Care Home: The Regency

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What the care home does well New people interested in living at the Regency are given good information about the service. This helps them to decide if they want to live there. People tell us that they are made to feel welcome from the moment they move in and that their needs are discussed with them and set out in a plan of care. Community professionals tell us that the team work in partnership. They also tell us that referrals are appropriately made and ensure that people`s healthcare needs are generally met. Families and friends say that they are encouraged to visit whenever they wish to and are kept informed about any changes. They tell us that the manager is very approachable and open about what needs to improve at the home. There is a good choice of appetising and well balanced meals at the home. People tell us that the choice is good and meals are "very nice" and always offered seconds. Staff are described as "kind" and caring. They are encouraged to do training, so that they learn how best to care for people that live at the home. People tell us that they feel safe when they hear the fire alarms being checked "every week". The provider is very committed to improving the quality of care for people living at the Regency and has ensured that there are sufficient staff on duty to meet the needs of people, particularly during what has been a difficult period for them. What has improved since the last inspection? At the random inspection on 26th March 2010, we made 2 immediate requirements that had to be met within 48 hours. This ensured that staffing levels increased and that wholesome, nutritious food was provided that met individual needs. Both of these were met. Some aspects of the monitoring of people`s health and well-being has improved. For example, everyone who is able to stand on scales has been weighed and is being done monthly. Height measurements are included so that people`s BMI (Body Mass Index) is assessed. People who are unable to weight bear have this estimated as per best practice guidance. If there are concerns about this, these have been raised with the individual`s GP. People`s needs are generally being met by the increase in staffing levels, both during the day and at night, consistent with the building layout, needs and mix of people living at the home and staff skills and expertise. People`s dignity is being maintained by the staff working at the home. The provider verified that screens are used in shared rooms and we saw that this is done. Measures have been put into place to ensure that the home is always fresh and clean and free of offensive odours. This includes the cleaning of toilets, bathrooms and equipment. Parts of the home have been redecorated since we last did a key inspection, which has made these areas more homely. Additional heating is available for people that require it and is suitable to their needs. What the care home could do better: The assessment process should be more person centred and followed consistently for people living in the home. Improvements have been made ensuring that each person living at the home has a care plan. However, these must reflect all of the needs identified with a person and/or their representative on admission. This will ensure that staff have detailed guidance about how the person`s needs are to be met. We have extended the timescale of a requirement set at the random inspection so that the provider is able to comply with this. Some working practices and systems are not fully ensuring potential risks to people`s safety. This includes the prevention of dehydration, choking, and malnutrition and prevention of potential harm of vulnerable people. Peoples medicines must be managed in a way that ensures the system in place is safe. People`s needs should be better met by working directly in partnership with healthcare specialists such as the speech and language therapist, tissue viability and continence nurse to ensure that best practice is always followed. The quality of life people lead could be improved. Activities should be person centred and pitched at a level that is suitable for the individual so that people are stimulated and occupied. We have extended the timescale of a requirement set at the random inspection so that the provider is able to comply with this. People`s human rights could be better met. The legal requirements of the Mental Capacity Act are not fully understood and being followed. This has resulted in some decisions being made that may not be in the best interest of that person eg finacial matters. People`s safety could be improved by ensuring that all parts of the home are appropriate for the individual`s living there. For example, by fitting radiator guards to the few radiators not already covered. People`s personal possessions could be better protected by providing everyone with lockable storage facilities for medication, money and valuables so that this is kept secure. People could be better protected from the risk of infection by carring out an assessment of current infection control management using the Department of Health Guidance to ensure that measures protect people that live in the home and staff that work there. People must be moved in a safe and dignified manner. The system for managing how people are moved and handled must include thorough assessments of people`s needs and instructions to staff as to how these needs should be met. And be carried out competently by staff that follow best practice. Key inspection report Care homes for older people Name: Address: The Regency Torrs Park The Regency Ilfracombe Devon EX34 8AZ     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: Susan Taylor     Date: 1 4 0 4 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 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: The Regency Torrs Park The Regency Ilfracombe Devon EX34 8AZ 01271862369 01271863012 nmcarehomesltd@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Norma Martin Care Homes Limited Name of registered manager (if applicable) Ms Norma Elfreda Martin 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 old age, not falling within any other category Additional conditions: The Regency is registered as a care home able to provide care accommodation for up to 20 service users in the categories OP Old Age (20), DE (E) Dementia over 65 (20) and MD (E) Mental Disorder over 65 (20). Date of last inspection Brief description of the care home The Regency is a care home providing accommodation and personal care for up to 20 people over the age of 65 years, who may have a diagnosis of dementia or mental disorder. The home is situated in the Devon seaside town of Ilfracombe. There is a short, steep walk from the High Street and local amenities. Accommodation is provided Care Homes for Older People Page 4 of 36 Over 65 20 20 20 0 0 0 1 0 0 7 2 0 0 9 Brief description of the care home on four floors. A ramp provides access to one floor and passenger lift to the remaining three. In April 2010, the range of fees was £320 to £400 per week. Additional charges are made for chiropody, hairdressing, newspapers, personal toiletries. People funded through the Local Authority have a financial assessment carried out in accordance with Fair Access to Care Services procedures. Local Authority or Primary Care Trust charges are determined by individual need and circumstances. