Care Home: The Willows

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What the care home does well Residents needs are appropriately assessed, before they are offered a place in the home to make sure that their needs would be met. They are also given the necessary information for them to make an informed decision about moving into the home. The home provides accommodation to residents in single bedrooms that are appropriately maintained, decorated and furnished. The bedrooms have been appropriately personalised to provide a homely environment for residents and most of them provide a view on the pleasant garden that surrounds the home. We noted that residents were able to exercise choices about their life in the home. They could make choices about where they wanted to spend their day, about their meals and about whether they wanted to take part in activities. The home has a permanent manager who is approachable and listens to residents and their visitors and to her staff. She runs the home in an open manner. The senior management of the organisation is very involved in monitoring and overseeing the home to ensure sustained and continuous improvement of the service. Comprehensive regulation 26 visits are carried out and reports are formulated with action plans, where required, to address areas that require improving. The home has a new conservatory that adds to the communal space of the home and provides a pleasant area for residents and their visitors to enjoy. What has improved since the last inspection? The quality of the care records that the home keeps has improved quite significantly and the home is commended for progress in this area. The assessments of the needs of residents are carried out comprehensively and care plans and risk assessments are put in place to address the needs of residents that have been identified and these were signed, dated and reviewed at least monthly. There was evidence of the involvement of residents and/or their representatives in agreeing the care plans. Particularly appropriate is the fact that the life history of the resident is described early on in the care plan to give a perspective on the resident life and to enable one to see the `person` in the resident. End of life care of residents is now an inclusive part of the assessment of the needs of residents and is addressed in a plan of care. The service users` guide has been updated following recent changes in registration and copies were seen in the office that would be given to all residents and/or their representatives. Those residents who are at risk of developing pressure ulcers or who have pressure ulcers have care plans in place, although the equipment that is used to provide pressure relief is not always described. The home has acquired a number of wheelchairs with footrests and cushions and we noted very few residents sitting in wheelchairs. Most residents sat in armchairs in the lounge area or in the new conservatory. The management of medicines has improved to some extent. Staff signed medicines records chart when they gave medicines or used a code when they did not administer the medicines. The members of staff that we talked to about medicines, had a good knowledge of medicines and their indications. The recruitment procedure is robustly adhered to, to ensure the safety of people who live in the home. Members of staff receive supervision and the home plans to re-start staff appraisal as, a way of addressing staff performance. The home now has reviewed the quality management system and there is an annual audit that is carried out based on the national minimum standards. This was being carried out on the first day of the inspection. The home has an emergency fire plan, a fire risk assessment and regular monthly emergency lights test. An up to date health and safety risk assessment was also available for inspection. The electrical wiring certificate was up to date. The window restrainers have been readjusted to ensure that they do not open that wide to enable a person pass through these. What the care home could do better: There must be appropriate risk assessments in place when residents are engaged in activities that carry a certain amount of risk. This is necessary not only to promote the safety of the residents but also to promote their independence. The condition of residents who are not well must be monitored carefully to ensure that they are not deteriorating and that medical input can be sought in a timely manner. Fluid balance charts must be kept if required to monitor the oral intake of residents to monitor for dehydration. All liquid medicines must be dated when they are opened as once opened, they have a limited shelf life. Topical medicines such as cream and ointments must have clear instructions about the location to apply these medicines. The lounge area is in need of redecoration and the carpet is stained and is in poor condition. The fixtures, fittings and furniture could also be renewed to provide a more pleasant environment. Some of the armchairs are of a cloth material and have odours. These cannot be easily cleaned when they are wet. There were some water outlets to which residents had access to, where we did not see any thermostatic valves to regulate the water temperature to below 44 degrees centigrade. The appropriate risk assessments must be carried out and control measures must be in place in cases where significant risks have been identified. We were unable to see regular records of the temperature checks at all the hot water outlets in the home to make sure that the thermostatic valves are working appropriately. The home should also consider a programme of routine checking of window restrainers at a frequency to be determined by the home`s risk assessment, to make sure that these are in good working order. Key inspection report Care homes for older people Name: Address: The Willows The Willows 136 Honeypot Lane London London NW9 9QA     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: Ram Sooriah     Date: 2 2 0 4 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 36 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: The Willows The Willows 136 Honeypot Lane London London NW9 9QA 02082045900 02082045999 m/laute@abbeyfield.