Care Home: The Old Parsonage

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What the care home does well The Old Parsonage in a small care home with nursing for older people with dementia and mental health care needs. As the home is small, it can provide a homely atmosphere for residents and reduce stresses for people with dementia, which can occur in larger environments. The home has modern, light wooden flooring which is easy to maintain at high standards of cleanliness for the client group, and light walls, with colour-coded doors for facilities such as toilets; this supports residents in locating such facilities. The home employs a core of staff who have worked in the home for many years and who know their residents well. Newer staff are fully supported when they start their roles, with full recruitment checks being made before employment. Where the home uses agency staff, the same individual return to home. Staff at all levels were enthusiastic in care provision, were keen to support residents in exercising choice in their daily lives. The new manager ensures that there are full systems for regular audit of the home environment and services provided to residents. People commented about the home. One person reported "this is a small and friendly home for both the residents and staff alike and we all love it here", another person commented on the "homely atmosphere" and another person described the home`s "pleasant and happy atmosphere". People commented on the care provided. One person reported "the home delivers excellent personal care, residents are treated with dignity and respect", another person, "the whole family is very happy with the level of care for [our relative]" and another "the improvements are on-going at the moment and we hope that, when finished, the residents will have a home that they deserve and love". What has improved since the last inspection? The provider has appointed a new manager for the home since the last inspection. They have ensured that all the requirements from the last inspection have been addressed. The new manager has put much effort into improving service provision. They have reviewed systems for assessment of residents need and care planning, introducing a more person-centred approach to care, including focusing on residents` mental health care needs, emphasising residents` strengths and areas for development for each resident. Systems relating to medicines administration and storage have been improved and safe systems are now in place for storage of controlled drugs. Records relating to administration of medicines and medicines care plans are now fully in place. Improvements have been made to the home environment, with redecoration of many areas and purchase of new furniture. Up-grades of bathing facilities for residents have nearly been completed. The new manager has performed a full audit of home facilities and put in an action plan which is being worked through, to develop facilities for residents. A fire risk assessment is now in place. The new manager has set up training and development programmes for all staff, to support them in their role. This has included a new teaching room as a resource for staff in the building. Quality audit programmes have been put in place, based both on receiving feedback from residents and their supporters and audit of clinical care of residents. Where matters have been identified, the new manager has put plans in place to develop and improve service provision. What the care home could do better: The home needs to further develop certain areas in relation to care planning and delivery of nursing and care. If a resident is assessed as being at risk of pressure ulceration, a care plan needs to be put in place to direct staff on how this risk is to be reduced, this needs to include documentation of changes of position where a resident spends time out of bed. Documentation relating to care plans would benefit from more precision, for example clearly describing parameters for diabetic care and using precise descriptive language when reporting on people with complex behaviours. Clear records must always be in place as to the reasons why residents have not been administered their prescribed medication. Residents would also benefit from development of care plans where they are prescribed medication which can affect their daily lives. Residents dignity would be more up-held if facilities and time were given to enable their clothes to be ironed, to avoid dressing them in creased clothes. Residents` social and recreational needs would benefit from increased hours for activities and diversional therapies, by people who are trained in the role. The proposed improvements to the kitchen will support the catering service. Principals of healthy eating would benefit from less use of pre-bought foods, which have a high sugar and salt content. The home environment continues to need improvement. The laundry room must be clean and dust-free and all laundry needs to be managed effectively to prevent risk of cross infection. Systems need to be in place to prevent communal use of clothing by residents. The home needs to have systems to ensure correct cleansing or disposal of sanitary items and clinical waste. All deteriorated mattresses need to be disposed of and replaced. Increased specialist beds are needed to support residents who have complex disability needs. Staffing levels need to be reviewed, to ensure that residents are not left unsupported by staff for extended periods when in sitting rooms. Additional staff are also needed to support residents at mealtimes. To improve the laundry service, a person should be employed to take responsibility for the service. As at the last two inspections, we recommend that the manager is supported by an administrator, to enable them to concentrate on their management role. Full and clear systems need to be put in place to ensure that moneys and valuables handed in, are securely stored, with a full written audit trail of all all items. The approach to residents` moneys should be modernised, to offer choice to residents and their supporters. Key inspection report Care homes for older people Name: Address: The Old Parsonage The Street Broughton Gifford Melksham Wiltshire SN12 8PR     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Susie Stratton     Date: 1 4 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 39 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 39 Information about the care home Name of care home: Address: The Old Parsonage The Street Broughton Gifford Melksham Wiltshire SN12 8PR 01225782167 01225783245 christine.rch@googlemail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Roseville Care Homes (Melksham) Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The staffing levels set out in the Notice of Decision dated 23 December 2004 must be met at all times Date of last inspection Brief description of the care home The Old Parsonage is a care home with nursing which specialises in the care of people aged 65 or over, who have dementia and other needs relating to their mental health. The Old Parsonage is situated on the outskirts of the village of Broughton Gifford. It is a 19th century listed building, which has been converted into a care home. The accommodation is on the ground and first floors, with a passenger lift available. The residents bedrooms are on both floors. Currently, there are 14 single rooms and 3 Care Homes for Older People Page 4 of 39 Over 65 20 20 0 0 0 4 0 2 2 0 0 9 Brief description of the care home double rooms. The communal rooms consist of two lounges and a dining room. The