Care Home: The Royal Care Home

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What the care home does well The home is welcoming and has a relaxed atmosphere. Staff showed a good understanding of what each individual likes and dislikes, and care being given was specific to each person`s needs. Individuals who spoke to us said `I like the home`, `they look after us well here` and `the staff take care of all of my needs`. People being cared for have good access to professional medical staff and are able to access external services such as dentists, opticians, physiotherapists, chiropody and dieticians, so their health is looked after and they are kept well. What has improved since the last inspection? There has been a high turnover of staff in the past 12 months and this has resulted in agency staff or bank staff covering a lot of shifts. The management team are working hard to improve the efficiency of the recruitment process and get new staff in place as fast as possible, whilst ensuring all necessary employment checks are completed. The home is focusing on putting a robust maintenance and refurbishment programme into place; the service has only been open 18 months, but the management team recognise that it is important that the environment continues to meet the needs of the people who use the service and that their surroundings are fit for purpose. Improvements have been made in the last 12 months to the outside areas of the home, with new garden furniture being purchased and a pergola created for people to sit out and enjoy the gardens in the better weather. The service is trying to improve the activities programme for people living in the home, developing links to the local churches and arranging monthly visits, adapting the activity programme to reflect people`s preferences and sourcing more links to the local community. Other areas of practice that are being improved upon are administration of medications and management of challenging behaviours (through staff training and better working practices). The service is working towards having a member of staff qualified with the skills and knowledge to deliver challenging behaviour training to other staff, and this training will be made available to new members of staff during their induction period. This will ensure that all staff know how to manage people`s challenging behaviours in an appropriate way, and are able to use safe and effective measures to keep people safe from harm. What the care home could do better: The service needs to improve the staff training programme to include specialist training for staff around Mental Health, Dementia and conditions associated with Old Age. This will help staff develop the knowledge and skills to meet the specific needs of people using the service. Key inspection report Care homes for older people Name: Address: The Royal Care Home Queen Marys Road New Rossington Doncaster DN11 0SN     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: Eileen Engelmann     Date: 1 2 0 3 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 34 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 34 Information about the care home Name of care home: Address: The Royal Care Home Queen Marys Road New Rossington Doncaster DN11 0SN 01302863764 01302869073 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Ladhar Group Homes Name of registered manager (if applicable) Type of registration: Number of places registered: care home 57 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 57 The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP Dementia - Code DE Date of last inspection Brief description of the care home The Royal Care Home is situated in the village of Rossington near Doncaster. It is within reach of local shops, a post office and a church. It is registered to provide both nursing and personal care for up to 57 people in the categories of older people and people with dementia. This is a no smoking home. Care Homes for Older People Page 4 of 34 Over 65 0 57 57 0 2 6 1 1 2 0 0 8 Brief description of the care home It is a two storey purpose built home. Accomodation is provided on both floors, with access to the upper floor by use of a passenger lift or stairs. There are communal areas located on both floors. The kitchen and office are situated on the ground floor and the laundry is situated on the first floor. There is a level and secure garden area to the rear of the building. Adequate car parking is available onsite. Information about the home and services available is detailed within the homes statement of purpose and service user guide. Care Homes for Older People Page 5 of 34 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: We completed an Annual Service Review (ASR) for The Royal care home on 9 February 2010. We only do an ASR for good or excellent services that have not had a key inspection in the last year. An ASR is part of our regulatory activity and is an assessment of our current knowledge of a service rather than an inspection. The published review is a result of the assessment and does not come from our power to enter and inspect a service. Information has been gathered from a number of different sources over the past 16 months since the service had its last key inspection visit on 26 November 2008, this has been analysed and used with information from this visit to reach the outcomes of this report. We have not received any formal complaints about the service over the past 12 months, however there have been 11 safeguarding of adults from abuse alerts made by the home in this time frame and six of these have been investigated by the local authority safeguarding team. One alert made in February 2010 is still being Care Homes for Older People Page 6 of 34 investigated. We received information in March 2010, from Doncaster Social Services, that staffing levels in the home had been reduced and that the numbers of people using the service had increased. The registered manager for this service left her post in 2009. A new manager has been recruited, but this person is not registered with the Care Quality Commission. Two inspectors from the Care Quality Commission (Eileen Engelmann and Sarah Powell) carried out this unannounced visit with the manager, staff and people using the service. The visit took place over 1 day and included a tour of the premises, examination of staff and peoples files, and records relating to the service. The inspectors looked around the home and spoke to a number of staff, relatives and people using the service. Peoples comments and views have been used within this report where appropriate. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 34 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 8 of 34 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 34 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 34 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. People wanting to use the service undergo a needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met. Evidence: Four peoples care and records were looked at as part of this visit. Each person has his or her own individual file and the funding authority or the home, before a placement is offered to the individual, completes a need assessment. The home develops a care plan from the assessments, identifying the individuals problems, needs and abilities using the information gathered from the person and their family. Staff members on duty were knowledgeable about the needs of each person they looked after and had a good understanding of the care given on a daily basis. Discussion with people and relatives indicates they are satisfied with the levels of care being given by the staff, and individuals said their needs are being met. Care Homes for Older People Page 11 of 34 Evidence: Discussion with the manager indicates that people in the home are from a mix of different ethnic backgrounds, although the majority of the people using the service are of White/British nationality. The home does accept people with specific cultural or diverse needs and everyone is assessed on an individual basis. Discussion with the manager indicated that the home looks after a number of people from the local community, although placements are open to individuals from all areas. The home is able to offer a choice of staff gender to people who express preferences about care delivery, as they employ a good ratio of female and male care staff. We observed that peoples preferences and choices were respected and put into practice. Information from the training files and training matrix indicates that the majority of staff are up to date with their basic mandatory safe working practice training, but the manager recognises the need for them to have access to a range of more specialised subjects that link to the needs of people using the service. The manager told us that she has a number of training sessions booked for staff and that by the end of June 2010 all staff should be up to date with mandatory training subjects and she will then concentrate on sourcing more specialist training. The home does not have any intermediate care beds and therefore standard six does not apply to this service Care Homes for Older People Page 12 of 34 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. The health, personal and social care needs of the people living in the home are clearly documented and are being met by the service and staff. The medication at the home is well managed promoting good health. Evidence: The care of four people was looked at in depth during this visit and included checking of their personal care plans. Each individual using the service has a care plan, which identifies each persons needs and abilities, choice and decisions and likes and dislikes. In addition to this information there are risk assessments to cover daily activities of life, behaviour management plans where a risk to the person or others has been identified, and clear information about health and input from professionals and the outcomes for people. The service looks after a number of people who have challenging behaviour and/or complex needs. As these individuals also have dementia it can mean that they are sometimes unable to express their personal wishes or choices around care and their daily lives. Mental Capacity is the ability to make a decision, or take action, at the Care Homes for Older People Page 13 of 34 Evidence: time the decision or action needs to be taken. The Mental Capacity Act (MCA) covers situations where someone is unable to make a decision because the way in which their mind or brain works is affected - for instance by illness or disability. It includes everyday decisions such as what to wear or when to take a bath, as well as more serious decisions such as where to live. Best Interest meetings take place when informed choice cannot be made by the individual and includes the views of all those involved in the individuals care. The service has made a start on assessing individuals as to their capacity to make their own choices and decisions around care with regard to the Mental Capacity Act legislation. However, the assessments and documentation need to be completed as soon as possible so there is clear guidance to staff about how to give appropriate care to the people using the service. People said that they have good access to their GPs, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Comments from the people using the service indicate they are satisfied with the level of medical support given to them. Entries in the care plans specify where individuals have dietary needs, and nutrition risk assessments have been completed. The staff weighs everyone on a regular basis and evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. Staff are completing diet and fluid charts for some individuals, however the written information on these is not satisfactory. One person whose care we looked at has been losing weight, the food chart documented that the person had eaten a quarter of their meal, but did not say what had been on the plate to start with. This makes it