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): The Abbeyfield Society Name of registered manager (if applicable) Manjit Kaur Laute Type of registration: Number of places registered: care home 28 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 28 The registered person may provide the following categories of service only, Care Home only, Code PC, to service users of the following gender, either, whose primary care needs on admission to the home are within the following categories, Old Age, not falling within any other category, Code OP Date of last inspection Brief description of the care home The Willows has been a care home since 1986. It was previously run by the West London Abbeyfield Society and in 2007 merged with Abbeyfield UK. Since 21st April 2009 it is operated by the Abbeyfield Society. The Abbeyfield Society was launched in 1956 to provide housing with support and care to older people from all walks of life regardless of income. It is a registered charity. Care Homes for Older People Page 4 of 36 Over 65 28 0 Brief description of the care home The home accommodates older people of mixed gender who require assistance and support with personal care. It is located in Kingsbury on Honeypot Lane and is easily accessible by car. There is a car park for about seven cars in the grounds of the home. The home is also well served by public transport, as there are a number of buses that pass in front of the home. The underground station is an approximate ten minute bus ride away. The home benefits from well maintained gardens, lawns, flower beds/shrubs and trees on the sides and at the back. It is purpose built and covers two floors. Residents are accommodated over the two floors in single bedrooms. All bedrooms have a wash hand basin and 5 bedrooms have an en-suite, which consists of a toilet and shower. There are bathrooms and toilets for communal use on each floor. There is a kitchen and large communal areas on the ground floor. A conservatory has been added during the last year to improve the quality of the accommodation. Access to each floor is via a shaft lift and stairs. A number of offices and storage areas are available throughout the home. The registered manager is Manjit Laute and she runs the home with the support of the deputy manager and line management from the Abbeyfield Society. The home charges 584.33 pounds for a single room to 639.45 pounds for a single ensuite room. The fees do not include hairdressing, dry cleaning, toiletries, newspapers and other personal expenses. There were 26 residents in the home at the time of this inspection. Care Homes for Older People Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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 report contains the findings of a key unannounced inspection that took place on Monday 20th April 2009 from 10:20-16:50 and continued on Wednesday 22nd April 2009 from 10:45-15:00. The last key inspection took place on the 22nd April 2008. During the inspection we talked to seven residents and two relatives, toured the premises, looked at a sample of records, inspected a sample of medicines and talked to seven members of staff. We also received 10 satisfaction questionnaires from residents, 1 from a member of staff and 1 from a health care professional. The manager completed an Annual Quality Assurance Assessment (AQAA) that we have used where possible in this report. This was on the whole appropriately completed and was informative. We would like to thank the residents for a kind welcome to the home and the manager Care Homes for Older People Page 6 of 36 and all her staff for their cooperation and support during the inspection. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? The quality of the care records that the home keeps has improved quite significantly and the home is commended for progress in this area. The assessments of the needs of residents are carried out comprehensively and care plans and risk assessments are put in place to address the needs of residents that have been identified and these were signed, dated and reviewed at least monthly. There was evidence of the involvement of residents and/or their representatives in agreeing the care plans. Particularly appropriate is the fact that the life history of the resident is described early on in the care plan to give a perspective on the resident life and to enable one to see the person in the resident. End of life care of residents is now an inclusive part of the assessment of the needs of residents and is addressed in a plan of care. The service users guide has been updated following recent changes in registration and copies were seen in the office that would be given to all residents and/or their representatives. Those residents who are at risk of developing pressure ulcers or who have pressure ulcers have care plans in place, although the equipment that is used to provide pressure relief is not always described. The home has acquired a number of wheelchairs with footrests and cushions and we noted very few residents sitting in wheelchairs. Most residents sat in armchairs in the lounge area or in the new conservatory. Care Homes for Older People Page 8 of 36 The management of medicines has improved to some extent. Staff signed medicines records chart when they gave medicines or used a code when they did not administer the medicines. The members of staff that we talked to about medicines, had a good knowledge of medicines and their indications. The recruitment procedure is robustly adhered to, to ensure the safety of people who live in the home. Members of staff receive supervision and the home plans to re-start staff appraisal as, a way of addressing staff performance. The home now has reviewed the quality management system and there is an annual audit that is carried out based on the national minimum standards. This was being carried out on the first day of the inspection. The home has an emergency fire plan, a fire risk assessment and regular monthly emergency lights test. An up to date health and safety risk assessment was also available for inspection. The electrical wiring certificate was up to date. The window restrainers have been readjusted to ensure that they do not open that wide to enable a person pass through these. What they could do better: There must be appropriate