Care Home: The Shrubbery

What the care home does well People living in the home able to expresss a view said that they did not have complaints or concerns about the home or their care. They said that staff treated them well and with respect. This is a small home where relationships are close and easily established between the people living here and the staff group. Discussions with staff revealed that they are knowledgeable about people`s health and personal care needs and try hard to meet those needs. There is a relaxed atmosphere people moving around the home as they wish. Some like to wander within the home throughout the day and staff try to monitor their safety and wellbeing. The garden area is now secure and people can use this pleasant area during the summer months - an invaluable facility for those who need to be on the move and wish to go outside but be safe. The home is a pleasant place for people to live, some improvements have been made since the last inspection others are needed. Although we did not see the homes development plan, we were told an extension to the home is in the early stages of planning. What has improved since the last inspection? There was no manager at the time of the last inspection. A new Acting Manager was appointed 8 months ago and progress has been made in several areas. The care planning format has been changed. All plans are now transferred to the new format that is more concise and gives good current information carers need to enable them to meet the assessed needs of each person. A new system for daily recording has been introduced and provides a brief but concise record of the care provided for each person on a daily basis. Some shortfalls in staff training identified in the last report have been progressed. There is now a training matrix giving clear information about training completed, needed and planned. Progress has been made in this area and if the training plan in place for June/July 2010 is completed the shortfalls in staff training will be satisfactorily addressed. Nutritional risk assessments clearly show when people should be weighed more regularly. It is now practice for each person to be weighed two weekly and where there are concerns about weight loss they are weighed weekly. Records clearly identify this. Some improvements required in medication have been addressed. All prescribed medication is now always available in the home with a system to record medication not received. All written additions to Medication Administration Record (MAR) sheets are now countersigned by another member of staff, ensuring greater accuracy and safety for people. Variable dose medication is now clearly recorded with the actual dose given. This allows the home to track what medication people have been taking. There were concerns on the last inspection that staff did not understand their roles and responsibilities under the Mental Capacity Act and Deprivation of Liberty Safeguards (DOLS). Some staff training has taken place another course planned for remaining staff in July. The home have in fact made an application under DOLS that was approved and has been legally extended to ensure the rights and interests of the person are protected. We were concerned at the last inspection, about some bedroom windows being sealed and not accessible in the event of fire. The home have removed the restrictions. All staff have now had training in the special activities and needs of people with dementia as outlined in their own statement of purpose. The development of activities and social interactions for people have been reviewed and extended to provide people with daily stimulation and much needed community contact. Considerable progress has been made in this area. An Activities Co-ordinator has been appointed and works closely with staff in leading on both internal and external activities. This has been successful and we will watch with interest to ensure this is maintained. A Quality Assurance exercise involving questionnaires to people living at The Shrubbery and their relatives has taken place. The responses have been summarised and action taken to improve the issues identified in the surveys. What the care home could do better: Some furniture identified needs replacement and we recommend that in bedrooms notices about domestic matters are removed along with stocks of continence pads, suitcases and other items stored on top of wardrobes. This will improve the presentation of those areas providing a more homely comfortable presentation of the rooms. A large crack in the wall in a bedroom identified should be filled and redecorated to improve presentation of that room. It is important that Care Plans are established for all new people. This includes those admitted for respite/short stay care. We found one instance of this that had led to some confusion about aspects of care. The Statement of Purpose/Service Users Guide needs review and updating to include current information. The present documents are dated and inaccurate. Improvements have been made in medication administration, but we identified other areas where improvements are needed: It is important that MAR sheets include medication brought forward from the previous cycle. This will allow an audit of each item of medication at any time. We saw anti-psychotic medication prescribed PRN (as needed). It is important that a protocol from the prescriber is provided to define the circumstances in which this is given and what the repeat dose (if any) is. It is also important for staff to record the time, reason, and outcome of the medication on the back of the MAR chart, when given. A first aid trained member of staff must be on duty at all times. This will ensure safety for people in an emergency. Key inspection report Care homes for older people Name: Address: The Shrubbery 33 Woodgreen Road Wednesbury West Midlands WS10 9QS     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: Peter Dawson     Date: 1 1 0 6 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 30 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 30 Information about the care home Name of care home: Address: The Shrubbery 33 Woodgreen Road Wednesbury West Midlands WS10 9QS 01215568899 01215568899 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Amarjit Kaur Sandhu,Mr Avtar Singh Sandhu Name of registered manager (if applicable) Manager Post Vacant Type of registration: Number of places registered: care home 15 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: The maximum number of service users who can be accommodated is: 15 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Date of last inspection Brief description of the care home The home is situated on a main route between Wednesbury and the M6 and is easy to access by public transport and car. The facilities offered by Wednesbury town centre are also in easy reach. The house itself is a mature detached residence set in its own grounds and well screened from the road with ample off road car parking. The house has three floors, all accessible by lift. There are many pleasing period features that have been retained that add character and ambience to the home. The ground floor consists of two lounges, a quiet room, a dining room, one bedroom, bathroom, toilets Care Homes for Older People Page 4 of 30 Over 65 0 15 Brief description of the care home and service areas kitchen, laundry. The other two floors contain bedrooms, toilets and bathshower rooms. The home has a range of adaptations that include bath hoists, grab rails, raised toilet seats; call system, although the home is not seen as suitable for people who are permanent wheelchair users. The range of fees the home charges for residency are not included in the service use guide. People are asked to contact the home directly for this information. Care Homes for Older People Page 5 of 30 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: This unannounced key inspection was carried out by one inspector on one day from 08:30 am - 17:00 pm. The home did not know we were coming. The last key inspection of the home was on 15th September 2009 when the home did not have a Registered Manager. We made 8 requirements and 9 recommendations on that date. The focus on this inspection was to review compliance with the previous requirements and also to review the management arrangements in the home. The home completed an Annual Quality Assurance Assessment (AQAA) - a legally required self-assessment by the service outlining the standards of care being provided. This focuses upon what the home does well, how they evidence this and any areas in need of improvement. This document was returned to us on time and provided us with adequate information, but with some omissions including the fact that a Registered Manager had not been appointed to the home, or arrangements in place to provide Care Homes for Older People Page 6 of 30 this. There were 15 people in residence at the time of this inspection. There were no vacancies. We saw and spoke with several people during the inspection and also the staff on duty. We were able to observe interactions between people living in the home and staff. We looked at care plans, risk assessments, medication records, staff records and other documents. We inspected the communal areas of the home and a sample of bedrooms. The Acting Manager and the Providers representative were both present throughout the inspection and we gave feedback to them about our findings at the end of the inspection. The National Minimum Standards for Older People were used as the basis for assessment of the service. Care Homes for Older People Page 7 of 30 What the care home does well: What has improved since the last inspection? There was no manager at the time of the last inspection. A new Acting Manager was appointed 8 months ago and progress has been made in several areas. The care planning format has been changed. All plans are now transferred to the new format that is more concise and gives good current information carers need to enable them to meet the assessed needs of each person. A new system for daily recording has been introduced and provides a brief but concise record of the care provided for each person on a daily basis. Some shortfalls in staff training identified in the last report have been progressed. There is now a training matrix giving clear information about training completed, needed and planned. Progress has been made in this area and if the training plan in place for June/July 2010 is completed the shortfalls in staff training will be satisfactorily addressed. Nutritional risk assessments clearly show when people should be weighed more regularly. It is now practice for each person to be weighed two weekly and where there are concerns about weight loss they are weighed weekly. Records clearly identify this. Some improvements required in medication have been addressed. All prescribed medication is now always available in the home with a system