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk 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: The quality rating for this service is 1 star. This means the people who use this service experience ADEQUATE quality outcomes. This unannounced key inspection was brought forward as a result of a random inspection on 26th March 2010 and Safeguarding processes, which highlighted concerns about the quality of care that people living at the Regency are receiving. We (the Commission-3 inspectors) were at the home with people for 11 hours. We looked at key standards covering - choice of home, individual needs and choices, lifestyle, personal and healthcare support, concerns, complaints and protection, environment, staffing and conduct and management of the home. During this visit we spoke with or observed the majority of people living here. We could not speak with some people because they have communication difficulties such as dementia. We looked closely at the care, services and accommodation offered to 4 people living here. This is called case tracking and helps us to make a judgment about the standard of Care Homes for Older People Page 6 of 36 care, and helps us to understand the experiences of people who live here. We looked at the care and attention given by staff to these people and we looked at their assessments and at their care planning records. We looked at the environment in relation to their needs and how their health and personal care needs are met. We also spoke with visitors to the home, with staff and the manager. We visited some of the bedrooms of the people we case tracked and saw all service and communal areas of the home. Prior to the inspection the provider sent us their Annual Quality Assurance Assessment (AQAA) which gave us information about the home and its management and about the needs of people living here. This document asks for evidence in relation to what the home does well and what they think they can improve upon. In addition, we sent surveys to 15 people living at the Regency and 7 were returned. Their comments are included throughout this report. In April 2010, the fees ranged between 320 to 400 pounds per week for personal care. Additional charges are made for personal telephone lines, chiropody, hairdressing, newspapers and toiletries and these vary. People funded through the Local Authority have a financial assessment carried out in accordance with Fair Access to Care Services procedures. Local Authority or Primary Care Trust charges are determined by individual need and circumstances. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? At the random inspection on 26th March 2010, we made 2 immediate requirements that had to be met within 48 hours. This ensured that staffing levels increased and that wholesome, nutritious food was provided that met individual needs. Both of these were met. Some aspects of the monitoring of peoples health and well-being has improved. For example, everyone who is able to stand on scales has been weighed and is being done monthly. Height measurements are included so that peoples BMI (Body Mass Index) is assessed. People who are unable to weight bear have this estimated as per best practice guidance. If there are concerns about this, these have been raised with the individuals GP. Peoples needs are generally being met by the increase in staffing levels, both during the day and at night, consistent with the building layout, needs and mix of people living at the home and staff skills and expertise. Peoples dignity is being maintained by the staff working at the home. The provider verified that screens are used in shared rooms and we saw that this is done. Measures have been put into place to ensure that the home is always fresh and clean and free of offensive odours. This includes the cleaning of toilets, bathrooms and Care Homes for Older People Page 8 of 36 equipment. Parts of the home have been redecorated since we last did a key inspection, which has made these areas more homely. Additional heating is available for people that require it and is suitable to their needs. What they could do better: The assessment process should be more person centred and followed consistently for people living in the home. Improvements have been made ensuring that each person living at the home has a care plan. However, these must reflect all of the needs identified with a person and/or their representative on admission. This will ensure that staff have detailed guidance about how the persons needs are to be met. We have extended the timescale of a requirement set at the random inspection so that the provider is able to comply with this. Some working practices and systems are not fully ensuring potential risks to peoples safety. This includes the prevention of dehydration, choking, and malnutrition and prevention of potential harm of vulnerable people. Peoples medicines must be managed in a way that ensures the system in place is safe. Peoples needs should be better met by working directly in partnership with healthcare specialists such as the speech and language therapist, tissue viability and continence nurse to ensure that best practice is always followed. The quality of life people lead could be improved. Activities should be person centred and pitched at a level that is suitable for the individual so that people are stimulated and occupied. We have extended the timescale of a requirement set at the random inspection so that the provider is able to comply with this. Peoples human rights