outside space includes a secure paved courtyard and a driveway with parking areas. The Old Parsonage was purchased by Roseville Care Homes (Melksham) Ltd in December 2004. The registered managers post is currently vacant; a person is acting into this role, they lead a team of nursing, care and ancillary staff. The fee at the time of the inspection started at 625 pounds a week. A copy of the last inspection report is available in the home. Inspection reports are also available through the Commissions website at: www.csci.org.uk Care Homes for Older People Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: As part of the inspection, 30 questionnaires were sent out and nine were returned. Comments made by people in the questionnaires and to us during the inspection process have been included when drawing up the report. The homes file was reviewed and information obtained since the previous inspection considered. The new manager also submitted an Annual Quality Assessment Audit (AQAA). This is their assessment of the quality of their service provision. It also provided numerical information on services provided. We looked at the AQAA, the surveys and reviewed all the other information that we have received about the home since the last inspection. This helped us to decide what areas we should focus on when doing the inspection. The site visit was performed by one inspector. This person is referred to as we throughout the report, as the report is made on behalf of the Care Quality Commission (CQC). The site visit took place on Thursday 14th January 2010, between 9:30am and 5:30pm. The visit was unannounced. A registered nurse was in charge of the home Care Homes for Older People Page 6 of 39 when we commenced our visit and the new manager came on duty during the morning. The new manager was available for the feedback at the end of the inspection. During the site visit, we met with a range of residents and also observed their care. We toured all of the home and observed care provided at different times of day and in different areas of the home. We reviewed care provision and documentation in detail for three residents, including a resident who had recently been admitted to the home and looked at specific records relating to a further three residents. As well as meeting with residents, we met with a registered nurse, three carers, an agency carer, two domestics and part-time cook. We observed a lunchtime meal. We reviewed systems for storage of medicines and observed one medicines administration round. A range of records were reviewed, including staff training records, staff employment records, complaints records and maintenance records. Care Homes for Older People Page 7 of 39 What the care home does well: What has improved since the last inspection? The provider has appointed a new manager for the home since the last inspection. They have ensured that all the requirements from the last inspection have been addressed. The new manager has put much effort into improving service provision. They have reviewed systems for assessment of residents need and care planning, introducing a more person-centred approach to care, including focusing on residents mental health care needs, emphasising residents strengths and areas for development for each resident. Systems relating to medicines administration and storage have been improved and safe systems are now in place for storage of controlled drugs. Records relating to administration of medicines and medicines care plans are now fully in place. Improvements have been made to the home environment, with redecoration of many areas and purchase of new furniture. Up-grades of bathing facilities for residents have nearly been completed. The new manager has performed a full audit of home facilities and put in an action plan which is being worked through, to develop facilities for residents. A fire risk assessment is now in place. The new manager has set up training and development programmes for all staff, to support them in their role. This has included a new teaching room as a resource for staff in the building. Quality audit programmes have been put in place, based both on receiving feedback from residents and their supporters and audit of clinical care of residents. Where matters have been identified, the new manager has put plans in place to develop and improve service provision. Care Homes for Older People Page 8 of 39 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 39 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 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their supporters will know that the home is able to meet their needs. Evidence: In their AQAA, the home reported that they encourage residents and their families to visit the home before admission. The manager reported that they were happy to meet with and support residents families, to ensure that they could make an informed choice about being admitted to the home. They also reported on the improved preadmission documentation that they had introduced. We observed nursing and care provision for a person who had been recently admitted to the home. Due to their dementia care needs, this person was not able to inform us about their own admission process. We observed that the new pre-admission assessment for this person was comprehensive and detailed. The assessment documented the persons range of needs, including nursing and mental health needs. This reflected what we observed and staff told us. As well as the homes own Care Homes for Older People Page 11 of 39 Evidence: assessment, they had also obtained information from the persons previous provider. Clear instructions were on the persons file about their family and which persons were to be contacted to support the home in finding out more information about meeting the persons individual needs. Care Homes for Older People Page 12 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health and personal care needs will be supported by the homes systems for management of care. Evidence: In their AQAA, the new home manager reported that since their appointment they had worked to ensure that staff delivered individual person-centred care to each resident. They reported on developments in documentation systems to support practice, including risk assessments. The importance of providing care in a discrete and sensitive manner was recognised in the AQAA. They reported that a key worker and named nurse system has been introduced to support these developments. People commented on the care provided. One person reported the patients are all kindly and well treated with great patience by ALL the staff, another I feel all the staff look after the residents well and another that the home delivers excellent personal care. A member of staff commented since [the new manager] has taken over as manager, a lot of effort has been put into improving the standard of care and another the staff treat the residents as they would their own family. Care Homes for Older People Page 13 of 39 Evidence: During the inspection, we met with residents and observed nursing and care provision. Due to their dementia, most of the residents were not able to comment on delivery of the service. We observed that residents were nicely turned out and looked comfortable. This would have been improved if cotton clothes had been ironed. We discussed this with staff, who reported that while the home did wash residents, clothes, as there was not a designated person to perform the laundry or full facilities for ironing, cotton clothes were not ironed. We inspected residents drawers and cupboards in their own rooms. We found