to record medication not received. All written additions to Medication Administration Record (MAR) sheets are now countersigned by another member of staff, ensuring greater accuracy and safety for people. Variable dose medication is now clearly recorded with the actual dose given. This allows the home to track what medication people have been taking. Care Homes for Older People Page 8 of 30 There were concerns on the last inspection that staff did not understand their roles and responsibilities under the Mental Capacity Act and Deprivation of Liberty Safeguards (DOLS). Some staff training has taken place another course planned for remaining staff in July. The home have in fact made an application under DOLS that was approved and has been legally extended to ensure the rights and interests of the person are protected. We were concerned at the last inspection, about some bedroom windows being sealed and not accessible in the event of fire. The home have removed the restrictions. All staff have now had training in the special activities and needs of people with dementia as outlined in their own statement of purpose. The development of activities and social interactions for people have been reviewed and extended to provide people with daily stimulation and much needed community contact. Considerable progress has been made in this area. An Activities Co-ordinator has been appointed and works closely with staff in leading on both internal and external activities. This has been successful and we will watch with interest to ensure this is maintained. A Quality Assurance exercise involving questionnaires to people living at The Shrubbery and their relatives has taken place. The responses have been summarised and action taken to improve the issues identified in the surveys. What they could do better: Some furniture identified needs replacement and we recommend that in bedrooms notices about domestic matters are removed along with stocks of continence pads, suitcases and other items stored on top of wardrobes. This will improve the presentation of those areas providing a more homely comfortable presentation of the rooms. A large crack in the wall in a bedroom identified should be filled and redecorated to improve presentation of that room. It is important that Care Plans are established for all new people. This includes those admitted for respite/short stay care. We found one instance of this that had led to some confusion about aspects of care. The Statement of Purpose/Service Users Guide needs review and updating to include current information. The present documents are dated and inaccurate. Improvements have been made in medication administration, but we identified other areas where improvements are needed: It is important that MAR sheets include medication brought forward from the previous cycle. This will allow an audit of each item of medication at any time. We saw anti-psychotic medication prescribed PRN (as needed). It is important that a protocol from the prescriber is provided to define the circumstances in which this is given and what the repeat dose (if any) is. It is also important for staff to record the time, reason, and outcome of the medication on the back of the MAR chart, when given. Care Homes for Older People Page 9 of 30 A first aid trained member of staff must be on duty at all times. This will ensure safety for people in an emergency. 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 30 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 30 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. A complete review of pre admission information would ensure people have the information they need to make an informed decision about admission. Evidence: A recommendation was made at the time of the last inspection to include the weekly fees in the Statement of Purpose/Service Users Guide. That has not been done. We found that there were two dated Statement of Purpose/Service Users Guides in the reception area of the home. Both were out of date. The service must review and update these documents and include the weekly fees charged and also include more detailed information about the specialist service offered to people with dementia care needs. It is important to provide people with full information allowing them to make an informed decision about the suitability of the home for them. People considering admission are always invited to vist to assess the facilities and suitability of the home. Care Homes for Older People Page 12 of 30 Evidence: Assessments are carried out prior to admission and people are informed in writing that the home can meet their needs. We saw samples of pre-admission assessments providing a good level of information and the Social Workers multi-agency assessment had been obtained prior to admission. People funded by the local authority are provided with contracts and we saw a sample of a Condition of residency given to both funded and self-funding people. This home does not provide intermediate care. Care Homes for Older People Page 13 of 30 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. People living in this home can expect their physical health needs to be met and improvement in medication administration mean that people have the medication prescribed to ensure their health and wellbeing. Evidence: We made four requirements in this outcome area at our last inspection. Three related to medication: Ensure prescribed medication is always available in the home. Two staff must