could be better met. The legal requirements of the Mental Capacity Act are not fully understood and being followed. This has resulted in some decisions being made that may not be in the best interest of that person eg finacial matters. Peoples safety could be improved by ensuring that all parts of the home are appropriate for the individuals living there. For example, by fitting radiator guards to the few radiators not already covered. Peoples personal possessions could be better protected by providing everyone with lockable storage facilities for medication, money and valuables so that this is kept secure. People could be better protected from the risk of infection by carring out an assessment of current infection control management using the Department of Health Guidance to ensure that measures protect people that live in the home and staff that work there. People must be moved in a safe and dignified manner. The system for managing how Care Homes for Older People Page 9 of 36 people are moved and handled must include thorough assessments of peoples needs and instructions to staff as to how these needs should be met. And be carried out competently by staff that follow best practice. 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 10 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 11 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. People living in the home are generally confident that their needs are known. Evidence: The home has a Statement of Purpose (SOP) a copy of which is displayed in the entrance hall and helps people to understand what the home offers and whether it is suitable for their individual needs. Information that the provider sent to us verified that a brochure is given to all people which sets out what the service will provide and includes a contract of terms and conditions, fees payable and other useful information to help people decide whether the home is right for them. 100 percent of people responding in a survey (7) have received sufficient information with which to make a decision about whether to move into the home. We looked at the admission process for 2 people who had moved to the home since February 2010. One person had been admitted as an emergency for a short placement. There was a record of discussion of the persons needs with the care Care Homes for Older People Page 12 of 36 Evidence: manager, which was based on their physical and psychological needs. However, important information obtained as part of this process did not have a corresponding care plan and therefore staff did not have sufficient information about how to manage all of this persons needs. This is discussed further in the health and personal care and complaints and protection sections of this report. We spoke to this person who told us the minute I arrived I felt welcome. They described the Regency as an excellent place to be and that staff are all so caring and have tremendous patience. At the same time, both the person themselves and the provider were clear that the placement was temporary and not ideal for the individual who wanted to live independently. We discussed the statement of purpose and categories of registration with the manager who told us that they take responsibility for the assessment and agreement of placements at the Regency. They told us that their intention is always to provide a service aimed at caring and supporting older people, some of whom may have dementia. And therefore, if approached again to take a younger adult falling outside of the service stated in the statement of purpose they would not do so. Another person had been admitted after a hospital stay. We saw a detailed assessment for this individual, corresponding with hospital discharge information that had been sent to the home. A detailed care plan had been written for the person. We saw evidence that the home wrote to prospective people to confirm the home could meet their assessed needs, which is good practice. Care Homes for Older People Page 13 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. Risk management systems need improvement to ensure that people are kept safe and well. People are generally respected and their dignity and privacy is maintained. Evidence: We casetracked the experiences of 4 people at the home. We looked at the care plan for a person with continence needs. This was well written and directly linked to needs that had been identified as part of the assessment process. For example, it stated that the person uses continence aids and gave clear guidance for staff about how they should promote the individuals independence. We read other records, which showed that the individual had been encouraged to retain independence and was regularly able to empty their own catheter at night with minimal assistance. This demonstrates that this person was actively involved in their care and retained a degree of independence as a result of this. We looked at the care plan of a person whose care records state that they have dementia, anxiety, do not like having their personal hygeine attended to, wanders, is at risk of falling and has diet controlled diabetes. We met with this person as they Care Homes for Older People Page 14 of 36 Evidence: walked around the home and sat in the lounge. This person showed signs of aggression, anxiety and challenged other people in the home, verbally and by standing in front of them. People living in the home managed this by being polite and allowing this person to do what they wished to do. For example, this person took a cushion from another person. The individual allowed this to happen and told us that this is normal and its best to let her get on or she might get worse. We saw this person challenging visitors to the home in the presence of staff, who ignored the situation. This indicates that staff have become used to this persons behaviour and have accepted it as the norm. We looked at the care records belonging to this person. We saw records that show that this person has pushed another person, been agitated on occasions, scratched staff and been aggressive on occasions. We looked to see if there is a care plan in place to inform about how these behaviours might be prevented or managed. The care plan states that this person should be monitored, listened to, kept informed and given their medication. The only intervention recorded is that this person is given their medication which is prescribed for them. Visitors to the home told us that this person