risk assessments in place when residents are engaged in activities that carry a certain amount of risk. This is necessary not only to promote the safety of the residents but also to promote their independence. The condition of residents who are not well must be monitored carefully to ensure that they are not deteriorating and that medical input can be sought in a timely manner. Fluid balance charts must be kept if required to monitor the oral intake of residents to monitor for dehydration. All liquid medicines must be dated when they are opened as once opened, they have a limited shelf life. Topical medicines such as cream and ointments must have clear instructions about the location to apply these medicines. The lounge area is in need of redecoration and the carpet is stained and is in poor condition. The fixtures, fittings and furniture could also be renewed to provide a more pleasant environment. Some of the armchairs are of a cloth material and have odours. These cannot be easily cleaned when they are wet. There were some water outlets to which residents had access to, where we did not see any thermostatic valves to regulate the water temperature to below 44 degrees centigrade. The appropriate risk assessments must be carried out and control measures must be in place in cases where significant risks have been identified. We were unable to see regular records of the temperature checks at all the hot water outlets in the home to make sure that the thermostatic valves are working appropriately. The home should also consider a programme of routine checking of window restrainers at a frequency to be determined by the homes risk assessment, to make sure that these are in good working order. Care Homes for Older People Page 9 of 36 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 36 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home offers information to people who want to use the service to enable them make an informed decision about moving in. All people have their needs assessed before they are offered a place in the home. Evidence: Following the re-registration of the organisation from Abbeyfield UK to Abbeyfield Society, the service users guide (SUG) and the statement of purpose (SoP) have been updated. We noted that the SUG was produced in an easy to read format and with pictures. The manager stated that the updated SUG will be distributed to the residents who live in the home. The majority of residents who responded to our questionnaires and the residents that we spoke to during the inspection stated that they receive enough information about the service before deciding whether they would like to live in the home. In some cases their relatives and friends received the information about the service. Some residents Care Homes for Older People Page 12 of 36 Evidence: said that they were able to visit the home with their relatives/friends before deciding to move into the home. People who are referred to the home have their needs assessed by the manager prior to them being offered a place in the home, to make sure that the home will be able to meet the needs of the prospective residents. During the inspection we had the opportunity to look at the preadmission assessment records for two residents. We noted that these were appropriately completed to enable a person reading the records understand the needs of the prospective residents. Residents that are admitted to the home or their representatives receive a contract. We checked the contracts for two residents and noted that these were in place. The contracts were generally comprehensive but could have been more precise with regards to the party that is responsible for paying the fees for the stay of the resident in the home. Eight out of ten responses to our questionnaires said that residents have received a contract and one person did not respond to that section of the questionnaire. The home is appropriately staffed and is appropriately equipped to care for elderly residents who require personal care. Staff receive a range of training and understand the needs of the residents, including the cultural and spiritual needs. The one member of staff who sent a questionnaire and staff that we spoke to during the inspection confirmed that they receive the necessary support and training to do their job appropriately. Care Homes for Older People Page 13 of 36 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There has been a marked improvement in the content and quality of the care records as compared to the findings of the last key inspection. Residents and their relatives are now involved in the care planning process. Residents are supported by staff in meeting their personal and health care needs, although staff did not always seem to appreciate the more complex needs of residents. Medicines management has on the whole improved to ensure the safety of residents, with few issues noted. The end of life care needs of residents are addressed in the care records of all residents and are managed appropriately in cases of those residents who develop these needs. Evidence: We looked at the care records of four residents. We noted that there has been a vast improvement in the content of the care records. The assessment of the needs of residents were appropriately completed and a range of risk assessments were in place as required to ensure the safety of residents and of staff. The home has an initial Care Homes for Older People Page 14 of 36 Evidence: format for risk assessment that looks at most areas of the life of residents. Depending on the findings of the risk assessments, more detailed and in depth risk assessments are in place to address areas where residents have been identified at high risk. This was generally well carried out, but in one case a risk assessment and control measures to reduce the risks were not in place for a resident who was at significant risk, as they tended to come down the stairs at night on their own, even though they had some mobility impairment. Care plans were in place to address all the needs of residents, including the cultural and spiritual aspects of their needs. The plans of care were on the whole comprehensive and have improved beyond recognition compared to what was in place previously. However, some could have