sign handwritten entries on MAR (Medication Administration Record) sheets. Quantify variable dose medication given. One requirement was made to ensure people were weighed weekly where the risk assessment indicated. We found that the four requirements made had been met. Since the last inspection the new Acting Manager has established a new care planning format. Updating, reviewing and revising the information based upon assessed and known needs. The new plans are in place for vitually all people. They are more concise and give clearer instructions to staff to meet the health, personal and social care Care Homes for Older People Page 14 of 30 Evidence: needs of each person. They are more user friendly and person centred. Care plans showed detailed information about people wishes and choices and their preferences for personal care. Health care needs were clearly identified with nutritional, falls and general risk assessments in place. There was one exception to this - a person admitted 7 weeks previously for respite care did not have a care plan. The home had obtained a copy of the social workers assessment, although this information was not used to establish a care plan. Risk assessments were not in place and the person not weighed upon admission. Subsequent body maps were established to identify marks but no reference made in the daily notes about this. The person was sent to hospital (A&E) but the date not recorded and advice upon discharge not clear. These omissions were not helped by the fact that a care plan had not been established. We saw good information in care plans, including detailed social histories and clear documentation about health care needs. It was clear that everyone is now weighed every 2 weeks and where weight loss becomes evident referrals to GP and dietitian take place and also weekly weighing to monitor progress. The home had initiated a Deprivation of Liberty Safeguard (DOLS) for a person without capacity who was determined to leave the home. This had been extended initially to 6 weeks and more recently to 6 months by the Supervising Authority. This was to ensure the safety and wellbeing of the person. At this time there are no incidents of pressure damage in the home and no-one is presently on food/fluid charts to monitor inputs. We spoke with the visiting District Nurse who visits twice daily to administer insulin. She told us that good relationships existed between staff at The Shrubbery and the District Nursing Service. She said that staff were pro-active in referring potential health care issues and were keen to follow any instructions to improve health care matters. She describe the home as A good, friendly home, that I recommend to people when asked. We looked at the medication system in the home, soon to be changed to an alternative pharmacy. We found that all medication prescribed was in stock and that all variable dose medication had been quantified ( for example number of tablets given). Handwritten entries on MAR sheets had been countersigned by a second member of staff to ensure accuracy. We noticed that the grid at the bottom of MAR sheets was not used correctly to define why medication had not been given, this should always be done. We noticed that anti- Care Homes for Older People Page 15 of 30 Evidence: psychotic medication prescribed PRN (as needed) had not been recorded giving the time and reason for administering the medication with a recorded outcome. There was no protocol in place for administering this medication. This should be obtained from the prescriber and also include details of quantity and timing of repeat doses if any. There was no record on MAR sheets of medication already in stock at the start of the medication cycle. This should be added to the amount of medication received, allowing an ongoing count of medication audit at any point in the cycle. We also noticed that the medication fridge temperatures had been recorded in the past with the exception of the two days prior to this inspection. All staff have had training in medication administration. Only senior staff administer, but all have undergone training. Additionally some staff have also undertaken a distance learning course in medication from a reputable provider. The new pharmacy are scheduling further training for staff prior to the change of supplier. We saw that the dementia care needs of people have been improved due to an increase in staffing in the home. Care Homes for Older People Page 16 of 30 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. A new range of daily activities and stimulation and increasing community contact has improved the quality of life for people living in this home. Evidence: We expressed concerns at the last inspection of the service about the lack of activities and stimulation for people. Some said that they were bored and were asking for more activities. People were suggesting improvements in garden seating and being taken to the shops rather than sitting in the home all day. There was no evidence that people were occupied, their needs being identified in their records. It was also felt specialist training was needed for staff in relation to activities for people with dementia. This was discussed with the provider who felt that the additional staffing costs would not be finanicially viable. We were pleased to learn on this visit that additional staff have been appointed to support both activities and general support for people who have specialist dementia care