often tries to leave the home through the front door and windows. This persons bedroom is situated next to the front door. The front door has a key pad exit system and all windows have restricted openings which help to prevent this person from leaving the home. The fire exits however have push bar mechanisms which can easily be opened. Although the manager reports that this person has never tried to leave the home through the fire doors, the consequences for this person if it were to happen are significant. Although staff are instructed to monitor this person, this is difficult to do in a large busy home. This person is described in the care plan as having diet controlled diabetes. Staff told us this person has a normal diet and we observed them eating sugary snacks. The manager told us that this information in the care plan may not be correct. She has spoken with the GP about this who has advised her that this diagnosis probably incorrect. For that reason, and because it is so difficult to control what this person eats, they have a normal diet as agreed with the GP. This persons care records indicate that they are losing weight. We found that a nutritional assessment had taken place and this showed that individual is not at risk of malnutrition. As a consequence, according to the assessment tool used, there is no need to take any action. However, when we recalculated this we found some errors in the scores. We calculated that this person is at moderate risk of malnutrition which Care Homes for Older People Page 15 of 36 Evidence: would result in this person needing additional calories to help maintain their weight. The care plan states that this person has a major dislike of having their personal hygiene attended to. However, despite this records show that when staff can support this individual with their personal hygeine they look for changes or skin damage. Recently a sore on this persons foot was noted. A referral was immediately made to the GP and treatment started. In addition, records show that this person was showing signs of having a urine infection. The GP was contacted and antibiotics commenced. This shows this service is responding to peoples health needs. We looked at the care records of another person. This states that this person must have a pureed diet as they are at risk of choking. We checked with staff and they showed us the type of diet this person has which is pureed. They also showed us that this person has the fluids they drink thickened, to help prevent them choking. This is good practice and shows that staff are following advice. However, we spoke with one carer who told us that on good days they offer this person items of food such as cake. This is contrary to the specialist advice given and puts this person at risk of choking. Since the inspection, the manager has informed us that they made a direct referral to the Speech and Language Therapist. The person has since been assessed by the Speech and Language Therapist and recommendations made about the type of diet, fluids and techniques to be used. This means that the risk of choking for this person has been minimised. This person is cared for in bed. Their risk assessment shows that they are at risk of developing pressure sores. They are cared for on an airwaves mattress which staff say the District Nurses provide and manage. We noted that the pressure setting for this mattress was set to the highest pressure. This pressure is usually used for people who are very heavy. However, this person has a low weight. We asked the manager to review this by looking at the manufacturer instructions and taking further advice from the tissue viability nurse specialist. It is identified in the care plan that this person is also at risk of becoming dehydrated. We asked staff how they manage this risk. We were told that this person is offered fluids every hour and they also told us that they use a calculation based on weight as is good practice. The care instructions say that this person should have between 5 and 6 glasses to drink per day. We calculate this would equate to between 1000 and 1500 mls per day. However, when we looked at records relating to what this person drink over a period of 8 days, this target had not been reached. The most this person drank in one day was 930mls and the least this person drank was 220mls. On average, according to records this person has approximately 550mls to drink each day. Records Care Homes for Older People Page 16 of 36 Evidence: also show that on 4 days this person did not have a drink between 4 or 5pm and 8am the next morning. Following the inspection, the manager verified that during the period we looked at the individual concerned had been reluctant to drink fluids due to having a chest infection. They also went on to tell us that advice had been sought from the GP as they were concerned that this person might be at risk of dehydration. This demonstrates that appropriate advice is sought, however monitoring systems could be further strengthened so that increasing risk is identified more quickly for individuals to ensure they do not become dehydrated. We spoke to another individual who had been admitted as an emergency. The person told us that they are diabetic and this is controlled by insulin, which they administer themselves with supervision. A detailed care plan had been agreed with the person, providing good guidance for staff about how the persons short term health goals needed to be managed. For example, the guidance tells staff about how to monitor this person for signs of low or high blood glucose levels, behaviours that might be observed and what action they should take if this occurs. Additionally, the individual told us that their care plan had been discussed and agreed with them. At the same time, the person said since living at the Regency their diabetes is much more stable because I am well monitored and eating properly. This demonstrated that the service has the ability to promote some aspects of person centred care. Conversely, the same individual also told us that they had a history of alcohol addiction. There was no risk assessment or care plan with information about this or guidance for staff about how they should manage this persons addictive behaviour. In discussion with staff, there had been 3 occaisions when staff and other people living in the home were scared and frightened by this persons behaviour. Additionally, we were told that staff had tried to calm the