been more accurate such as when addressing the continence needs of residents or the management of the pressure area care of residents. We noted that the incontinence aids to use to manage incontinence were not always identified in the care records of residents and that the equipment in place to manage the pressure area care of residents were also not always clearly identified. Care plans and risk assessments were generally kept under review and were signed by residents or their relatives to show that they have been consulted about these documents and have agreed to them. A few assessments in the care records of a resident had not been reviewed monthly but the plans to meet the needs of the resident had been reviewed monthly. The care records of residents were audited by the regional care services manager to make sure that these were kept up to date and appropriate. Actions plans were in place for each care plan that had been audited to address areas where improvement was required. This is good practice. Progress notes were usually made for day and night shifts to record the care and support that residents received. We noted that the care records of two residents that we sampled, did not contain entries for two consecutive days. As a result the care that was delivered on these days was not documented. Residents presented as appropriately dressed and groomed. Male residents were appropriately shaved. At least two residents were observed with nails that would benefit from better nail care. One respondent to our residents questionnaires stated that they always receive the care and support that they need and eight said usually. One however, commented that no one help my relative to walk, another said I have to wait for a long time for someone to come when I need help and two said staff rush me. Care Homes for Older People Page 15 of 36 Evidence: No residents said that staff are always available when one is needed. Eight said that staff are usually available and two said that staff are sometimes available when one is needed. One respondent said that It is difficult to get in and out of bed, as no one is available and another said that more staff is needed and that there is a reliance on relatives and friends to care and support residents. Six residents who responded to comment cards stated that their health care needs in the home are always met and three said usually. The health care professional who responded to one of our comment cards stated that the home would benefit from trained nurses, to the question whether the care service seeks advice and acts upon it to manage and improve an individuals health care needs. The respondent added that medical advice is at times sought for trivial conditions. The manager responded to the above when we gave feedback to her, and reported that the home has recently recruited two skilled and experienced senior members of staff, one of which is the deputy manager, who will support residents with their health care needs and make the appropriate decision when medical input is required. There was evidence that residents were seen by the GP, optician, chiropodist and district nurse when required. Residents were referred through the GP to other health care professionals if that was required. Records were kept about the outcomes of the visits by the various health care professionals. Residents health care needs were generally addressed in the care records of residents. Those who were at risk of malnutrition had care plans in place to address this need. There were also care plans for residents who were at risk of developing pressure ulcers. As mentioned above, the equipment in place to prevent pressure ulcers or to manage current pressure ulcers were not always recorded to enable the reader make a decision about the suitability of the equipment that is in place. We noted that a newly admitted resident developed a pressure ulcer in the home. Whilst the home sought advice from the district nurse service and equipment was provided, we noted that the pressure relief cushion that had been supplied was placed in a corner of the room and was not being used. A misunderstanding apparently occurred with regards to how to connect the pressure relief cushion to a compressor. As a result the cushion was not being used, until we asked questions about it. The same resident had a problem with nausea and vomiting and there was no monitoring in place with regards to the amount of fluid and food that was being taken by the resident to monitor for dehydration and malnutrition. There was no care plan in place Care Homes for Older People Page 16 of 36 Evidence: to manage the nausea and vomiting. Residents had a continence assessment and care plans were in place to promote continence and manage incontinence. The care plans as we stated above do not appropriately addressed the management of incontinence. A residents relative mentioned that at times the resident does not wear the appropriate pad and as a result gets wet. We also noted the use of incontinence chair pads on some of the chairs in the communal areas. We were told that this is necessary because the chairs get wet. Incontinence chair pads are not discreet and raise issues about privacy and dignity. These, if required must only be used on the basis of a full continence assessment of the resident and as a last resort when all other more discreet incontinence aids have been proved not to be suitable. There was an odour coming from at least two chairs in the communal areas and from one bedroom on the ground floor, which then caused an odour in the communal area and in part of the home. Further more there was at least one wheelchair that was used to move residents that had been incontinent and these had not been cleaned. As a result this also contributed to the odour in part of the home. The management of medicines was inspected. The home kept some controlled medicines and we found that the records regarding the management of controlled medicines were in good order. There had been some entries in the controlled book made a few years ago, of medicines that had been received into the home. There were no records whether the medicines were returned to be disposed of, which would suggest that these medicines were still in the home. In cases when controlled