needs. An Activities Co-ordinator has been appointed and working 16 hours per week over five days leading on activities and promoting access to the community. In addition to the two members of staff on duty throughout the 24 hour period (plus the Manager) an additional member of staff now works from 7.30am - 1pm and 3pm Care Homes for Older People Page 17 of 30 Evidence: 9pm. This has increased the individual support to people throughout the day and allowed the development of activities. People now go for a pub lunch every Friday and there have been external visits and events. There are photographs in the home demonstrating the new range of activities and social occupation clearly enjoyed by people using the service. There have been birthday and other events with preparations involving people in art/craft actvity leading to the events. There is a range of the usual internal activities including large peice games. On the day of inspection people were playing Play Your Cards Right and singing and dancing, clearly enjoying what is an ongoing activity programme. Staff are extremely keen and committed and readily giving their own time to take people into the community and plan events. Considerable progress has been made in the 9 months since the last inspection in providing a greater range of activities suitable for the needs of people with dementia. We saw two people who were taking care of their family, in the form of a teddy bear and a doll. This has made a considerable difference to these people who now purposefully focus upon their new charges. It was not possible to speak with visitors during this inspection due to the fact that an outbreak of diahorrea and sickness had been diagnosed that day and visitors warned about the risks as advised by the Health Protection Agency. We saw breakfast and lunch being served. There is a varied 8 week menu with choice at each mealtime. People told us that they enjoyed the food, saying the food is lovely and we can have anything we want to eat. At the time of the last inspection we were concerned to see that people were given their lunch on teaplates and not dinner plates. We were concerned about the possiblity of reduced food intake for some people. There has been a change in catering arrangements and we saw large bowls used at breakfast time and dinner plates at lunch time. On the last two inspections we made recommendations that the heated food trolley was repaired so that meals were kept hot when transported. We found on this visit that the trolley had been fitted with a new element but although used to serve lunch had not been heated, but food served from the kitchen. The provider agrees that the heated trolley should be used in future. We will monitor the progress made and look for continuity in the positive changes made. Care Homes for Older People Page 18 of 30 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. Peoples concerns are listened to and acted upon. Staff training in Safeguarding and the Mental Capacity Act and DOLS has heightened awareness ensuring people are protected and their rights upheld. Evidence: There is an excellent pictorial complaints procedure in place and includes all current and clear information. In contrast the 4 - 5 page complaints procedure available to visitors was dated, lengthy and unclear. We recommend that this is reviewed and updated to give a clear and concise procedure for making a complaint. We looked at the complaints record and saw that two complaints had been received in relation to ongoing issues. These had been swiftly and appropriately responded to in writing. We looked at the several referrals the home had made under Safeguarding Regulations. Five referrals have been made - most relating to disputes and fights between people living in the home. We also found that 3 additional referrals had been made directly to the police relating to the same type of incidents. The police had visited but no action taken. We advised the home that unless there was immediate concern for the safety of people in the home referrals should be made to the Local Authority Safeguarding team and not directly to the police. These referrals need the benefit of a multi-agency approach. Care Homes for Older People Page 19 of 30 Evidence: All referrals made had been made correctly, in the interests of the safety of people using the service. There is no criticism of the home in this respect. The route of the police referrals was inappropriate and should have been made directly to the Local Authority. At the time of the last inspection we made a requirement that all staff must understand their roles and responsibilities under the Mental Capacity Act and Deprivation of Liberties (DOLS). This was to ensure peoples liberty was not restricted inappropriately. Since the last inspection some staff have undertaken training in these important areas. Four senior staff have completed a four day training course. It was reassuring to see that the home had initiated a referral under DOLS in relation to a person actively determined to leave the home. The application was accepted and the Safeguard put into place initially for 6 weeks and had been extended for a period of 6 months. This was positive action by the home. We saw that further DOLS training for the remaining 7 members of staff had also been planned for July 2010. Care Homes for Older People Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is adequately maintained. Attention to some aspects of the environment would