difficult for anyone to determine how much food the person has eaten and what type of food is being consumed. Also two food charts for the 6 and 7 March 2010 could not be found for this person. Concerns around missing food and fluid charts were raised at a safeguarding meeting earlier in 2010, when it was found that staff had shredded the records (by mistake). The registered person must ensure that staff understand that these records are legal documents and must be kept for not less than three years from the date of the last entry. The qualified nurses in the care home are responsible for wound care and documentation. We looked at the care plan for one person and found that the individual had been referred to a Tissue Viability Nurse and GP appropriately. However, the documented wound care written by the homes nurses was not clear as the dates written against the entries did not correspond with the progress of the wound; for example the body map dated 15 February 2010 says the wound was 3cm across, 16 February 2010 the nurse had written the wound was 2cm across, and an Care Homes for Older People Page 14 of 34 Evidence: entry dated 18 February 2010 says the wound size was 2.5cm across. This makes it difficult for anyone to assess what the condition of the wound is. The registered person must ensure that the nurses review how they are documenting wound care and that the written evidence is clear and consise. Checks of the medication show the home is using Boots as their pharmacy supplier and the medication system in use is a Monitored Dosage System (MDS) where tablets are supplied in a pop out sheet. We looked at the medication records and found that on the whole these are up to date and completed to an acceptable standard. We found two areas where staff could improve their practice and these were: On one medication record the pain relieving medication Co-codamol was out of stock for one person for 48 hours, this individual takes it four times a day. This is not acceptable practice and the manager assured us she would speak to the staff about this concern. On one unit we noticed that changes made on the medication records, were not signed by the staff member making the amendments. On the other unit staff were signing appropriately against the changes. The manager said she would ensure all staff signed against any changes to the medication records. The service has asked for input from the Care Homes Advisory Team (CHAT) about their medication practices in the home. CHAT are from the local Primary Care Trust and offer advice on medicines management to care homes in a bid to improve patient safety. We were given a copy of their report, which the home had only received the day of our visit, and it was very positive about the service. Information from the report and our observation of the systems and records in the home showed that policies around medication are comprehensive, clear and consise. There is a self administration policy in place, but no one in the home self administers. The home has produced a simple running tally form for medicines that are to be administered which are in boxes rather than the pop out system. This running tally is checked after every administration and cross referenced with the tablets remaining. Each person has a photograph on their medication record to enable easy identification. Only qualified nurses administer medicines, and Boots, the pharmacy provider, have offered training packages which the service have started. Competency assessments, for those responsible for giving out medicines, are in place in the form of observations and questions. Care Homes for Older People Page 15 of 34 Evidence: Information from the manager is that staff undertake a daily audit of the medication paperwork to ensure it is completed correctly and the manager carries out a monthly audit. Checks of the controlled drugs and register showed that these are up to date, accurate and well managed. People we spoke to were very positive about the service, staff and the care they received. Observation of the service showed there is good interaction between the staff and people, with friendly and supportive care practices being used to assist people in their daily lives. One relative who spoke to us said my experience is that the staff are extremely friendly and approachable, the rooms are always clean and tidy and my relative is always clean and well cared for. We found during our visit that people using the service were busy talking to visitors, relatives, staff and each other and enjoying the opportunity of socialising with others. Care Homes for Older People Page 16 of 34 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are given the opportunity to take part in a variety of activities both within the home and in the community. Where possible staff gathers information on community based events and try to make individual arrangements for people to attend. Evidence: The home employs two activities co-ordinators who work full time hours. At the moment there is a range of group activities and one to one sessions taking place, which reflect the interests of the people living in the home and also their gender. On the day we visited the home one activty organiser was on leave; the second activity organiser was seen in the morning to be painting peoples fingernails and had organised a group game of dominoes. In the afternoon she was talking to people on a 1-1 basis. The Annual Quality Assurance Assessment completed by the manager in December 2009, informed us that the service is trying to improve the activities programme for people living in the home, developing links to the local churches and arranging monthly visits, adapting the activity programme to reflect peoples preferences and sourcing more links to the local community. Care Homes for Older People Page 17 of 34 Evidence: The manager told us that recent events had included a pet therapy session where an individual from the local community centre (Rachel Project) had brought in a dog for people to pat and stroke. On 10 May 