that many clothes were not named, that the name had faded so as to be unreadable or the drawers and cupboards showed had clothes named for people other than the person in the room. Wearing of other peoples clothes does not up-hold a residents dignity. We asked staff about this. It was reported that new residents now had their clothes named on admission but that staff did not have time to ensure that all residents clothes were named and as there was not a designated person in charge of the laundry, it was difficult to ensure that all clothes were named and returned to the correct resident. We advise that the provider should look into appointing a person to perform the laundry, who will have sufficient time alloted to iron clothes and ensure that all clothes are named and returned to the correct person, to ensure that residents privacy and dignity is up-held. Staff were observed to be prompt to notice where a resident needed support in maintaining their dignity. For example, a resident decided to lower their trousers and walk down the corridor, this was promptly noted by a member of staff, who appropriately supported the resident. Where residents needed personal care due to incontinence, staff promptly attended to them, whatever the time of day, to ensure that the resident was comfortable. When performing manual handling, staff ensured that the resident was fully informed of what they were going to do throughout the procedure, so that the resident was not alarmed. They also thanked residents when they were able to assist in the process and ensured that they remained fully covered, when using a hoist. Staff at all levels knocked on residents doors before entering the persons room. We looked at residents records and observed that assessments of residents needs were clear and very detailed, using non-judgemental language. All residents were assessed for risk, including manual handling, risk of pressure ulceration, falls and malnutrition. One persons manual handling care plan detailed risks presented when the person became agitated during manual handling. Where a risk or a care need was identified, generally care plans were put in place. Care plans relating to mental health care needs were clear and included detail of actions to be taken by staff and how the persons mental health care needs affected the person. For example one residents Care Homes for Older People Page 14 of 39 Evidence: care plan described how they experienced difficulty with agreeing to personal care when their mental health condition was unstable, and how staff were to support the resident at such times. Care plans were written in a positive style, emphasising the residents strengths and individual personality. A few areas needed improvement. We observed that where residents were assessed as being at high risk of pressure ulceration, sometimes care plans were not drawn up to detail how risk was to be reduced. This is of concern, as one resident had recently sustained pressure ulceration in the home and their records indicated that appropriate action was not taken until after the ulceration had developed. Another person had a care plan about how pressure ulceration was to be prevented when they were in bed but not when they were up in the sitting rooms. As pressure ulceration does not reduce when a person is sitting out of bed, their care plan needs to detail actions to be taken by staff at such times. Their turn chart should also provide evidence that the person was having their position moved when they were out of bed, which was not happening. Where residents had additional medical needs, there were generally clear care plans in place. One resident had a history of epilepsy, they had a care plan about management of this condition, including actions to be taken in an emergency and a record of any fits experienced. Another person had a history of constipation, which could affect their dementia care needs. This person had an individualised care plan, including directions that their bowel state was to be monitored on a daily basis, with full evidence that this was taking place. Improvements are advised in diabetic care plans. One person who was a diabetic did not have the parameters aimed for documented numerically and what actions staff were to take if the persons blood sugar levels were outside these parameters. The care plan also did not consider risks to tissue viability and uptake of insulin presented by decisions relating to choice of injection sites. Staff we spoke to reported that they were well informed about residents needs. One newer care assistant reported on how useful they had found the care plans in finding out about how to care for residents when they commenced their role. The home now has a key worker and lead nurse system in place. Lead nurses draw up care plans for residents and review them regularly with the resident, relative and key workers. Care assistants document observations such as the residents weight and bowel habit in their records but they do not at yet draw up care plans or document in daily records. We reviewed daily records and observed that often the only record relating to the resident was documented at night duty. Some documentation in daily records needs review and words such as difficult when describing a residents needs should be avoided. Records should clearly state what a residents behaviours and needs were. Care Homes for Older People Page 15 of 39 Evidence: We discussed with the new manager, that care assistants should document observations that they have made about a resident in the daily records, rather than reporting them to a registered nurse for them to document. Key workers should also be supported in developing skills in drawing up care plans for their key residents. Staff reported on the homes effective working relationships with health care professionals. Full records of visits by residents GPs are maintained. All people who had wounds are seen regularly by the tissue viability specialist nurse. The home has clear wound care plans, together with records of the wounds response to treatment. The new manager has been able to ensure that residents with complex mental health needs have been seen by specialist clinician at the home, to support them in providing the resident with the most effective interventions to meet the persons needs. We inspected systems for management of medicines. Medicines were all securely and safely stored. Controlled drugs were inspected and found to be correct, with full records in place. Medicines which needed cold storage were stored in a medicines refrigerator. Full records of medicines administered to residents were completed, this included dietary supplements and topical creams. Any hand-written instructions on medicines administration records were dated and signed. We observed that one resident was not being given two of their medicines at the frequency directed on their medicines administration record. This was reported to be because their GP was reviewing the persons medication. There were no records relating to this. This is needed so that the home can fully evidence that they were giving the person their medicines as directed by the prescriber. Since the last inspection, the home has reported two medicines administration errors. These have been fully reviewed by the new manager, who has put changed practice in place to prevent re-occurrence. Were residents were prescribed medication on an as required basis, such as pain killers or apperients, a clear individual protocol was drawn up for each medicine, to direct registered nurses on when, why and how often the resident needed to be administered