medicines have been returned to be disposed of, the total balance must be updated. Medicines administration records charts were signed when medicines were administered or the relevant code was used when a medicine was not administered. Instructions for the administration of medicines were generally clear, except for creams and lotions when it was not always clear where these were to be administered. The date of opening of a number of liquid medicines were not recorded on the bottles/containers. These included an antibiotic, a medicine to manage pain and two liquid homely remedies. The home has a list of homely remedies that had been agreed by the GP. A list was kept of the homely remedies in the home and of the residents who had received the homely remedies. We noted that one of the homely remedies had expired and needed to be replaced. Care Homes for Older People Page 17 of 36 Evidence: The manager reported that residents are able to stay in the home for end of life care as long as the home is able to meet the needs of the resident and if the right support is available in the community. Care plans tend to address death and dying. There was also evidence that a few members of staff have had some training in End of Life care. The home has notified us when residents have died in the home and we have noted that the end of life care of the residents have been managed appropriately. Care Homes for Older People Page 18 of 36 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home offers social and recreational activities to residents that generally meet their individual needs. Residents have the opportunity to enjoy well presented meals according to their personal choices. Evidence: The home has an activities coordinator who works Monday to Friday. A programme of activities was arranged for the day to day arrangements. There are also outside entertainers who visit the home to provide shows for the residents. For example an entertainer had been booked for St Georges day. We were informed and were able to witness that the home has a range of communal activities but there are also one-to-one activities. On one day we noted an exercise session that consisted of ball throwing and during one afternoon residents sat outside with their visitors enjoying the pleasant weather. We talked to residents and visitors about the activities and a few said that the activities tended to be repetitive. They cite the exercise sessions which tended to be mostly ball and balloon throwing sessions. We talked to the manager about this and Care Homes for Older People Page 19 of 36 Evidence: she said that there are videos that are used during the exercise sessions with music and prompts about the exercises that are suitable for older people. Care Plans contained a life history of residents at the very front and provide a useful perspective on the life of residents that informs the reader about the kind of social and recreational activities that the residents would enjoy. There was a care plan in place to address the social and recreational needs that have been identified. Outings are arranged for residents normally once every month. The home hires a mini bus that is driven by a volunteer. We were informed that some residents have been to the Ruislip Lido and the RAF museum. The activities coordinator told us that representatives from the Church of England and the Roman Catholic Church visit the home weekly. She added that residents from other cultures and religions are supported by their relatives and staff in celebrating their cultural and religious festivals and important days. From talking to residents and from feedback from questionnaires we noted that some residents chose which activities to join in, with at least one person saying that they prefer to keep to themselves and not to join in communal activities. Six residents said that there are always activities that they can take part in, three said usually and one said sometimes. One person stated that there are no activities at the weekend and the time drags. We have to concur with this as we indeed noted that there are no activities arranged for the weekend and although staff said that the weekend is for relatives and visitors, there are residents who do not get any visitors and would benefit from more organised activities. Catering in the home is contracted out. On the first day of the inspection there was homemade moussaka, vegetable casserole, saute potatoes, garden peas, grilled tomatoes and for desert there was apple and pear crumble. In addition to the above there was also an alternative menu that consisted of meals such as salads, omelettes and jacket potatoes. Residents were involved in menu planning and in agreeing the meals as the manager said that there was a summer menu that was waiting to go out when it had been agreed by residents. All residents were encouraged to use the dining areas, where tables were appropriately set to provide a pleasant dining experience. Even residents who tended not to join other residents for communal activities and to sit in the communal areas, Care Homes for Older People Page 20 of 36 Evidence: joined all the other residents at mealtimes. We observed that residents were asked about their choices that were recorded. for those residents who were unable to make choices staff chose the residents meals according to the likes and dislikes of the residents. Those residents who required feeding were supported in a discreet and appropriate manner. During the last inspection we made a note in the report about the nutritional content of some of the vegetarian meals that are provided in the home, as they do not seem to contain the recommended daily intake of protein according to guidance from the government on the preparation of meals in care homes and on the nutritional content of the meals, as per The eat well plate (see Food Standards Agency, (2007) Guidance on Food served to older people in residential care. www.food.gov.uk, and Food Standards Agency, (2006). On the second day of the inspection we noted that the home served rice with a vegetable curry as a second choice. We noted that quite a number of people were having the meal. The source of protein for the meal was however not very clear. There was semolina with jam sauce, but is is unlikely