improve the presentation of the home and provide a more homely setting. Evidence: All areas of the home were clean and hygenic. All bathroom and toilet areas have liquid soap and paper towels fitted. A stock of protective equipment seen around the home including gloves and aprons being used by staff. There was an identified outbreak of diahorrea and vomiting identified during the day of this inspection. The home contacted the Health Protection Agency and followed their advice in detail. This involved informing visitors before entering the home and making additional hand hygiene procedures in place for all. Some areas of the home need refurbishment. Some work has been carried out since the last inspection. We were concerned about the potential hazard of a frayed carpet at the entrance to the dining room. This has been resolved with replacement vinyl flooring to this room with a new threshold cover. We made a requirement at the time of the last inspection to seek approval from the Fire Officer for sealed bedrooms windows on the first floor that had been screwed shut restricting exit in the event of a fire. The provider told us that the screws had been Care Homes for Older People Page 21 of 30 Evidence: removed allowing exit in an emergency. The fence and side door entry to the garden area presented a security risk on the last inspection, but the fence and exit gate have been replaced, ensuring a safe garden area where people can relax or wander. We were told that the external fire door from the kitchen was not closing properly and presented a security hazard. We found that this had been repaired and was protected by a key operated closure, with break-glass facility in the event of fire. We were told that bedroom 5 had a crack from floor to ceiling. We found that this was correct and was an unacceptable defect. The provider stated his intention of re plastering and redecoration of the room in the next 2 weeks. We found that a drawer pack to a chest of drawers in the ground floor bedroom were impossible to fully open and needed replacement. The provider said that this would be replaced swiftly. We saw that all hot water outlets had fail-safe valves fitted. We were told that some valves presenting difficulties had been replaced. We saw a sample of bedrooms that were bright, pleasant, homely and generally well furnished, reflecting individuality. We were concerned that there were notices (about domestic arrangements) in several bedrooms, in one there were two extremely large cartons of continence aids and several had suitcases and other items inappropriately stored on top of wardrobes. All these items should be removed and stored elsewhere to improve the homely presentation of of those bedrooms. We expressed concern that the TV in the main lounge area was on from the time we arrived (8.30) it was loud and inappropriate for this resident group who were not watching or were asleep. It was almost impossible to converse with people because of the TV. We suggested that people may respond more positively to background music that presented a calmer and more relaxing atmosphere. Care Homes for Older People Page 22 of 30 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. Improved staffing levels support peoples need for social interaction and specialist activity for people with dementia. Ongoing improvements in staff training ensure current knowledge and best practice. Evidence: The home is staffed with 2 carers throughout the 24 hour period. Additionally there is a carer from 7.30 - 1.00pm and from 3 - 9 pm. The Manager is additional to those numbers. The home have therefore increased the staffing numbers as recommended in the last report. An Activities co-ordinator has also been recruited working 16 hours per week. At the time of the last inspection there was no regular domestic cover, but this has now been resolved with cover over five days. Laundry duties continue to be part of care staff duties. These changes mean that instead of basic staff numbers, the dependency levels and specialist activity needs of people with dementia can now be met. We examined a sample of staff files and found good recruitment practices. We found that all checks, references and other required documents were in place. This means that people are protected by ensuring unsuitable people are not employed. Regular supervision of staff is in place. We saw that a recently appointed member of Care Homes for Older People Page 23 of 30 Evidence: staff had two personal supervision meetings. We were told that supervision is monthly for the 3 months following new appointment. We made a recommendation in the last report because of concerns about some shortfalls in training and inadequate training records. On this visit we found a training matrix had been established clearly identifying training undertaken and highlighting training needs. The new Acting Manager has addressed training as a priority and arranged training in several areas. All staff have now had training in Dementia Care, Moving & Handling. Training in Safeguarding Vulnerable Adults has been undertaken by half the staff group, other staff require this important training also. There are still some shortfalls but these have been addressed with a training programme in June/July 2010, posted in the home. The training schedule includes all staff, with courses in the following areas: Medication, Palliative Care, Dementia (part 3), DOLS, Challenging Behaviours and Care Planning - 50 separate training