information was out of date. There were no other alternative formats for people who may not be able to read or understand written information. There had been two complaints made to us since last random inspection in June 2009. We referred one complaint to the Local Authority as the lead agency for safeguarding vulnerable adults. This was investigated and upheld. There was a further anonymous complaint, which was also investigated and upheld. As a result the organisation took action to improve the cleanliness of the home and increase staffing levels. We saw evidence that additional new staff had been recruited and staffing levels were improved, with three care staff on duty on all shifts throughout the waking day. We spoke to the complainant who felt generally satisfied but had some outstanding issues about the length of time they were left waiting for attention at times. With the persons consent we discussed this with the acting manager, who held a meeting with the person during this inspection visit to reach an acceptable resolution. We recommended that the management of the service should confirm that complainants Care Homes for Older People Page 21 of 36 Evidence: are satisfied with actions to resolve complaints. We looked at the new complaints log. There were no recorded complaints about the home or people living there. We spoke to relatives and people living at the home, who told us they felt they could tell the staff or manager if they wanted to complain. The home had policies and procedures to inform staff about abuse and responsibilities for reporting suspicions or incidents. Some of these needed to be reviewed and updated. We saw that there was a programme of safeguarding training and certificates for the majority of staff who had attended training. The acting manager told us that she had booked training places for staff who had not received safeguarding training. We spoke to three members of staff who told us that they knew where they must report allegations or suspicions of abuse. The acting manager had displayed the details of contacts in the Local Authority so that they were available to staff, relatives and people at the home, which meant they could report directly any concerns, suspicion or witnessed incident of abuse. Care Homes for Older People Page 22 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a generally homely and comfortable environment for people living there. The systems in place for maintaining infection control are not sufficiently robust. Evidence: The home was a traditional detached property, which had been adapted and extended to provide accommodation for up to 18 older people. There were gardens to the front and rear and some off road parking facilities. The gardens had been tided since the random in June 2009 but required further needed attention. The work needed to exterior paintwork had not been undertaken and it was worn and flaking. At the previous key inspection in June 2008 it was reported that the front door bell did not work. Staff told us that when it worked it could not be heard throughout the home. No action had been taken to provide a new door bell or pager so that people could gain access to the home without waiting until someone heard them using the door knocker. Visitors and a social care manager told us they had difficulty in making staff hear and gaining access to see people at the home. The interior was homely, with a lounge, separate dining room, a conservatory, and a small lounge, located in an extension, which could be used to entertain visitors. At the random inspection in June 2009 the communal areas, kitchen and some bedrooms were not adequately cleaned and many carpets were faded and heavily stained. There Care Homes for Older People Page 23 of 36 Evidence: were some improvements and the acting manager had devised a maintenance plan. There was handyperson, employed to undertake all decorating, maintenance and repairs for three homes in the Dudley area. However timescales to make more than superficial or cosmetic improvements depended on decisions made by the director of the company. This meant that the management of the service could not demonstrate when actions identified at the random inspection would be completed. The newer extension to the home was generally better maintained and provided a pleasant environment for people. Examples were the attractive quiet lounge, the main corridor, with lots of pictures, information and weekly activities on offer, and a display of posters, photos, old records, and light switches for sensory stimulation. We viewed a sample of bedrooms with peoples permission where possible. Some had been personalised with possessions such as photographs and ornaments. However some bedrooms had malodours, which the acting manager told us were difficult to eradicate because the floor coverings were not suitable. We also saw a stained bed base and mattress, which was uncomfortable with springs protruding. Another bed had a propad overlay pressure reliving mattress placed directly onto the bed base. An appropriate mattress must also be provided. The management must audit all beds and floor coverings and arrange renovation or replacements to acceptable standards for the comfort and safety of people at the home. At the random inspection in June 2009 we noted that the Environmental Health Services (EHO) had inspected the kitchen in January 2009 and issued 13 legal requirements and four recommendations. We also highlighted areas, which needed to be improved. The cook told us there were insufficient catering hours to be able to carry out a thorough cleaning schedule. The Environment Health Officer (EHO) report indicated that there would be a follow up visit but the home could not confirm whether this had taken place or that improvements made were satisfactory. At this inspection visit we were told the cook had resigned and there had been difficulty recruiting a suitable replacement, though a new cook had been recruited and was waiting for clearances to start employment. The carer covering catering duties was knowledgeable and the food safety checks and cleaning regime had been improved. The majority of high-risk areas were provided with liquid soap, paper towels, gloves and hand wash signs. However we noted that the first floor bathroom did not have a supply of liquid soap, paper towels, disposable gloves and aprons, needed to maintain effective infection control. We also noted that there were no had washing signs in en suite facilities and some of the ventilation fans were not in working order. Care Homes for Older People Page 24 of 36 Evidence: The small laundry was located well away from any food preparation area. It had adequate machines for washing and drying. We were told that the home did not have separate sluicing facilities and commode pots were cleaned