that residents would be receiving 30 of the 50 gram (the daily recommended protein intake) with their lunch meal, unless the semolina desert was enriched with protein. Other examples of meals where the protein content of meals was not very clear, include vegetables samousas, stuffed tomatoes, vegetable crumble and vegetable stew with herb dumplings. Care Homes for Older People Page 21 of 36 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that all complaints are logged and addressed as appropriate, although the records that were kept were not detailed enough to describe the action that has been taken with regards to the complaints. The manager and her staff take all suspicions and allegations of abuse seriously and are aware of the action to take to safeguard residents interests. Evidence: Nine people who responded to our questionnaires stated that they knew how to make a complaint. One person said that complaining does not do any good. Two persons said that they knew who to speak to if they were unhappy about the service that they receive and six said that they usually know who to speak to. We looked at the complaints policy from the Abbeyfield Society and noted three stages of managing complaints and an informal stage at the home level, which the organisation calls dealing with with concerns. During the last inspection we suggested some clarification between concerns and complaints because complaints and concerns do not mean the same things. According to the complaints records of the home there have been five recorded informal complaints or concerns (according to the service). The manager stated that she had given the opportunity to the people who raised issues to complain formally and they had not. We noted that whilst there was a record of the complaints, the Care Homes for Older People Page 22 of 36 Evidence: records do not always clarify the action that had been taken to investigate the complaints or concerns, the findings of the investigations and the way that feedback was given to the complainants. The organisations complaints procedure continues to say that the service does not accept anonymous complaints. There is guidance from the Department of Health on the Statutory Complaints Procedure of local authority social services departments, that can be used as an example of good practice. It says that the fact that the complaint is from an anonymous source should not in itself justify a decision not to pursue the matter, nor should it rule out referral to other procedures as appropriate (DH, (2006). Learning from complaints Pg 11, section 2.7, www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidanc e/DH_4137785). We have however clarified with the responsible individual and with the manager that the home deals with anonymous complaints but, not according to the complaints procedure. Therefore it is not strictly true that the home does not accept anonymous complaints and as a result the statement that the home does not accept anonymous complaints could discourage people from coming forward in an anonymous manner, when they might have serious issues to raise about the safety of residents. The registered provider therefore could be missing an opportunity to address serious issues and as a result is strongly recommended to review the statement in the complaints procedure that it does not accept anonymous complaints. The home referred one matter to the safeguarding adult team of the local authority as per the procedures to safeguard people. This was on the whole dealt appropriately. We also noted that most members of staff have had training on safeguarding people. They were able to correctly state the action that they would take if they witness or suspect abuse, when we ask them about this. Care Homes for Older People Page 23 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides comfortable accommodation for residents and is on the whole suited for the residents that live in the home, but the main communal area would benefit from a refurbishment to further improve the standard of accommodation. Evidence: The grounds of the home are well maintained, tidy and inviting. There is a range of trees, bushes and shrubs, and well tended lawns. Most of the bedrooms have a view on the garden that surrounds the home. There are patio areas for residents to sit outside and to enjoy the garden of the home. On one of the days of the inspection, the weather was warm and we noted that residents sat outside to enjoy the nice weather. The building was maintained and in good condition. Entry to the home is restricted and there is a buzzer system. People are only allowed in when they ring the bell and introduce themselves. There is a coded pad to exit the home. The corridors were in an acceptable state of decoration but the large communal area looks like it will benefit from redecoration. The carpet in the communal area was bubbling up in the area where it joins the main corridor. It also looked stained and passed its useful life. Furniture in the communal area, particularly the armchairs looked as needing to be replaced. Most of the armchairs were made of cloth material Care Homes for Older People Page 24 of 36 Evidence: and at least two had an odour. The bathrooms, showers and toilets were in good condition and in most cases provided full disabled access. We noted that a few toilets only had a grab rail on one side. As a result a person with a disability on one side of the body, could find it difficult to use the toilet if the grab rail is situated on the same side as the affected side of the person. Bedrooms of residents were clean and tidy. They were on the whole in a good state of decoration and personalised with the residents pictures, photos and personal belongings. The fixtures and fittings were all of a homely nature that contributed to make the bedrooms more personalised. The home was overall clean but there was an odour in a few areas of the communal room where a few chairs smelled. An odour was also noted in the stairwell on the side of the home, because at least one of the wheelchairs that were kept in that area, had been wet and had not been cleaned appropriately. This finding is reflected to some extent in the satisfaction questionnaires. Two respondents said that home is always fresh and clean and