2010 a singer is booked to come in and entertain and most fridays the activity co-ordinators take people out to the local market and to the cafe for drinks before returning to the service. We spoke to people using the service and relatives visiting the home; one person said it is good here, the carers are nice and the food is okay. A relative who visits daily said I am very happy with the care, the staff are very approachable and very caring. Another relative said I am satisfied with the service, I have had to raise two concerns and these were dealt with quickly. I am pleased with the staff, they are very good. People seemed to spend a lot of time sat on chairs in the corridors talking to one another. One person said I dont like the sitting room, I prefer the corridor so I can watch people go by. One person said I get very bored, with nothing to do. Information from the care plans indicates that people have good contact with their families and friends. Two relatives told us that they can come into the home when they like and that they are always made welcome. Staff told us that the manager has an open door policy for staff, relatives and visitors which works well and ensures people can talk about any issues they may have. We spoke to the administrator for The Royal Care Home and looked at the financial records for peoples personal allowances. We found that the majority of people have a family member who looks after their finances and individuals can access their monies on request. People and relatives are able to voice their opinions of the service at meetings held with the manager and minutes of these meetings are available for inspection. We could not see any information on Advocacy, the Mental Capacity Act or Deprivation of Liberty Safeguards around the home, for people and relatives to look at. The manager told us that she is in the process of getting information booklets from the Department of Health and will put these out on a display stand when they arrive. Checks of the staffing matrix given to us on 12 March 2010 showed that the staff have not accessed training around Equality and Diversity, the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLs). This knowledge and information is used to ensure that peoples choices and human rights are maintained. Ensuring that any limitations on facilities or personal choice are only made following assessment, best interest meetings, risk assessments and discussion with the person concerned or their Care Homes for Older People Page 18 of 34 Evidence: representative. The manager said that she and the senior nurses had received training around these areas of care, and that she is planning to source this training for the rest of the staff. The registered person should ensure that this training is given to all staff so that they can ensure peoples rights are understood and protected. We spent some time sat in the lounge area of the upstairs unit and observed that there was no sign of water or juice on the unit for people to help themselves to or for staff to give out. We saw that people using the service were asking for the tea trolley from 10:25 am; all those who we spoke to said the trolley was late and that they had not had a drink since breakfast time. Individuals told us they were parched and ready for a drink, The tea trolley finally appeared at 11:05 am, and we saw that one individual drank their cup of tea quickly and asked for another. The member of staff giving out the drinks told the individual that they would have to wait until she was finished and if there was any tea left then she would be back. The staff member did come back at 11:30 am and give the person another cup of tea. The registered person should ensure that hot and cold drinks are available at all times for the people using the service and that adequate fluids are given on a regular basis to those who cannot help themselves to drinks. Lunch was fish and chips, peas and sweetcorn or sausage and mashed potatoes. The appearance and quality of the food was adequate and people were seen to be eating it well. However, the presentation of the food could have been better and there was no sign of any sauces to accompany the fish. Condiments such as vinegar and salt/pepper were seen in the dining room. People were offered orange squash to drink. The sweet prepared for the lunch time meal was apple crumble and custard; the kitchen assistant said they cater for diabetics and other specials diets on a daily basis and puddings were made without sugar or with sweetners for the diabetics. Acting on the dieticians advice diabetics are offered yogurts or crisps as an alternative to biscuits or cake mid morning and mid afternoon. Supper time snacks are available and staff can always access sandwiches, cereals and drinks for people using the service on a 24 hour basis. Care Homes for Older People Page 19 of 34 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. Training of staff in the area of protection is regularly arranged by the home. Other training around dealing with physical and verbal aggression is also made available to the staff as needed. So that staff are confident about how to manage peoples care and behaviours in an appropriate way. Evidence: The home has a complaints policy and procedure that is found within the statement of purpose and service user guide, it is also on display within the home. We looked at the complaints records and found there had been eight complaints addressed by the previous manager and only one since the new manager came into post in November 2009. We discussed with the manager that there is no record of any minor concerns or niggles and grumbles, and suggested that she might start recording issues that have required some action on her part to resolve. Discussion with people and relatives indicates that they are satisfied with how the service manages any concerns and complaints, and that they are confident of going to the manager or staff with any issues that are bothering them. One person told us I have had to raise concerns on two