Care Home: Tower House [Salisbury]

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What the care home does well People considering seeking a placement at the home were provided with very good information, and were encouraged to visit and experience life there. Thorough assessments were carried out before offering a placement. This meant people received good support through the settling-in period, and care plans were commenced on the basis of sound information. Throughout our visits we saw kind, attentive interactions between care staff and the people in their care. A frequent visitor to the home said, `the carers have a brilliant way with them towards X and treat her well`. People living in the home appeared comfortable in how they were dressed. They received evident support to hair, make-up and nail care. People`s relatives that we spoke to said the people they visited always presented as well cared for. People we spoke to in the home said staff always respected their privacy and dignity. For the few people sharing rooms, care plans included directions on how to preserve privacy. People confirmed to us that they got up and went to bed when they chose. People were encouraged to take meals in the dining rooms, for the social benefits and to promote exercise in going there. We saw that a number of people chose to eat in their rooms or in lounge chairs, their choices to do so being respected. We could see that the home had established working relationships with the various GP practices in Salisbury, and with the mental health and adult care services. A person`s relative said they were impressed by the quality of liaison they had seen between the home and GP and hospital services. Records demonstrated that staff were prompt in recognising and responding to health concerns and accidents. When specific monitoring was required, for example of a person`s fluid intake, this was undertaken efficiently. A nutritional screening tool had been introduced and was completed for all people. The care staff kept brief, objective notes of their care interactions, which demonstrated that they worked in accordance with care plans. We watched at lunchtime when staff gave some people their medicines and patiently helped them with taking these. Two locked medicine trolleys were in use, so that accepted safe practices could be followed. Medicines were administered promptly. Each person was allocated a key worker, a member of staff who aims to support their individual needs through spending one-to-one time with them. In all the care records we looked at, we saw that people had specific key worker time at least monthly. As a result, staff were identifying and pursuing the kinds of engagement to which people responded positively. Care staff told us they regarded activity provision as an integral part of their role. Some staff spoke about seeking to involve all residents, every day, in some activity, describing games, discussion topics and reminiscence sessions. There were photographs to provide some evidence of specific activities. We saw that family visits were facilitated at any time, and relatives told us they always felt welcomed. There were a variety of places where people could receive visitors as alternatives to bedrooms. There were facilities for visitors to make hot drinks.The main meal of the day was a two-course lunch. There were two choices of main course. People made a final choice at the point of service. Additionally, people could choose alternatives if they did not want either main choice. Meals were served on good quality crockery and the dining rooms provided a pleasant ambience, whilst tray service was also good. People were unhurried and were offered discrete assistance to eat, if they wished. All people we observed at lunch appeared to enjoy their meals. The home provided both fresh and convenience vegetables and there was plentiful provision of fresh fruit. Cakes were baked in-house. The chef had information in the kitchen about special diets, and had a good personal knowledge of the resident group. The home had received no complaints through its formal complaints procedure. There was a record of minor complaints and how they had been addressed quickly. This is good practice, because it demonstrates that people`s dissatisfaction at any time is acknowledged as important. Relatives that we spoke to said they had been given clear information about how to raise concerns or make a formal complaint. All described the management and staff as `approachable`. We saw that people living in the home made use of communal areas, some having clear favourite sitting places and some liking the freedom to move around. Bedrooms presented as individual, with personal items around. Carpets throughout the home were good quality, and Eileen O`Connor-Marsh said their practice was to replace carpets quickly if they began showing deterioration. Standards of cleaning around the home were very high, with no unpleasant odours. An environmental health officer had visited the kitchen within the preceding year and awarded it five stars [top rating] for food safety practice. The home has benefited from a stable care staff team, most of whom have gained NVQ [National Vocational Qualification] to level 2 or 3. Those without NVQ were working towards it. We saw that staff were readily available to people, and people resident in the home told us that staff were there when they needed them. A recognised training company was used for delivering most of the mandatory training courses. There was a training plan that showed staff were required to undertake refresher courses as they became due. We found that staff we spoke with were well motivated towards training. They