the majority (six) said that the home is usually fresh and clean. Training records showed that staff have not had infection control training. This training is also important for ancillary staff, who are responsible for cleaning the home, to ensure a high standard of hygiene. The manager stated that this training has been booked for staff. There is now a sluicing disinfector in the home for the appropriate cleaning and disinfection of bedpans and urinals. Care Homes for Older People Page 25 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides adequate numbers of staff to meet the needs of residents. The home complies with tits recruitment procedure to ensure the safety of people who live in the home. Training is generally provided by the home to ensure that staff are competent and skilled to care and support the residents. Evidence: The manager of the home is supernumerary. There are normally five care staff on duty in the morning shift and four care staff during the afternoon shift, inclusive of a senior (team leader) in charge of the shift. At night there is one senior and two carers. The staffing levels seem to be adequate for the number and needs of residents that are accommodated in the home. Feedback from residents about staff was mixed. They seemed to indicate that there are some very good members of staff and some that are not so good. One person said that staff are kind, dedicated and cheerful although more initiative can be shown. Four out of ten persons who sent questionnaires said that staff listen and act on what residents say. Four said sometimes, one did not respond and one said no. One respondent said some staff are good, others do not take notice. Another comment said domestic staff are very efficient but the standards of the carers are much lower.A third person wrote staff listen but do not act. A fourth person said that staff Care Homes for Older People Page 26 of 36 Evidence: need more knowledge in understanding the needs of residents in relation to certain medical condition. We discussed the above with the management of the home and we were informed that the organisation has introduced systems to monitor and address the performance of members of staff, particularly those who are under-performing. We looked at the personnel file of three members of staff. All the files contained appropriately completed application forms with a work history, two references, a CRAB check and proof of identity and eligibility to work in the UK. A statement of terms and conditions was also available for each member of staff. There was evidence that all new members of staff were offered induction and that care staff also completed an induction which included the common induction standards from skills for care. The manager kindly provided a copy of the homes training matrix. Most members of the care staff team have an NV qualification in care. The home is commended for progress in this area. We noted that staff were up to date with manual handling training and health and safety. They have also received dementia care training and training on abuse. The records showed that staff receive two yearly fire training and take part in three monthly fire drills. New members of staff cover fire procedures in the home and the fire emergency plan as, part of their induction, but do not get the full fire training as, these are arranged every two years. The manager stated that she was arranging for new members of staff to have the full fire training. As mentioned in the previous outcome area, the training matrix showed that staff have not received formal infection control training. We also noted that ancillary staff have not received manual handling training and infection control training. There was a supervision programmer in place and records to show that members of staff were receiving supervision. Staff have had training in conducting supervision and while supervision had not been regular in the past, the manager said that she was determined that each member of the care staff would receive supervision at least once every two months. The manager added that she would ensure ensure that all members of staff receive an annual appraisal. She clarified that she would address situations where staff are not performing to the right level in supervision and appraisal sessions. Care Homes for Older People Page 27 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager runs the home in an open and transparent manner and has been able to improve the quality of the service that it provides. The organisation has a quality management system to monitor the quality of the service that is provided. Residents personal money is appropriately managed to safeguard the interests of the residents. Health and safety issues are taken seriously and are addressed to ensure the safety of all people who use the premises. Evidence: The manager has been in post for about two years and is registered. She has the registered managers award and has an NVQ level 4 in care. She has also completed another management qualification . We noted during the inspection that she was well aware of the national minimum standards and of her responsibilities in ensuring that these were met by the service. She usually holds monthly staff meetings, night staff meetings and residents/relatives Care Homes for Older People Page 28 of 36 Evidence: meetings. Minutes of the meetings were kindly forwarded to the inspector. We noted during our inspection that the manager knew residents and their relatives quite well and was able to describe the needs of the residents when talking to us. During the course of the inspection we noted that she was approachable to residents and their visitors, and staff. We looked at the management of personal money of residents. the home is not responsible for the management of the social benefits of residents but does keep a small amount of pocket money for each resident. The money for each resident was kept separate and there were separate records for each resident to provide information about the expenses of resident and the balance of money that remained. There were two signatures when money was withdrawn or expenses made. Receipts were also kept for all expenses. The records showed that the personal money of residents was also audited by the