situation by asking the individual to go to their room. Staff also verified that whilst they had done a short course on dementia, which dealt with some aspects of dealing with challenging behaviours, they had not had sufficient training about defusing escalating aggressive behaviour or management of addiction. We discussed these incidents with the manager, who verified that we had access to all of the information available for staff about the individual concerned. They confirmed that they had also needed to challenge the persons behaviour. We asked the manager whether the person had a discharge plan in place to move to independent living as they wished to do this. We were told that the individuals care manager had not been in contact since the persons placement had been extended and we asked them to discuss move on arrangements with them as a matter of urgency. Care Homes for Older People Page 17 of 36 Evidence: We saw that staff try to protect peoples dignity and privacy by for example discreetly asking if people wanted to go to the toilet, adjusting clothing and ensuring people were clean and tidy after eating. All personal care was delivered in private and where people share rooms, screening is used. We looked at how medicines are managed. We saw that staff always sign when they have given medication and records indicate that medicines are given as prescribed. However, we noted that the system for counting medicines into the home is not robust enough to support an audit. We wanted to compare the records about how many medicines should be in the home with the actual amounts by counting them. However, the records kept do not support this. We discussed this with the manager and she has agreed to address this. As is good practice some people living here manage their own medicines. However, records relating to the way stock for these people is managed are not sufficient to account for the amount of these medicines. The manager has agreed to address this. The home has a dedicated fridge for storing medicines that need refridgeration. This is locked and the key holder is the only person who has access to this, as is good practice in the management of medicines. The temperature of the fridge is recorded daily, however we noted with the manager that the minimum/maximum thermometer may be broken. We looked at the way drugs to be stored as controlled drugs are managed. We found these are kept securely and that the record system used means that it is easy to audit these medicines. Only the key holder has access to these medicines. We counted one set of drugs and found them to be in order. Care Homes for Older People Page 18 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. Routines and activities are flexible for people and they are listened to regarding a limited choice of daily activity. This could be more person centred so that people are stimulated and occupied. Evidence: People responding in a survey (7) had mixed views with regard to the accessibility and availability of activities ranging from always to sometimes. We saw in some care plans that peoples interests had been identified. However, we could not find that a connection had been made between these interests and the activities that the home arranges. For example, a person with dementia who we case tracked had a long standing interest in needlework that hadnt been explored for that individual. We observed this person sometimes picks at material or cushions but most of the time wandered aimlesly around the home as if looking for something and in need of occupation. The home does arrange activities for each day of the week. On the day of this inspection the home had planned a musical session. However, the musician was unable to attend so staff arranged a card making activity. We asked staff about this Care Homes for Older People Page 19 of 36 Evidence: and they told us that about 4 of the 17 people living here had attended this. We saw people sitting for long periods of time. Some people read and two people chatted with each other. One person moved around the home and seemed very happy to do this. We spoke with some the able people living here and they told us they like to stay in their bedrooms and for example watch television or read. We looked at how the engagement needs of very disabled people are met and could not find evidence that these needs are addressed. Staff told us they spend time with these people when they attend to their care needs or support them to eat or drink. This demonstrates that interactions are task orientated for these people. We asked people if they like the food here. They told us they do. They say they have a hot lunch and usually soup and sandwiches at tea time. We saw people enjoying the mid day meal which looked appetising and was piping hot. Tables are small helping the meal to be a social event. We looked at the way people who need help with eating are supported. We saw that each person gets individual attention. Those people who need a pureed diet have their foods separately pureed ensuring they experience and enjoy different tastes. At a random inspection on 26th March 2010 we made an immediate requirement to ensure that people are given wholesome and suitable food, which is properly prepared and meets individidual needs. We are satisfied that this requirement was complied with. We have seen improvement in the way meals are served to people who choose not to come to the dining room. In addition to this, a monitoring system has been set up to ensure that peoples weights are known and carefully monitored. 