were proud both of their achievements and the effect they saw training have on their practice. Many were involved in distance-learning, based on work books and weekly tutor visits, in medication practice, dementia care, nutrition, infection control, and palliative care. Staff were expected to move on from one subject to the next. Eileen O`Connor-Marsh, as provider, maintained a daily presence in the home, and was therefore as well known to people there as any of the staff. She has fostered a team approach to management, with a regular meeting of all the unit managers and deputy managers. Lisa Mulholland carried out routine monitoring of standards in the home, including health and safety, cleanliness, maintenance, and regularity of key worker meetings with residents. Audit records showed that shortfalls identified this way were highlighted for prompt attention. There were What has improved since the last inspection? During the inspection we identified that storage of medicines, in a stock cupboard, in the medicine trolleys and in a fridge, was potentially compromised in terms of temperature and security. These shortfalls had been corrected by the time of our second visit, and a controlled drug cupboard compliant with current legislation had been installed. The home was on the point of introducing forms to assist with capacity assessments in the light of the Mental Capacity Act. Arrangements were in hand with the home`s usual training organisation to provide staff training in issues around the Mental Capacity Act including deprivation of liberties. There had been considerable redecoration in both the older and newer buildings over the past year. The environment had been further enhanced by provision of a conservatory and secure patio area, extending choice for people in the home, and their visitors. Some of the senior staff in Tower House and its sister homes have been developed as team leaders. They have gained the Registered Managers Award and begun to take on more delegated roles, including supervision of more junior staff. This supervision was regular and followed a standard format, with constructive outcomes. What the care home could do better: Two relatives we spoke to said they were not aware of care plan contents and would like to be more directly involved. We found care plans were not signed by the people they were about, or by relatives or other advocates. To obtain such overt agreement would demonstrate transparency and shared aims, and give people the opportunity to question care plan aims and how these were being met. Many care plans, in identifying needs to be addressed, were prefaced `due to dementia`, but this was not necessarily a primary factor. We would like to see more `person-centred` planning, that recognises how an individual experiences their dementia, what positives remain in their life, and what needs may not be primarily related to dementia. There was also scope for developing the evaluation of care plans, in order to ascertain to what extent they meet their goals. We considered it a shortfall that, where a care plan directed a specific number of checks at night, there was no recording mechanism to show when these checks had been made. We also saw it as a compromise to privacy that care records were sometimes left in too public a place in the older part of the home. We noted some points for attention in respect of medications practice. A number of people were prescribed medication to use as required or with a variable dose. Staff need to have clear written guidance on how to make a decision to administer a particular medicine at a particular dose. The arrangements for handling and recording prescribed medicines applied to the skin needed some improvement. There were two standard record books in place for keeping the extra records needed for controlled drugs. More attention to detail in these records was needed in order to keep a full account of these medicines. Some entries were muddled and not at all clear. We explained the proper way to keep these records. For a significant number of residents, there was no care plan for social care needs. Building on key worker knowledge and life history information, it is necessary to devise such plans for all. This would identify in what ways people may be supported to be more physically or mentally stimulated. It would be a basis on which to plan individual and group activities more coherently, and to evaluate them. We also considered `occupation` needed to be provided for as much as `activities`. We noted that all toilet brushes were standing in receptacles, sometimes in liquid. Toilet brush holders should be of suspended design, to minimise the risk of harbouring infection. A routine internal audit of areas presenting high risks to infection control could identify and rectify these kinds of issues. Care staff received infection control training, but housekeepers did not. They need to be trained so they understand the rationale behind the precautionary measures they are required to take, and to be proactive in identifying infection control risk factors. Lisa Mulholland said she saw all accident records, but they were not endorsed to show that she did so, neither was there a monthly or quarterly summary of the records. This would assist analysis to show if any emergent patterns needed closer scrutiny. Key inspection report Care homes for older people Name: Address: Tower House [Salisbury] 43 Manor Road Salisbury Wiltshire SP1 1JT     The quality rating for this care home is:   three star excellent 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: Alyson Fairweather     Date: 0 5 1 1 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 39 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 39 Information about the care home Name of care home: Address: Tower House [Salisbury] 43 Manor Road Salisbury Wiltshire SP1 1JT 01722338395 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Eoconnormarsh@aol.com Mrs Eileen O`Connor-Marsh care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: No more than 12 service users falling within the category of (DE(E)) may be accommodated in the extension at any one time The registered person must ensure that the staffing levels meet the needs of the residents at all times and do not fall below that stipulated in the Residential Forum `Care Staffing in Homes for Older People` Model. 