the medication. Some residents were regularly prescribed medicines which can affect their daily lives, such as mood altering drugs or night sedation. When this is the case, to support staff in evaluating such medicines effectiveness, care plans should include reference to all such drugs, so that their effectiveness for the resident can be regularly evaluated. Care Homes for Older People Page 16 of 39 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. Residents will be supported in exercising choice and maintaining relationships with their families, however their dementia care needs will not be supported by the lack of recreational activities and a lack of staff support at mealtimes. Evidence: In their AQAA, the new manager reported on the increased emphasis on activities, including aiming at orientating residents to different times of the year, such as Halloween. They also reported on improved documentation relating to residents activities in their records. The new manager outlined plans for development of activities provision for residents. The home does not employ a dedicated activities coordinator and activities are undertaken by carers between 3pm and 5pm every day. Carers have not been trained in this role. In their AQAA the new manager reported that they were trying to recruit an activities co-coordinator. They reported at the inspection that they had appointed a person to work 20 hours a week. The need to improve this area was commented on by people in questionnaires. One relative commented I would like to think that more could be done to relieve boredom and another that the home needed to provide more entertainment for clients. A member of staff reported that the home should provide trips out for Care Homes for Older People Page 17 of 39 Evidence: clients. In dementia care, provision of activities is seen as a key area to support residents in maintaining the skills they have and to reduce complex behaviours which may be associated with boredom or a change in their condition. Staff who provide activities need to be trained in this specialist area and relevant equipment needs to be provided. During the inspection, we observed that no activities were taking place during the morning or early afternoon. Throughout both the morning and afternoon, residents were sitting in one of the two sitting rooms with with music playing in one lounge and the television on in the other lounge. The television was showing an American hospital drama; only one resident appeared to be watching. The manager has made efforts to engage residents. The front sitting room had several vases of brightly coloured fresh flowers, which a resident reported they liked. The rear sitting room had a range of different soft toys which residents could pick up and handle. One resident had been provided with a net bag for their zimmer frame, in which they had a range of objects to handle and examine. Our observations showed that most residents were sitting passively and not engaged with anything. One resident was showing restless behaviours, shaking and twitching themselves in their chair. People with dementia will need support to engage with their surroundings and may show restless or passive behaviours if they are not engaged. The new manager was able to report on how they were planning to support the new activities person in developing their service. As the new activities co-coordinator is to work 20 hours a week, this is unlikely to be sufficient time to support residents with dementia care needs and if the provider wishes to specialise in this area, to meet the needs of residents, they need to consider how peoples needs are to be met, including increasing time devoted to activities provision. Additionally residents must not be left for significant periods of time unsupported, as they may be placed at risk. Staff reported on the importance of maintaining good links with residents families. One person commented in their survey that visitors feel comfortable and welcome and a member of staff commented that they have a great relationship with many relatives. The homes records document communication with residents relatives and these documents provided evidence of close working links with residents relatives, including evidence that staff reported on residents changes in condition to their relatives. Provision of choice is a complex area in dementia care. The new care plans are highly individualised and direct staff on how residents choices are to be supported. For example, one residents records detailed how they liked to be supported in their Care Homes for Older People Page 18 of 39 Evidence: personal care and their preferences for clothing. We observed that one resident who preferred to remain in bed continued to be there for most of the morning. Another resident preferred to remain in their room on their own and they confirmed that staff did not try to persuade them to mix with other residents, as they did not wish to do this. We observed that one resident went back and forth from their own room to the sitting rooms as they wished. A care assistant discussed this resident with us, describing how important it was that the resident should be able to do what they want and that the person was much more relaxed and happy if they continued to be supported in walking about the home. More than one resident wished to continue to smoke. When they wanted to do this, they asked a member of staff for their cigarettes and lighter, with staff not seeking to limit their choice to smoke. We observed a mealtime and met with the cook. One relative commented in their survey meals are very good - look appetising and smell lovely, another described the excellent food and another meals are patient-centred, well thought, well prepared and served in different forms and consistency that suits the resident. Some residents were able to comment on the meals. One person reported the foods good, you get a choice and another food pretty good, very good infact. Staff reported on the supports from the catering staff. One person described the full-time cook as brilliant. We observed that meals were served hot, with attention being paid to portion size to suit the individual. During the meal, a resident asked for a different choice and they were given one. Where residents needed a liquidised meal, the cook took great care to ensure that the meal was attractively presented. The full-time cook was not on duty during the inspection, so we met with the person who filled in when the full-time cook was not on duty. This person showed a detailed knowledge of residents and their preferences for meals. They were keen to give residents what they liked, in a way that suited them. They reported on the effective communications between themselves and the full-time cook. The cook reported that, while the home cooked some meals up from raw ingredients, they also gave residents pre-prepared meals as well. On the day of the inspection, the residents had a choice of shop-bought beef or chicken pies. The cook also reported that whilst some soups and sauces were made up from raw ingredients, most were of the powdered, preprepared variety. We looked at some of the ingredients in these pre-prepared foodstuffs and many of them contained high levels of salt and sugar, which is not advised for diabetics or people with heart conditions. The provider is advised that they should review systems for purchasing of food-stuffs, equipment and hours devoted to the catering service, to ensure that residents can be given nutritious meals based on the principals of health eating. Care Homes for Older People Page 19 of 39 Evidence: We observed a mealtime. It was reported that lunch was generally served at 1:00pm. However on the day of our inspection, lunch did not start until 1:45pm. This related to the homes staffing levels. Three of the residents who were being assisted to go to the dining room needed urgent personal care and we noted as good practice that the staff did not expect residents to eat their meals in an uncomfortable, unclean state but assisted them in becoming clean and fresh, before their meal. Due to the needs of these residents, two carers were needed to support the residents in doing this. This meant that there were only two carers available to support residents in getting to the dining room and most of the residents needed manual handling by two members of staff, to support them in doing this. The only other available member of staff was the registered nurse, who was supporting two residents who needed artificial feeding. The effect was that for a period of up to an hour, no member of staff was available to support the more physically able residents in the dining room. Several of the residents who were more mobile needed supports to remain in the dining room and we observed on several occasions that staff had to stop supporting a resident with manual handling needs, to support such residents before their meal. When lunch was served, staff were careful to ensure that residents had what they wanted to eat and we observed that they kept in close contact with each other, to ensure that the meal progressed in an organised manner. Several residents needed to be fed their meals, when staff did this, they sat with the resident, helping them and engaging them in conversation. As so many residents needed to be fed their meals, there were no members of staff available to support other residents who needed support to concentrate on eating their meal, to prevent them from either forgetting to eat, whilst the meal became cold, or from getting up from the table before they had finished eating what they had wanted to eat. We observed on more than one occasion that a carer who was was feeding a person their meal had to get up to support another resident. We noted as good practice that when this was necessary, the carer always apologised to the resident. We also observed as good practice that when a resident needed verbal support, members of staff never raised their voice to the resident. The situation as observed is not ideal, staff were clearly up-holding principals of good care but to support people with dementia care needs, more staff need to be made available by the provider at meal times. Care Homes for Older People Page 20 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be able to bring up matters of concern to them, knowing that they will be fully considered within the homes procedures. People will be safeguarded, however there is risk to residents when they are unsupported in sitting rooms. Evidence: The new manager reported in her AQAA on the emphasis they had placed on ensuring that people can raise issues about service provision. They reported that they have supported staff in making sure that people can raise issues with the senior staff, if they feel they need to. All of the people who responded in surveys reported that they knew how to raise complaints. We looked at the homes complaints record. This provided evidence that the new manager was complying in full with the homes complaints procedure. All complaints were fully investigated in an impartial manner. Where actions were identified as part of a complaint, there was evidence that action had been taken to address matters. We noted as good practice that the new manager also documents verbal concerns and complaints, treating them in the same manner as formal complaints. The new manager reported that they regarded complaints as an important part of quality audit, to show how service provision affected people and a means of identifying necessary improvements. Records showed that staff are aware of whistle-blowing in practice, to ensure that they Care Homes for Older People Page 21 of 39 Evidence: support vulnerable people. The new manager reported that as part of their quality audit they had performed spot checks on staff members awareness of how to safeguard residents and the homes whistle-blowing policy. In their AQAA, the new manager reported that they had ensured that all staff had been trained in abuse awareness, since they had come in post. We discussed scenarios with a range of staff, including a cleaner and the part-time cook and all were aware of their responsibilities for safeguarding residents. The manager was aware of their own responsibilities for reporting any safeguarding concerns under local multiagency procedures. We discussed arrangements for manging residents moneys with the manager and we advised that the systems needed more development, to fully prevent any risk of financial abuse. The Old Parsonage cares for residents who have mental health conditions, including dementia. As such, some residents will not be aware of risks presented by the environment. Some residents will experience complex conditions, including verbal and physical behaviours towards themselves or others. Some residents may not recall that they are unable to perform basic activities of daily living, such as standing up. To ensure that residents are safeguarded, the home has ensured that all windows are restricted and external doors locked. However residents spend periods of time without staff supports when in the sitting rooms, particularly during the mornings, when other residents need support from staff for personal care. While residents are unsupported by staff in sitting rooms, they could clearly be at risk from themselves, the home environment or each other. To prevent this risk, sufficient staff are needed to ensure that residents are not left for any extended period without support and observation from staff. Care Homes for Older People Page 22 of 39 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. Residents will be supported by an environment which is being developed to meet their needs, however developments continue to be needed, particularly in equipment for people with a disability. Laundry facilities and systems for management of potentially infected items needs more emphasis, to ensure safe practice in the prevention of spread of infection. Evidence: The new manager reported that since they came in post, they had performed a full audit of the home environment and put an action plan in place to ensure that the home environment is improved. This has included, among other areas, moving the dining room to a light, airy sitting room at the front of the building and converting the previous dining room into a smaller, quieter lounge, with easy access to the patio courtyard. The new manager has worked with the provider to improve bathing facilities and by the time of the inspection, one bathroom had been upgraded and was waiting minor areas of kitting out and two other bathrooms were in the process of being fully up-graded, with suitable equipment and facilities to meet the needs of people with complex disability. The new manager reported in her AQAA, that the home environment is an area which will need attention on an on-going basis. People commented on the environment in surveys. One person commented decor is shabby and furniture old but this is being addressed, another main improvements Care Homes for Older People Page 23 of 39 Evidence: needed - furnishings, decoration and a member of staff reported on how the home needed more storage space for larger items such as wheelchairs and