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. Individuals views are generally listened to and acted upon. However, risks need to be effectively managed to ensure that peoples human rights are maintained and they are safeguarded from potential harm. Evidence: 100 percent of people responding in a survey (7) verified that they knew how to complain and who to speak to if they were unhappy. The home has a complaints procedure and copies of this are posted throughout the home and are included in the homes information that is given to all people admitted to the home. People we spoke to verified that they were confident that if they had any concerns these would be listened to and acted upon. For example, one person told us that the food is lovely, but the portions were too small for me. I went and spoke to XXX and she immediately sorted it out. The manager informed us that they have received 1 complaint, which we were aware of under safeguarding procedures and looked at how this had been investigated. We read correspondence in respect of concerns raised about the care of an individual. The manager had followed the process up to concluding the investigation. Records demonstrated that the investigation was sound and that statements had been taken from staff, which enabled the manager to form an overall judgement. However, there was no record of the outcome having been communicated to the informant. We discussed this with the manager who verified that an email had been sent to the Care Homes for Older People Page 21 of 36 Evidence: informant, which did not respresent [the] business and that communication broke down. We highlighted that it was important that the procedure be completed in a professional manner so that the matter was concluded. Since the inspection, we have received written confirmation from the manager that this was done. Other concerns relating to specific individuals have been dealt with under safeguarding procedures and resulted in some people being reviewed. We carried out a random inspection on 26th March 2010 in response to safeguarding procedures and a complaint about the temperature of the food, poor bedding and low staffing levels. We wrote a report about our findings and brought this key inspection forward to determine whether peoples needs are being met and to decide whether the home is being run effectively. The manager is involved in the Safeguarding process and has been working in partnership with professionals visiting the home to ensure that peoples needs our met. Our observations during this inspection, demonstrated that peoples needs are generally well met but there are potential risks, which need to be managed more effectively. For example, we were told about incidents that had had occurred on 3 occaisions when staff and other people living in the home were scared and frightened by a persons behaviour. Additionally, we were told that staff had tried to calm the situation by asking the individual to go to their room. However, this had not been sustained and more vulnerable people living in the home felt uncomfortable as a result. Staff also verified that whilst they had done a short course on dementia, which dealt with some aspects of dealing with challenging behaviours, they had not had sufficient training about defusing escalating aggressive behaviours or management of addiction. We discussed these incidents with the manager, who verified that we had seen all of the information availble for staff about the individual concerned. They confirmed that they had also needed to challenge the person about certain behaviours and verified that the placement of this individual at the home did not meet the stated aims and objectives of the service. This demonstrates that some recent admission practices could have put vulnerable people at risk of harm or abuse. However, we discussed the statement of purpose and categories of registration with the manager who told us that they take responsibility for the assessment and agreement of placements at the Regency. They told us that their intention is always to provide a service aimed at caring and supporting older people, some of whom may have dementia. And therefore, if approached again to take a younger adult falling outside of the service stated in the statement of purpose they would not do so. Care Homes for Older People Page 22 of 36 Evidence: In comparision, the manager has demonstrated an understanding of safeguarding procedures. In January 2010, the Commission was notified that there had been a theft at the home. The manager contacted appropriate agencies, including the police, promptly and took immediate steps to safeguard peoples financial interests. We read disciplinary records and were told that the key holding procedures had changed so that the manager is now the sole key holder. We spoke to the relatives who act on behalf of the individual involved in this incident. Both said that the manager had done everything she could to protect XXX money and had been let down. They told us that they were completely satisfied with the way the matter had been dealt with and arrangements that had been put into effect as a result. We were shown a mental capacity assessment, which the manager had completed for this individual that had some good practice elements in it. For example, the involvement of relatives in decision making when a person lacks capacity. However, deprivation of liberty safeguards such as making a referral to the local authority to establish whether decisions are made in the persons best interests were missing from this procedure. We suggested that further training be sourced from Devon County Council about Deprivation of Liberty Safeguards and the Mental Capacity Act. Additionally, that advice and support about decision making for people lacking capacity should always be obtained from Devon County Council. Following this inspection, the manager informed us that they have made a referral for assessment to the local authority for an individual and taken advice from the Deprivation of Liberty Safeguarding Team about managing the behaviour of another person we case tracked so that their human rights are maintained. Care Homes for Older People Page 23 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. People living at The Regency are provided with an adequately clean and comfortable living environment. Evidence: Information sent to the Commission (AQQA) tells us that electrical, gas and fire safety systems are regularly maintained. Since we last inspected some parts of the home have been nicely decorated and give a fresh appearance, which people appreciated. There are areas of the home that are potentially unsafe given the needs of some people living at the home due to physical frailty, falls and mental health needs. For example, the radiators in the top floor bathroom and the first floor bathroom are unguarded and hot too touch. Information sent to the Commission (AQAA) does not tell us specifically whether these hot surfaces will be covered with radiator guards. However, the manager told us that risk assessments are done and regularly reviewed. One of the people we casetracked showed us their bedroom, which was clean and odour free. There was a lock on the door, but when we asked the person if they were able to use it they said I dont have a key. There was no lockable storage in the individuals room so that their valuables and money is kept secure. We looked in some of the bedrooms and all of the communal and service areas. All Care Homes for Older People Page 24 of 36 Evidence: areas are clean and tidy. There are hand washing faciliites throughout the home for staff to use to help prevent the spread of infection. However, we noted that people who cannot walk or who need support to walk were not offered the opportunity to wash their hands before eating. We noticed that although staff washed their hands, they then for example held the hands of people who hadnt, and therefore cannot be assured that the spread of infection is being controlled. Additionally, during our tour of the building, we saw that the sluice rooms have no hand washing facilities, which compromises good hygiene practices. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment practices are robust, which ensures that people are being cared for by suitably qualified and experienced staff with the right qualities. Evidence: At the random inspection on 26th March 2010, we made an immediate requirement to ensure that staffing levels correspond to the assessed needs of people. The manager responded promptly to this and sent the Commission written evidence to demonstrate that staffing levels had increased. The manager verified that a local agency was being used and that a small group of staff were working at the home for continuity. Additionally, 3 permanent staff were in the process of being recruited. We looked at duty rosters for the period after the random inspection and including this key inspection. People made positive comments about the staff like theyre all very kind and I cant remember who is on, but theres always someone around. Always 2 waking staff at night. We looked at the recruitment files of two members of staff working at the Regency. Both had completed application forms detailing their experience, qualifications and employment history. Both had medical declarations and proof of identity in their files. One person was employed via an agency and all the necessary checks had been carried out by this agency including references. Checks included a police check from Care Homes for Older People Page 26 of 36 Evidence: the staff members country of origin and a police check carried out in this country. Both were obtained prior to this person starting to work in the home. The second member of staff whose recruitment file we looked at was recruited by the manager. A check against the list of people prohibited from working with vulnerable adults was made prior to this person starting work and a full police check has been requested as it should be. Whilst the manager awaits this, she reports this member of staff is supervised although there were no records available. This person had two references, one from the previous employer as is good practice. Following the inspection, the manager showed us the CRB (Criminal Records Bureau) that had arrived for this individual, which was satisfactory. This demonstrates that recruitment practices are more robust and have improved since we last did a key inspection. We also looked at the evidence the home receive from agencies in relation to the agency staff they use. We found that the agency provides the home with a statement that a police check has been undertaken and a statement relating to the member of staffs experience and training. This is good practice and helps to protect people from unsuitable staff. We spoke with some visitors to the home who described staff as lovely and very obliging. We looked at training records and saw that each member of staff has a portfolio, containing evidence of their skills, experience and on going development. Information sent to the Commission (AQAA) tells us that 8 out of 9 (88 percent) of staff hold NVQs or equivalent awards in care. 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 quality of the service people receive is showing some improvement. However, risk management and communication systems are not yet effective enough, which could put the health and safety of people living in the home at risk. Evidence: The registered manager is a registered nurse and since the last inspection has completed the NVQ level 4 in care home management. Throughout the inspection we found she has a reasonably good understanding of her role. However, there are areas such as the Deprivation of Liberty Safeguards, Mental Capacity Act and person centred planning where the manager needs to undertake training to ensure that best practice is followed so peoples human rights are maintained. Information sent to the Commission by the manager/provider told us that this has been an exceptionally difficult six month period, in which changes had to be made to the staffing. The manager moved back into the home and duty rosters show a high level of commitment with her working 17 hour days. During the safeguarding process, Care Homes for Older People Page 28 of 36 Evidence: this was recognised and it was recommended that additional staffing be put into place so that the manager/provider is able to reduce the number of hours being worked giving direct care. We are satisfied that prompt action had been taken to address immediate requirements made at the random inspection on 26th March 2010, the report of which is published. Our overall judgement is that the quality of the service has improved with regard to staffing, and ensuring people are given wholesome and suitable food, which is properly prepared and meets individidual needs. Additionally, recruitment procedures have improved since we last did a key inspection. In case tracking the experiences of 4 people, we saw that the quality of care people receive is generally good. Although, there were areas such as the assessment of risks in relation to the management of peoples health and safeguarding where information gathered has not yet been used effectively or consistently to demonstrate that the risks for people are being sufficiently minimised. We have made requirements about this. The manager gave the Commission a reasonable picture of the current situation in the service, in a document entitled AQAA (Annual Quality Assurance Assessment). Further supporting evidence would further illustrate what the service has done in the last year, and explicitly how it is planning to improve. We did observe examples of good practice. This included the assessment of mental capacity and some, but not all care plans were more detailed, had been reviewed