occassions, but I felt that I was listened to and the concerns are now resolved. I think the manager is approachable and deals with things efficiently. In the past 12 months there have been 11 safeguarding of adults from abuse Care Homes for Older People Page 20 of 34 Evidence: allegations made by the home and six of these have been investigated by the local authority safeguarding team. One safeguarding allegation was still being investigated at the time of our visit. The service has fully co-operated with the safeguarding team during their investigations and is working hard to implement changes to practices within the home as a result of the outcomes of the investigations. The contract compliance team from Doncaster Social Services has been going into the home to look at documentation and staff work practices, and they are satisfied with the progress being made by the service. Staff training has been given around care planning and person centred care and the manager is improving the services communication processes between staff and people using the service, as well as relatives. Other areas of practice that are being improved upon are administration of medications and management of challenging behaviours (through staff training and better working practices). The service is working towards having a member of staff qualified with the skills and knowledge to deliver challenging behaviour training to other staff, and this training will be made available to new members of staff during their induction period. This will ensure that all staff know how to manage peoples challenging behaviours in an appropriate way, and are able to use safe and effective measures to keep people safe from harm. On the day of our visit 11 members of staff including 5 new employees had received challenging behaviour and physical intervention training, other training days are booked within the next three months. We spoke to one agency care worker who covers 1-1 care on the downstairs unit for a specific individual who exhibits challenging behaviour. They are satisfied that they have received appropriate training on managing challenging behaviour and restraint. The staff member told us that when the individual displays challenging behaviour they use diversion tactics to diffuse the situation, but they do have to use restraint on occassion. Records for the person receiving care shows that they are aggressive verbally and physically on most days, staff say they are unable to find specific triggers for this behaviour. There is a daily record kept for the 1-1 input received by the person using the service, showing how the time is spent and the care given to each person. We observed a member of staff being hit in the face by a person using the service. The staff member carried on their work as if nothing had occurred. We were concerned that incidents are happening on a regular basis and are not being reported by the staff to the manager. Discussion with the manager indicated that staff do Care Homes for Older People Page 21 of 34 Evidence: record these incidents and are able to discuss any concerns or problems with the manager on a 1-1 basis. Care Homes for Older People Page 22 of 34 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of environment within the home is good, providing people with a comfortable and homely place to live. Evidence: The home has an ongoing maintenance and refurbishment programme and the manager was able to show us the work that has been completed in the past 12 months and discuss work that is planned for this year. Walking around the home we found that the communal living spaces on each of the two units are warm, well decorated and welcoming. Attention to detail on the dementia units ensures that surroundings are familiar to people and homely. We had noted a strong odour of urine in the entrance to the home on our arrival, however all areas that we visited were extremely clean and there were no odours elsewhere in the home. The manager and staff told us that there is a rigourous cleaning programme in place and that carpets and chairs had been replaced throughout the home wherever needed. The manager telephoned us later to say that the cause of the odour had been found and the area had been deep cleaned. Bedrooms in the home are all single rooms with en-suite toilet facilities. Each unit has its own communal assisted bathing facilities, with bathrooms and shower rooms being provided within the home. On the ground floor people have access to outside garden Care Homes for Older People Page 23 of 34 Evidence: areas with plants and lawned sections, plus a newly built pergola to sit under. Doorways to bedrooms, communal space and toilet/bathing facilities are wide enough for wheelchairs, and corridors are spacious and have enough room for people in wheelchairs or with walking frames to pass by comfortably. Discussion with the staff and manager indicates that there is a wide range of equipment provided to help with the moving and handling of the people using the service and to encourage their independence within the home. There are 10 profiling beds, which have intergrated bed rails, in use within the home. These beds are raised and lowered using a handset and are designed to take pressure relieving mattresses to give comfort and ease to people who may have to spend a long time in bed. Discussions during this visit indicate that people using the service are satisfied with the laundry service provided by the home. Infection control policies and procedures are in place, and staff have access to good supplies of aprons and gloves for use in personal care. The staffing matrix supplied to us on 12 March 2010 indicates that infection control training is part of the rolling programme of training and that 12 staff attended this in March 2010 and more sessions are booked for May and July 2010. Care Homes for Older People Page 24 of 34 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. Improvements to staff induction, recruitment and training are resulting in higher staff morale and a