hoists. When we inspected the home, we observed that a light, wooden non-slip flooring was provided throughout, this was warm in colour and easy to keep clean. New chairs have been provided in sitting rooms and the dining room presented a light, attractive area. The home is in the process of being re-decorated room by room and the corridor areas have been redecorated, although scrapes were visible on door frames in corridors. The new manager reported that due to such scrapes occurring, they had increased the frequency of the painting maintenance programme for corridors. All toilet doors and frames have been painted in a warm red colour and bathroom doors and frames in blue, this is to help residents identify such facilities. On the main corridor on the ground floor there was an attractive wall covering with a garden scene; this provided interest and stimulation for residents. The inspection took place on a cold winters day, but the home felt warm and comfortable throughout. We asked a resident about the temperature of the home and they replied warm enough? oh yes, yes. Where new equipment and furnishings are provided, they are suitable for the clientgroup. For example lighting in residents rooms are in recessed fittings, integral with the ceilings. This reduces risks to residents associated with pendant light fittings and reduces the need for dusting of lamp-shades and the like. All lights are fully dimmable. New chairs are in the process of being purchased. The home has a mixture of profiling, variable height and fixed divan beds. At present there are not enough variable height and profiling beds to meet the needs of residents with a disability. The new manager reported that the provider has been purchasing profiling beds. We asked for a purchasing programme for profiling beds, but the new manager reported that the provider had not supplied them with one. A written programme is needed so that the provider can demonstrate that they have a planned approach to providing equipment needed to meet residents who have a complex disability need. When we inspected the home, we identified that many of the mattresses suitable for people who have a medium risk of pressure ulceration were old and had bottomed out. This means that such mattresses will not be reducing risk of pressure ulceration for people and due to the nature of the mattresses deterioration, are likely to increase risks for people. All such mattresses must be surveyed and any which are in a deteriorated condition must be disposed of and replaced. The new manager was aware that many areas of the home needed attention. There are plans in place to fully up-grade the kitchen facilities. The new manager reported that the provider had been successful in gaining planning permission to convert double rooms to single rooms with en-suite facilities. Care Homes for Older People Page 24 of 39 Evidence: We inspected the laundry and observed that it was in a dusty and untidy state. Dust was visible behind the machines, on top of the detergent dispensers and was palpable on the floor. Bags for potentially infected laundry were placed on the floor. Washed laundry was spilling out of containers on top of the machines. The sink was not clean and there was no soap in the soap dispenser. We asked staff about the laundry and they informed us that the home did not have a member of staff who was responsible for the laundry. This is highly unusual in a care home with nursing. Due to the quantity of laundry produced and the risks associated with incorrect management of laundry to infection control measures, generally a member of staff is in post who can then be held accountable for correct management of the laundry. Currently the laundry has to potential to present a risk to cross infection. If laundry areas are not clean and free of dust, mico-organisms can grow. If clean laundry is not properly managed and fully separated from unwashed laundry, risk of cross-infection is present. As noted in health and personal care above, the home does not have clear systems for ensuring that personal items, particularly underwear, socks and tights are not used communally. This can also lead to a risk of cross-infection. We discussed the state of the laundry with the new manager, who reported that after the kitchen had been up-graded, that the laundry was next on the list. She was also planning to employ a person who had responsibility for the laundry, as well as caring duties. This needs to be progressed. The home has two sluice rooms which also function as cleaners cupboards. Neither sluice room has a washer disinfector or macerator for sanitary items needed to be used by residents. At present the home uses disposable-type items. These items are designed to be macerated, not placed with clinical waste. The home needs to review its facilities to ensure that it has appropriate measures for management and disposal of sanitary items needed by residents. This is to prevent risk of infection to residents and staff. The home uses a clinical waste system, using appropriate bags, which are collected for disposal by an approved company. We observed that all of the home was clean and smelt fresh, this included bed frames and under cushions on easy chairs. We discussed cleaning with a domestic, who reported that they had a good supply of chemicals and equipment. The cleaner reported on their programme for deep cleaning residents rooms, this was done in detail, including removing radiator covers and moving wardrobes to remove dust and debris from behind the radiator or furniture. We observed that some wheelchairs were not clean on their chassis. This appeared to relate to spillages at mealtimes. We advised that cleaning of wheelchairs should be included in cleaning schedules. Care Homes for Older People Page 25 of 39 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. Residents will be supported by staff who have been safely recruited and trained, however the number of staff on duty means that residents cannot be fully supported as they need. Evidence: In their AQAA, the new manager reported on the core of dedicated staff who have worked in the home for many years. They also reported that there had been some turnover before they came into post but that this had related to planned retirement, rather than other factors. Due to this, they reported that they had had to use agency staff, whilst they built up their staff team. They reported that recruitment was progressing and that where they did use agency staff, generally the same people were sent to the home. An agency carer was on duty when we visited. They reported to us that they had worked in the home several times before and their manner with residents indicated that they knew them well as individuals and understood their needs. People commented about staff in surveys. One person described the staff as friendly and helpful. However some people, particularly staff, felt that more staff were needed to meet resident needs. One person reported more staff - more resources would make delivery of care easier and more efficient. A person reported to us during the inspection that there were enough staff in the morning but not at lunch time. As Care Homes for Older People Page 26 of 39 Evidence: documented elsewhere in the report, we observed that residents spent much of their time unsupervised in sitting rooms during the morning. This was because staff were busy supporting other residents in meeting their personal care needs and there were not enough staff on duty to ensure that residents were also supported when in sitting rooms. Additionally, as is also documented above, the lunch