and demonstrated that people were involved in this process. The home has a policy and procedure for the management of petty cash. Monthly audits had taken place of the all the financial management systems. All of the people living in the home are being encouraged to open their own savings/bank accounts. The manager told us that they are the sole key holder for the safe and that this had changed following a safeguarding issue (discussed under the Complaints and Protection Section). We looked at records for 4 people. Balances tallied across records. People living in the home verified that the petty cash was accessible to them. Receipts for purchases had been obtained and balances tallied with records kept. We saw staff helping people to move. We saw two members of staff using an underarm lift which is not good practice. When we looked in the care plan to see if the staff had instructions about what to use for this person, there were no instructions written down. We asked staff about the moving and handling equipment they use. They told us that they have hoists and have training in how to use these. Two carers we spoke with said they had had training in July 2009 and their training portfolios supported this. We saw that hoisting equipment was last serviced in April 2009. The Care Homes for Older People Page 29 of 36 Evidence: manager reports that the service contract is for annual checks and is due in the near future. We looked at how food is stored. We saw that the home uses the Better Food, Better Hygeine system. Records show that fridges and freezes are cleaned regularly and that the temperatures of these are recorded daily. Records show they are running within the recommended temperatures. People we spoke to tell us that they feel very safe here, theres always someone around to monitor me if Im feeling unwell and that the fire Alarm is checked every week, it was done yesterday. This demonstrates that the health and safety of people living in the home is promoted. Care Homes for Older People Page 30 of 36 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 Each person living at the 10/04/2010 home must have a care plan. This relates to providing clear guidance for staff who care for people with swallowing difficulties. 2 8 13 People must be moved in a safe and dignified manner. Staff training and practice must be reviewed to ensure that people are moved safely and in a dignified manner. 30/04/2010 3 12 16 People must be provided with 30/04/2010 activities to suit their individual needs. This is to help people living at the home have a better quality of life. 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 Each person must have an accurate plan of care which sets out in detail how care needs are to be met. These must be reviewed when needed using all the information available. This will help to ensure that staff have the information they need, that care is delivered in a consisent way, the effect of which can be measured and its effectiveness determined. We have extended the timescale on this requirement so that the provider is able to fully comply with it. 31/05/2010 2 8 13 Actions must be taken to ensure that unnecessary risks to the health and safety of people living here are identified and so far as possible eliminated. This 18/06/2010 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 includes, but is not exclusive to, the management of behaviours likely to affect others or cause harm, the management of developing pressure sores, dehydration, choking, and malnutrition. This is to ensure that potential risks are identified and managed effectively for people. 3 9 13 Peoples medicines must be managed in a way that ensures the system in place is safe. This will help to ensure that medicines can be accounted for and that the audit system demontrates that each person receives the medicines they are prescribed. 4 12 16 People must be provided with activities to suit their individual needs. This is to help people living at the home have a better quality of life. 5 18 13 The registered person must ensure that unnecessary risks to the health or safety of people living in the home are identified and so far as possible eliminated. In 30/06/2010 09/07/2010 18/06/2010 Care Homes for Older People Page 33 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 paricular, staff should have the knowledge and skills to diffuse potentially abusive situations that may put vulnerable people at risk of harm. And knowledge about Deprivation of Liberty Safeguards and the Mental Capacity Act. This will ensure that people are safeguarded from potential harm. 6 38 13 The system for managing how people are moved and handled must include thorough assessments of peoples needs and instructions to staff as to how these needs should be met. This will help to ensure that staff only use appropriate moving and handling techniques and that people are supported to move safely. We have extended the timescale on this requirement so that the provider is able to fully comply with it. 30/06/2010 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 1 3 Needs should be consistently recorded in the assessment form used by the home to ensure that people experience person centred care. Direct advice should be sought, as necessary, from healthcare specialists such as the speech and language therapist, tissue viability and continence nurse to ensure that best practice is always followed and peoples needs are met. People should be provided with lockable storage facilities for medication, money and valuables so that this is kept secure. All parts of the home should be made safe for people to live in, and the fitting of guards to all radiators should be considered to achieve this. Consideration should be given to further improving the infection control practices by extending the hand washing facilities to people and installing washbasins in sluice rooms. There are areas such as the Deprivation of Liberty Safeguards, Mental Capacity Act and person centred planning where the manager needs to undertake training to ensure that best practice is followed and that peoples human rights are maintained. The assessment of peoples mental capacity to manage their own finances should involve the individuals care care manager, where appropriate, to ensure that decisions are always in the persons best interest. 2 8 3 24 4 25 5 26 6 31 7 35 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. 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