home manager on a regular basis. The home has carried out a satisfaction survey of residents and their relatives. A report summarising the findings of the survey was available for inspection. As well as regular in depth regulation 26 visits, the home also carries out an annual audit. The audit is based on the national minimum standards for older people and is carried out by an assessor that has been appointed by the organisation. The audit took place on the first day of the inspection. The home had an up to date electrical wiring certificate, gas safety certificate and portable appliances certificate. There were records to show that weekly fire detector tests and monthly fire emergency lights test were regularly carried out. We noted that the hot water system was regularly checked and maintained to prevent Legionella. Certificates were available for the hoists and the lift to show that these were tested to ensure that they were safe to use. We observed that there were no thermostatic valves at hot water outlets in a few wash basins to which residents had access to. We also noted that the hot water at outlets to which residents had access to were not regularly checked. The water temperature at the water outlet in a residents room was 52.7 degrees centigrade well above the recommended 44 degrees centigrade. The window restrainers in the home have been adjusted to ensure that they do not open to an extent to enable a person pass through. We however noted that at least one of the windows could be opened to enable a person pass through. Care Homes for Older People Page 29 of 36 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 30 of 36 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 A risk assessment with 27/07/2009 control measures must be in place for the resident who comes down the stairs at times during the night. To ensure the safety of the resident. 2 8 12 Pressure relief equipment must be used without delay when these are supplied, to ensure that residents receive the benefit of the use of these items of equipment, as soon as possible. To promote the welfare of residents. 27/07/2009 3 8 12 That residents oral intake is monitored when this is indicated such as, when residents have nausea and vomiting. To ensure the welfare of residents. 27/07/2009 Care Homes for Older People Page 31 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 8 12 Care plans on incontinence must be clear about the use of the incontinence aid to use to manage the incontinence. Incontinence chair pads must only be used after an individual and detailed continence assessment. To make sure that elimination needs of residents are being addressed appropriately and to ensure the privacy and dignity of residents. 27/07/2009 5 9 13 The date of opening of all liquid medicines must be recorded on the containers. The instructions for the administration of topical medicines, including creams and ointments, must be clear about the location to apply the medicines. To ensure the safety of residents in relation to the management of medicines. 27/07/2009 6 16 22 The home must record the action that is taken to investigate complaints and the outcome of the complaints investigation, including informal complaints. 03/08/2009 Care Homes for Older People Page 32 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To ensure that all complaints, including informal complaints, are appropriately dealt with. 7 20 23 The main communal area must be decorated as soon as possible. The home must consider replacing fixtures and fittings and particularly some of the armchairs. To ensure a high quality environment for residents. 8 22 23 The home must review the equipment in place in bathrooms and toilets, such as the availability of grab rails. To promote the independence of residents with impaired mobility. 9 26 23 The home must be free of odours and any wheelchairs and armchairs must be cleaned as appropriatre when they become wet. To ensure a pleasant environment for residents. 10 30 18 Staff must have infection control training. Ancillary staff must also be provided with all relevant training including manual handling. 27/07/2009 22/07/2009 22/07/2009 22/07/2009 Care Homes for Older People Page 33 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To make sure that staff are skilled and competent in the relevant areas of work. 11 38 13 Risk assessments must be 22/06/2009 carried out about residents access to all hot water outlets and the necessary control measures must be in place if risks are identified. To prevent residents from scalding. 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 2 The homes contract that is offered to residents should have information about the fees that are paid for the resident to stay in the home and the party(ies) responsible for paying the fees. The balance of medicines that are recorded in the controlled drug book must reflect the fact that the medicines have been returned to be disposed of. Otherwise the records show that the medicines are still in the home. The homely medicines that have expired must be disposed of and new medicines should be in place as soon as possible. The manager should review the provision of activities over the weekend to ensure that residents are occupied and stimulated not only during week days but also over the weekend. The home should review the nutritional content of particularly, the vegetarian options of meals, to make sure that the meals are nutritionally balanced. 2 9 3 9 4 12 5 15 Care Homes for Older People Page 34 of 36 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 6 30 That the provision of fire training is provided at shorter intervals than the two years, which is currently the case, to include new members of staff, who have not had the training. The home should consider having a programme for checking the window restrainers and for monitoring the temperature of the hot water at all outlets to which residents have access, at a frequency to be determined by its risk assessment. This is necessary to ensure that any risks are detected early and addressed to reduce the likelihood of harm from happening. 7 38 Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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. 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