meal was three quarters of an hour late. This was because staff were busy supporting residents who needed care, which meant that there were only two staff available to support residents getting to the dining room, with no-one available to support residents who were already in the dining room. Additionally some staff had to stop supporting some residents during the meal as residents needed additional supports. Staff are also performing laundry duties, as well as caring for residents, this has had the effect that the laundry service is not being well managed, as a person with responsibility for laundry is not in the role, to ensure accountability. The home, as at the last inspection, does not employ an administrator, so registered nurses are involved in performing administrative roles such as managing residents moneys and sending out letters associated with recruitment. This will take senior staff aware from managing the care of residents. The home needs to review its numbers, skill mix and shift patterns for staff, to ensure that it is able to meet residents individual needs in a timely manner, which ensures that they are safe. The new manager was in the process of recruiting staff. A registered nurse we spoke to reported that the staffing situation was getting better. We reviewed files relating to three recently employed staff. They showed that a full employment history had been obtained and any gaps in employment probed. All staff had full proof of identity on file. Two suitable references were obtained and all relevant police checks prior to the person commencing employment. The new manager reported that despite the need to recruit more staff, they understood the importance of safeguarding residents by ensuring that all relevant pre-employment checks were correctly carried out prior to employment. The new manager has developed a training room on the top floor of the house, to support staff learning opportunities. A newly appointed member of staff commented in their survey I have only been at the Parsonage for a short period of time and so far I have been welcomed into the team and find it a lovely home to work in. We met with a newly appointed member of staff, who reported on their induction and that it had given them the information that they had needed to perform their role. They reported that they had started by watching other members of staff providing care so that they understood what was needed, before giving care themselves. They reported that they had never worked alone during their induction period. We looked at written induction programmes, they showed that the home are complying with guidelines on induction Care Homes for Older People Page 27 of 39 Evidence: of staff in care homes. The new manager has developed a full matrix so that they can see at a glance that staff have been trained in mandatory areas. All staff we spoke with also confirmed that they had undertaken training in areas such as manual handling, infection control and fire safety. The manager has also ensured that staff are trained in areas relevant to the client group, including dementia care and managing challenging behaviour. One member of staff commented on the good support for staff in training at the home. Care Homes for Older People Page 28 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be supported by the improved management systems for the home, ensuring that their health and safety can be met. Improvements are needed in the management for residents finances. Evidence: The current manager has not yet been in post for a year. They are in the process of applying to us to become the registered manager. In their AQAA, they reported on the extensive management systems they have put in place to develop the service. This has included, among other areas, setting up staff meetings, ensuring that carers receive a handover when they come on duty, ensuring that staff given supervision, developing a planned training system, setting up risk assessments and quality audits of service provision. Where the manager has identified deficits, they have put action plans in place to improve service delivery. People commented in surveys on improvements put in by the new manager. One relative reported the new matron is exceptionally knowledgeable and always makes time to talk to relatives and explains everything. A member of staff commented since [the new manager] has taken over Care Homes for Older People Page 29 of 39 Evidence: as manager, a lot of effort has been put into improving the standard of care at the Old Parsonage, we have had regular training, staff meetings where our opinions are taken on board, and encouraged to work as a team. A carer commented to us during the inspection that the manager is really nice and another that I feel very supported by the new manager. The new manager has sought feed-back from residents relatives on service provision in questionnaires. She has also performed a full audit of the maintenance service, an audit of medicines and introduced a revised care planning system, to foster individualised care for residents. Where issues have been identified, there was a clear audit trail. For example they had identified a risk associated with a party wall on an adjoining premises and there was a clear audit trail of correspondence with the owner of the party wall and actions to be taken to ensure safety of residents, visitors and staff at the Old Parsonage. We reviewed systems for management of residents moneys and observed that improvements were needed. At present, there is not a full audit trail of moneys and valuables handed in for safekeeping or payment on behalf of residents for services such as hairdressing. All moneys and valuables handed in need to be securely stored, there needs to be a full dated record of when items are handed in, handed back or paid out on residents behalf, with cross-referencing of invoices and receipts to individual accounts. All records should be checked and counter-signed. We also recommend that the current system be modernised, to offer choice to residents relatives and allow for cash-less transactions, including a central invoicing system, managed by the provider, not the home. Where the home does keep cash and valuables on behalf of residents, records and items relating to this should be checked at each monthly visit by the provider, to ensure that such items are being safely managed. Performance of roles such as management of residents moneys is not a clinical role and takes registered nurses away from providing clinical care, they are also not necessarily trained in this role, so we recommend that the home provide an administrator, who has been trained in this role, to support the home. The new manager has developed systems for records across all needed areas in the home. Such records may be considered to be legal documents, so they need to be dated and signed to identify who drew up the document and when. Whilst most records were dated and signed, not all were and some staff may need support to ensure that they sign and date all records that they draw up. We observed that staff performed safe manual handling practice, working effectively together, using correct equipment and supporting residents throughout any manual Care Homes for Older People Page 30 of 39 Evidence: handling procedure. Staff used disposable gloves and aprons when appropriate. We observed that the home continues to use rails on beds, which due to the risks presented by their use, should only be used exceptional circumstances. The new manager advised that they continued to use bed rails because they did not as yet have sufficient