better retention of workers. The workforce is working positively with people using the service to improve their whole quality of life. Evidence: We received information in March 2010, from Doncaster Social Services, that staffing levels in the home had been reduced and that the numbers of people using the service had increased. This was a cause for concern as some of the outcomes from the recent safeguarding of adults investigations carried out by Social Services indicated that staffing numbers and the areas where staff were deployed, were key to reducing the number of accidents and incidents within the service. We looked at the staffing rotas for the week commencing 8th March 2010. We noted that the service is not always putting the role or qualifications of the staff on the rota. This makes it difficult to see who are nurses, care staff and anciliary staff. The agency staff who are used for 1-1 care and a twilight shift within the service were not on the rota, neither were the names of the agency nurses who were covering the regular agency nurse (now on sick leave). The administrator was able to give us copies of timesheets to show that these staff were on duty, but this was a time consuming exercise which would not be necessary if all staff were put onto the rota. Care Homes for Older People Page 25 of 34 Evidence: At the time of our visit the home had 52 people in residence and the staffing levels were as follows: The upstairs unit has 28 people, 11 people receiving nursing care and 17 people receiving personal care plus 1 empty bed. In the morning (8am to 2pm) there is one nurse and four care staff, in the afternoon/evening (2pm to 8pm) there is one nurse and three care staff plus an extra person doing 4pm to 8pm. At night (8pm to 8am) there is one nurse for the whole home, two care staff plus one person doing a 8pm to 12pm shift. The downstairs unit has 24 people who receive nursing care and 4 empty beds. During the daytime (8am to 8pm) there is one nurse and 4 care staff and at night (8pm to 8am) there are two care staff. In addition to the above numbers there are agency staff covering 18 hours of 1-1 care per day. Information from the manager on 12 March 2010, about staffing hours provided, and the dependency levels of the people using the service, was used with the Residential Staffing Forum Guidance. This showed that the home is exceeding the minimum hours asked for in the recommended guidelines for an older persons home. However, given the fact that everyone in the service has dementia and a number have complex needs then the excess hours are necessary to enable staff to meet these specific needs. Discussion with the manager indicated that the home has had a recent recruitment drive to employ more care staff and nurses. Two nurses and five care staff are in the process of doing their inductions and will join the workforce shortly. This should reduce the amount of agency used by the service and create a more cohesive team of staff. We found that only one bank nurse had a Registered Mental Health (RMN) qualification, all other nurses come from different specialist backgrounds. The home has recruited a further RMN but this still leaves a big gap in knowledge. We discussed this with the manager who agreed that there is a need to develop the training programme for staff. This to include specialist sessions on mental health, different types of dementia and conditions associated with this type of illness. The training is to also conditions relating to older people such as diabetes, heart problems and physical disabilities. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Less than 50 of the care staff have achieved a National Vocational Qualification in Care Homes for Older People Page 26 of 34 Evidence: Care (NVQ), however the manager said that this was being addressed and more staff would be undertaking this training in the next 12 months. We found that the home does not have an induction for new care staff, which meets Skills for Care criteria. The registered person must ensure that new staff with no previous knowledge of caring, undertake this type of induction in order to develop the necessary skills and knowledge to meet the needs of those using the service. The training programme for the home was not adhered to in 2009, prior to the new manager coming into post in November 2009. Since this time the manager has worked hard to bring the mandatory training sessions up to date and feels that these will be achieved by the end of June 2010. The focus will then be on more specialisist sessions as discussed in the above report. As part of our visit we looked at three staff files. Two care staff started before their police checks (CRB) were returned; information on the staff rotas shows which senior staff are acting as mentors for the new employees, but there is no written evidence of what type of supervision took place during this time. We also found that the manager needs to discuss any issues about a prospective employees previous employment during the interview stage of recruitment, and that a written explanation of any discussions and outcomes is recorded in the staff file. The manager is carrying out supervisions including practical sessions of observation of practices and feedback to the individual. She is aware that appraisals and supervisions are not fully on track but feels that she is getting there. Care Homes for Older People Page 27 of 34 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. The management of the home is satisfactory overall and the home regularly reviews aspects of its performance through a good programme of audits and consultations. This includes seeking the views of people using the service, staff and relatives. Evidence: The manager at The Royal Care Home started in post in November 2009, she is a registered nurse and has previous experience of management in a nursing home for older people with dementia. The manager is not registered with the Commission for Quality Care and we advised that she put forward her application as soon as