in the laundry. There was no procedure or protocol in place for this process. At the random inspection in June 2009 we recommended that the management should revise the laundry procedures to reflect good practice guidance in the Department of Health Essential Steps for Infection Control. The acting manager acknowledged that she did not have a copy of this guidance and had not undertaken an infection control audit or devised an action plan to ensure there were effective infection control measures throughout the home. She had obtained a copy of the infection control guidance by the second day of this inspection visit. Comments from relatives about what the home could do better included, corridor needs a new carpet and redecoration also the dining room used to be the lounge, this has been changed with each change of management and would like it to be reinstated as the lounge as it would give people more space and more use could be made of the conservatory. Care Homes for Older People Page 25 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The number and skill mix of staff usually meet the needs of people living at the home. The recruitment processes provide sufficient safeguards for people living at the home. There is a training programme in place to equip staff with skills to meet peoples needs. Evidence: There were fifteen people living at this home with a range of different needs. The acting manager had obtained information about each persons needs since the random inspection in June 2009. Following the investigations into complaints about poor staffing levels and people waiting for attention, the director of the company allowed the staffing levels to be increased. This should have been actioned proactively as a response to the requirement issued at the random inspection in June 2009; to ensure there are adequate numbers of qualified, experienced, and competent staff available at all times. We were told that there were three carers on duty for all early and late shifts, supported by domestic and catering staff each day. An additional cleaner had been and a new cook recruited. The acting manager told us she regularly monitored staffing levels and in future would act as an advocate to make sure staffing levels were adjusted to meet peoples needs. We looked at staffing rotas, and we spoke to people at the home, visitors and staff. The staffing rotas did not contain each persons full name, designation and it was Care Homes for Older People Page 26 of 36 Evidence: unclear on some shifts who was responsible for the running of the home, especially during night shifts. People generally felt there were improvements, and a relative commented, Individualised care is better. One person told us they still had to wait unacceptable lengths of time for attention, as already highlighted at the Complaints section of this report. We saw that care staff had duties other than caring for people, such as all the laundry duties. Care staff did the catering for tea, supper, snacks and drinks each day, when the cook was off duty. As highlighted at the Daily Life and Social Activities section of this report there were also no allocated hours to ensure that there were suitable activities and social events for each person living at the home. The management should closely monitor the impact of ancillary duties on allocated care hours available and make alternative arrangements as necessary. We looked at a sample of personnel files of staff recently employed. The files were organised with a recruitment checklist. The recruitment process had been improved and provided safeguards for people living at the home. One person had been employed on a POVA First basis before the full CRB (Criminal Records Bureau) disclosure had been received. There was a written risk assessment in place but it should be expanded to show full details of supervision arrangements. There was evidence of an in house induction on the staff files, some supervision records and evidence of the Skills for Care Common Induction Standards, which were in the process of being completed. The homes AQAA was incomplete and the acting manager appointed on 15 June 2009 could not find some data about staffing. She told us that three staff had left the homes employ since the random inspection in June 2009 but could not tell us how many staff had left in the last 12 months. The AQAA did not have information about the number of care staff who had achieved a NVQ (National Vocational Qualification) level 2 care award. The acting manager had started to work on a training and she showed us evidence that staff training in a number of areas had been booked. Care Homes for Older People Page 27 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management arrangements do not always provide sufficient safeguards for people living at this home. There are systems for consultation with people living at the home, with views sought and acted upon. Evidence: The acting manager was appointed in June 2009 and had submitted an application to be registered as manager for this home. She had previously worked with older people over a number of years and had achieved a National Vocation Qualification (NVQ) level 4 Care Awards. She had planned to commence the Leadership and Management skills training but was waiting for funding arrangements. We noted at the random inspection in June 2009 that the acting manager had started to carry out some quality assurance checks; these included the fire systems, emergency lights, residents weights, some care files, some staff files, where she had already noted omissions and accidents. There was no evidence that quality audits had been completed prior to her appointment. She had also put in place maintenance and Care Homes for Older People Page 28 of 36 Evidence: development plan and action plan, though the timescales were mainly reactive. There were areas needing attention identified during this inspection visit, which were not recorded on the maintenance programme. The information in the homes AQAA was incomplete. The management of the organisation must provide comprehensive information about quality assurance assessments when requested. There were records of recent staff meetings and staff told us they were useful and that they could share their views openly. There were monthly residents meetings, with topics such as food and activities, with recorded comments from people living at the home indicating they enjoyed the food but would like more activities and outings. Unannounced Regulation 26 visits to monitor the management and running of the home had taken place. The reports highlighted some good practices and some areas, which needed to be improved. We were told that people were offered the opportunity to manage their own money if they wished, and there were facilities to help keep it safe. We