profiling beds, which can be lowered down to near the floor and used with crash mats, to avoid the use of bed rails. As noted under environment above, the provider needs to continue to ensure that sufficient equipment for people with complex disability needs is provided. The home has clear records relating to maintenance. Records showed that equipment such as hoists, electrical devices and wheelchairs were serviced regularly as required to ensure their safety. Records showed that shower-heads were checked three monthly. As the home is in a high lime-scale area, this should take place monthly, to ensure risks of legionellum are reduced. Checks are made on hot water systems monthly. As many of the residents were not able to express themselves effectively and mixer systems on baths have been known to fail, particularly where lime-scale is present. To prevent risk of scalds to elderly people, staff should test bath-water temperatures before a resident is immersed in a bath, and maintain a record. The home has a fire risk assessment and all required checks on the fire safety system were being maintained. We advised that the home now needs to start drawing up individual evacuation plans for residents, so that residents safety can be maintained in the event of a fire, whilst awaiting attendance by the fire service. The fire risk assessment also needs to consider how any safety gates on stairs can be disabled in the event of an emergency, to ensure safe and prompt evacuation. Care Homes for Older People Page 31 of 39 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 32 of 39 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 12 Where a resident is assessed 26/02/2010 as being at risk of pressure ulceration, a care plan must always be drawn up. The care plan must detail all actions to be taken to prevent risk of pressure ulceration and monitoring records must always show that directives in care plans are being followed. Pressure ulcers, once developed are painful, take an extended period to heal and may present risk of infection, therefore the emphasis must always be on their prevention. 2 9 12 Where a resident is not being given a drug in accordance with directives on their medicines administration record, there must be full documentation as to why this is. 26/02/2010 Care Homes for Older People Page 33 of 39 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 This is to ensure that residents are given their medicines in accordance with the prescribers intentions. 3 18 13 Residents must not be left in 31/03/2010 sitting rooms for extended periods without supports from staff. Residents who have dementia will not be aware of risks presented by their condition or the environment and need support from staff to ensure their safety. 4 22 13 All mattresses must be 31/03/2010 surveyed and any which are no longer suitable for purpose must be disposed of and replaced. This is to prevent risk of pressure ulceration associated with the use of deteriorated mattresses. 5 22 24 The provider must demonstrate that it has a planned approach to providing appropriate beds to meet the needs of people with complex nursing and disability needs. 26/02/2010 Care Homes for Older People Page 34 of 39 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 This is to ensure that staff can meet individual residents needs in a safe manner. 6 26 13 Suitable equipment such as a washer disinfector or macerator must be provided to ensure safe cleansing/disposal of sanitary items. Sanitary times must be cleansed or disposed of in a safe mannger to prevent risks of cross infection. 7 26 13 The laundry room must be 19/02/2010 clean and free of all dust and debris at all times. Washed laundry must be dealt with safely to prevent contamination by un-washed laundry. Systems must be put in place to prevent the communal use of residents clothing. This is to prevent risk of cross infection to residents. 8 27 18 A full review of staff and action plan relating to numbers, skill mix and shift times must be drawn up, to ensure that there are enough staff on duty at all times to meet residents 31/03/2010 30/04/2010 Care Homes for Older People Page 35 of 39 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 individual needs and ensure their safety. Residents with complex mental health care needs need additional supports to ensure that their needs are met and they are safeguarded. 9 35 17 Systems must be put in 26/02/2010 place when residents hand moneys or valuables in for safekeeping, to ensure that they are securely stored and there is a full written audit trail of moneys handed in and paid out maintained. Moneys and valuables held on the behalf of residents must be kept securely and there must be clear information on all transactions to ensure residents finances are safeguarded. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 Care assistants should be supported in documenting in residents individual records, rather than verbally reporting matters to registered nurses and in developing care plans for their key residents. When referring to residents behaviours and needs in 2 7 Care Homes for Older People Page 36 of 39 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 records the precise issues presented should be documented and judgemental wording such as demanding be avoided. 3 8 Care plans relating to diabetes should document blood sugars aimed for, for the individual resident and include actions to be taken by staff if the persons blood sugar levels fall outside these parameters. Care plans should also include reference to injection sites and how they are to be rotated, to ensure tissue viability and effective up-take of insulin. Where a resident is prescribed a medicine which can affect their daily lives, reference to each medicine should be made in care plans, to support evaluation the effectiveness of the medicine. Facillites and relevant staff should be provided to ensure that residents clothes can be named for them and ironed. More than 20 hours should be devoted to the provision of therapeutic activities for residents. The provider should review purchasing systems for foodstuffs, equipment and staffing levels, to support the principals of healthy eating. A member of staff should hold designated responsibility for the management of the laundry service. The home should develop a written schedule to ensure that wheelchairs are regularly cleaned. Consideration should be given to employing an administrative person who can provide support to the manager. This recommendation has been advised for the last two inspection. 11 12 35 35 The provider should always audit moneys and valuables held on behalf of residents at every monthly visit. The home should modernise its approach to handing residents moneys on their behalf, to introduce choice and ensure that cash-less systems are available. All documents and records drawn up by the home should be dated and signed by the person drawing them up. Checks on shower heads should take place monthly and Page 37 of 39 4 9 5 6 7 10 12 15 8 9 10 26 26 27 13 14 37 38 Care Homes for Older People 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 records should be made of bath water temperatures every time before a resident is immersed in the water. 15 38 The fire risk assessment should be devloped, to consider the impact of safety gates on stairways in the event of fire and to introduce individual evacuation plans for residents. Care Homes for Older People Page 38 of 39 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. 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. 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