places for staff are booked. All staff have completed NVQ2 or above with the exception only of recently employed staff who are completing induction to Skills for Care Standards as a basis for NVQ training. Staff we spoke with said that improvements have been made in many areas and they were enthusiastic about their work. We noticed good engagement between staff and people using the service and a calm and supportive response to people with repetitive behaviours. Care Homes for Older People Page 24 of 30 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. Improvements made in several key areas need to be maintained to ensure peoples health, care and well-being are promoted. A Registered Manager application must be made. Evidence: At the time of the last Key Inspection on 15th September the home were without a Registered Manager and we made a requirement to appoint one. We were told they hoped to recruit a Manager swiftly. This has been done and the Acting Manager appointed 8 months ago has made progress in areas of care planning, staff training and medication. We are satisfied with the interim arrangements for management of the home but repeat the previous requirement that an application must be made for approval of a Registered Manager. The provider and representative have close daily oversight of the home. There is a sister home nearby and joint support and training exists between the two homes. Care Homes for Older People Page 25 of 30 Evidence: With the exception of the appointment of a Registered Manager the other 7 requirements of the last report have been satisfactorily addressed. The 9 recommendations of the last report have also been actioned. The home returned the AQAA to us by the required date and gave us a reasonable picture of the current situation in the home. It did not give us information about the appointment of an Acting Manager, or the fact that a Registered Manager was not in post and the action being taken to make an application. There was also a lack of information about the homes development plan, including the areas of the home needing further improvement. Quality Assurance in the form of questionnaires to relatives and people using the service were in place at the time of the last inspection, although no action had been taken to address the areas of concern expressed. Further questionnaires were sent out in November 2009 and included questionnaires to some external health professionals although non received from them. The results of the 16 questionniares returned have been analysed, with a summary of some areas of concern. These related mainly to lack of activities and staffing - issues that have in fact been addressed since the questionnaires were received. We feel that progress has been made in the area of management, although we will monitor that progress to ensure improvements are maintained. The home must make swift application to approve a Registered Manager. We found that adequate numbers of staff were not trained in first aid to ensure there was always a trained person on duty. This applied to the night prior to the inspection when neither of the two people on duty were first aid trained. This is a requirement of Health & Safety (First Aid) Regulations 1981 and must be addressed. Care Homes for Older People Page 26 of 30 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 27 of 30 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 31 8 An application must be made to appoint a Registered Manager This will ensure peoples care, interests and wellbeing are protected at all times. 30/08/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 The Statement of Purpose/Service Users Guide must be reviewed and updated to include all current information, including the weekly fees charged. This will give the information necessary for people to make a decision about the care and facilities offered by the home. A care plan must be established for each person at the point of admission. This includes people on respite/short stay care. This will ensure their needs are known and can be met by informed staff. Where medication is prescribed PRN (as needed) a protocol must be obtained from the prescriber and an entry made on the MAR sheet giving date, time, dose and the reason the medication was given, including the outcome. This will ensure people have as required medication for the correct Page 28 of 30 2 7 3 9 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations reasons. 4 9 Medication in stock at the start of the new medication cycle must be brought forward and added to medication received on MAR sheets. It will then be possible to carry out a medication audit of each medication at any time. This will allow further checks to the medication system and ensure people have the medication prescribed to ensure their wellbeing. The large crack in the wall of the bedroom identified must be filled and covered swiftly. Notices, incontinence pads and suitcases must be removed from bedrooms to improve presentation and a more homely appeal. The drawer pack in the ground floor bedroom is not operational and should be replaced. The planned training programme will ensure staff have the knowledge and competence to meet peoples needs. To comply with Health & Safety Regulations there must always be a first aid trained person on duty. 5 6 19 19 7 8 9 24 30 38 Care Homes for Older People Page 29 of 30 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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