possible. Policies and procedures within the home have been reviewed and updated to meet current legislation and good practice advice from the Department of Health, local/health authorities and specialist/professional organisations. The manager and senior staff complete in-house audits of the home and its service on a monthly basis, and the registered individual does spot checks and completes the regulation 26 visits. Care Homes for Older People Page 28 of 34 Evidence: The manager is aware of the need to send out satisfaction questionnaires to the staff, relatives, people using the service and healthcare professionals on a yearly basis, as part of the homes quality assurance process. The last questionnaires sent out by the service were in July 2009 and the manager plans to restart this process by June 2010. The manager is also aware of the need to produce an annual development plan based on the systematic cycle of planning-action-review, which reflects the aims and outcomes for service users, and this should be in place by June 2011. Checks of the finance systems within the home found that computerised records are kept for peoples personal allowances; the administrator on a weekly basis up dates these, and they are checked yearly by an outside auditor. Information from the administrator indicates the majority of people have their families looking after their financial affairs, and checks of the system show their relatives top up the persons individual allowance account on a regular basis. People who have asked the home to look after their personal allowances are able to access their money on request, and receipts are kept for any transactions. All monies are kept safe and secure within the home and only the administrator or manager has access to the funds. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff are receiving training in safe working practices and risk assessments were seen regarding fire, moving and handling, bed rails and daily activities of living. Care Homes for Older People Page 29 of 34 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 30 of 34 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 8 17 The registered person must 01/07/2010 ensure that food and fluid charts and wound care records, maintained in respect of each person using the service, are completed accurately and retained for not less than three years from the date of the last entry. So that a clear and accurate record of the care people received is available should there be a need for investigation or clarification by the appropriate authorities. 2 14 12 The registered person should ensure that all staff receive training around equality and diversity, deprivation of liberty and the mental capacity act. So staff have a good understanding of peoples 02/08/2010 Care Homes for Older People Page 31 of 34 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 human rights and that any limitations on facilities available or personal choices are only made following assessment, best interest meetings, risk assessment and discussion with the person concerned or their representative. 3 28 18 The registered person must 01/07/2010 ensure that new staff, who have no previous experience of care work, complete an induction which meets Skills of Care criteria. So that the service can be confident the staff have the necessary knowledge and skills to meet the needs of the people using the service. 4 30 18 The registered person must 01/10/2010 ensure that the staff receive specialist training around Mental Health, Dementia and Older People appropriate to the work they have to perform. So that staff can be confident that they have the skills and knowledge to meet the needs of the people using the service. Care Homes for Older People Page 32 of 34 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 The registered person should ensure that appropriate assessments and documentation is in place, for all people using the service, regarding The Mental Capacity Act and Deprivation of Liberty Safeguards by the end of June 2010. So there is clear guidance to staff about how to give appropriate care to individuals, whilst respecting the persons rights to make their own decisions and choices about their daily lives. The registered person should ensure that the staff are following the medication policies and procedures for the service appropriately, so that no one using the service runs out of their prescribed medication. The registered person should ensure that hot and cold drinks are available at all times for the people using the service and that adequate fluids are given on a regular basis to those who cannot help themselves to drinks. The registered person should ensure that a recorded staff rota is kept showing which staff are on duty at any time during the day and night and in what capacity. The registered person should ensure that 50 of care staff achieve an NVQ 2 in care by the end of January 2011. The registered person should ensure that any issues about a prospective employees previous employment are explored thoroughly during their interview stage and that a written explanation of any discussions and outcomes is recorded in the staff file. The registered person should ensure that where staff are being supervised because their CRB has not been received by the home, then the supervision is recorded and details what this entailed. The registered person should submit an application to the CQC for the registration of a manager by the end of June 2010. The registered person should ensure that the process of sending questionnaires to stakeholders is restarted by the end of June 2010 and that there is an annual development report created from the quality assurance process, to highlight where the service is going and/or indicate how the management team is addressing any shortfalls in the service by the end of June 2011. Page 33 of 34 2 9 3 15 4 27 5 6 28 29 7 29 8 31 9 33 Care Homes for Older People 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). 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