looked at a random sample of balances and records of monies held in temporary safekeeping on behalf of people living at the home, which were accurate, with records of all transactions. However some transactions did not have two signatures, which would demonstrate good practice to safeguard peoples finances. We saw supervision records, which showed us that staff had been receiving regular supervision since June 2009. We saw evidence that the acting manager was arranging mandatory training to ensure each person received training appropriate to their roles, such as fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training. We looked at a sample of heath and safety, fire safety and maintenance documentation, which were generally well organised. We noted that the report of the bacteriological water test in conducted in January 2009 stated the water system should be retested in six months but there was no evidence this had been done. The acting manager told us that the company director did not keep all of the service documents at the home; some may be at the company office. She confirmed that there was no record of a Legionella or Asbestos risk assessments at the home and was not aware of whether these risk assessments had been undertaken. Care Homes for Older People Page 29 of 36 Evidence: We viewed the hoists and lifts service work sheets available. The servicing company had identified work to be carried out on the passenger lift but there was no satisfactory service certificate available. We discussed the reports with the company director who insisted work was only a recommendation and did not necessarily need to be done. We expressed our concerns and informed him that we would refer this matter to Dudley MBC Environmental Services. Following our referral the Principle Environmental Officer authorised a visit the same day and subsequently wrote to the company director requiring evidence of satisfactory servicing of the lift and hoists in compliance with LOLER Regulations. We also looked at accident records and Regulation 37 notifications. The acting manager had implemented an accident analysis and evaluation, which identified trends and risks, which could be controlled or minimised. Care Homes for Older People Page 30 of 36 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 31 of 36 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 To ensure that there are care plans, which include all of each persons assessed needs that are appropriately evaluated and updated to accurately reflect all changes to health and needs. This is to ensure care for each persons health and well being is properly provided at all times. 30/11/2009 2 9 13 Arrangements must be 30/11/2009 made to ensure that care plans include detailed information and instructions for staff in respect of the administration and management of medicines, including the reasons to give medicines on an as and when required basis. This is to safeguard the health and well being of people living at the home. Care Homes for Older People Page 32 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 19 23 To audit equipment such as beds, floor coverings, ensuring each person is provided with suitable furniture and fittings for their comfort and safety. This is to promote the health, well being and comfort of people living at the home. 14/12/2009 4 25 13 To ensure that all areas of the home are clean and meet the infection control criteria. This is to ensure the health and well being of people living in the home is safeguarded. 14/12/2009 5 38 13 The management systems must ensure that the premises and equipment have robust risk assessments and evidence of satisfactory maintenance and servicing as required by legislation. This is to ensure people living at the home are safeguarded at all times. 14/12/2009 Care Homes for Older People Page 33 of 36 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 1 The range of fees should be published in the service user guide so that people have information to assist them to decide on their choice of home. The homes statement of purpose and service user guide should be revised, updated and reissued to people living at the home in easy to understand formats suited to their capabilities. The contract / terms and conditions of residence should be revised, updated and reissued to each person living at the home to and should reflect good practice guidance issued by The Office of Fair Trading. Care records should be organised so that information is easy to find, using aids such as an index and dividers. There should be evidence such as signatures to show person or their representative had been actively involved in the development of their care plan and monthly evaluations. Advice should be sought from PCT specialist services for people living at the home, with conditions such as rheumatoid arthritis, diabetes, Parkinsons and mental illness with records of support and advice offered together with any awareness training provided for staff. The type of hoist and size of sling should be recorded on moving and handling risk assessments and in care plans. An appropriate budget should be provided to fund equipment for activities and incentives such as small prizes for competitive activities. Inventories of each persons possessions should be recorded and should be kept up to date, signed and dated by the person or their representative and witnessed by the member of staff. The management of the service should establish that complainants are satisfied with actions to resolve complaints. The complaints procedure should be revised and expanded with timescales and updated contact details. The home policies and procedures relating to safeguarding vulnerable people should be revised, simplified and updated 2 1 3 2 4 5 7 7 6 8 7 8 8 12 9 14 10 16 11 12 16 18 Care Homes for Older People Page 34 of 36 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 to reflect current good practice guidance. 13 19 Maintenance, redecoration and refurbishment of the environment to an acceptable level should be undertaken be timescale to assure the comfort and safety of every person living at the home. The management should closely monitor the impact of ancillary duties on allocated care hours available and make alternative arrangements as necessary so that every persons needs are met at all times. Staff rotas should be expanded to show full names, designations, and designated person responsible for running the home on each shift including night shifts and include the on call arrangements. Risk assessments for staff employed without an up to date satisfactory CRB disclosure should be robust and show full details of supervision arrangements to safeguard people at the home. 14 27 15 27 16 29 Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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