08:00 to 14:00 Minimum of 5 care staff on duty 14:00 to 20:30 Minimum of 4 care staff on duty 20:30 to 08:00 2 waking night staff on duty with one member of care staff sleeping in each night. Date of last inspection Brief description of the care home Tower House is a private residential home registered to offer accommodation and personal care to 24 older people with a dementia or other mental health disorder . The home is one of three registered care homes owned by Mrs Eileen OConnor-Marsh, the other two being for younger adults with mental health needs. The three homes are Care Homes for Older People Page 4 of 39 Over 65 12 12 12 0 0 0 Brief description of the care home near to each other and many management functions, including provision of staff, are centralised. Tower House, originally a large detached Victorian property, was extended about five years ago, thereby doubling its capacity. All rooms have en suite facilities and most are for single occupation. There are shared sitting and dining rooms in each part of the building and there are limited grounds accessible to people living there. A central kitchen serves the old and new parts of the home, which otherwise operate largely separately. The home is situated just off the Salisbury ring road and has views over the city. There is some parking available on site, and time-limited parking in the street. The homes fees range from £550to £650 per week (November 2009). Information about the care and services provided is available from the home, in written form, by way of its service users guide. Care Homes for Older People Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We visited Tower House unannounced on Thursday 29th October 2009 between 9:00 a.m. and 5:00 p.m. and returned the following Thursday, 5th November, from 9:30 a.m. to 4:30 p.m. During the inspection we met with a number of residents, in the communal rooms and individual rooms. This allowed for discussion about their experience of care provided, and for observation of care interactions, including the service of meals. It was possible to share meal times in a different dining room at each visit. The entire home was toured. During the first day of this key inspection one of our pharmacist inspectors specifically examined some of the arrangements for the handling of medicines. We looked at some stocks and storage arrangements for medicines, various records about medication and saw staff helping people living in the home to take their medicines at lunchtime. Lisa Mulholland, the registered manager, was away on leave at our first visit, hence Care Homes for Older People Page 6 of 39 our delay in conducting the second days visit. Eileen OConnor-Marsh, one of the providers of the service and its responsible individual, was available throughout the inspection time, as was Lisa Mulholland at the second visit. We spoke with various staff on each day, including care workers, senior carers and the chef. At the end of the inspection we gave feedback to Eileen OConnor-Marsh and Lisa Mulholland. Documentation examined during the inspection included initial assessments, care plans and records of care, risk assessments, accident records and records of staff training and supervision. We saw how the home carried out its own quality assurance survey of residents and their supporters. Prior to the inspection we had received the homes Annual Quality Assurance Assessment, which gave some descriptive and numerical information. During the inspection we met with visitors to two people who live at the home. Afterwards we made telephone contact with three relatives of people living in the home, to widen our perspective on how the home is experienced as a care environment. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visits to the home. They take into account the views and experiences of people who live there. Care Homes for Older People Page 7 of 39 What the care home does well: People considering seeking a placement at the home were provided with very good information, and were encouraged to visit and experience life there. Thorough assessments were carried out before offering a placement. This meant people received good support through the settling-in period, and care plans were commenced on the basis of sound information. Throughout our visits we saw kind, attentive interactions between care staff and the people in their care. A frequent visitor to the home said, the carers have a brilliant way with them towards X and treat her well. People living in the home appeared comfortable in how they were dressed. They received evident support to hair, make-up and nail care. Peoples relatives that we spoke to said the people they visited always presented as well cared for. People we spoke to in the home said staff always respected their privacy and dignity. For the few people sharing rooms, care plans included directions on how to preserve privacy. People confirmed to us that they got up and went to bed when they chose. People were encouraged to take meals in the dining rooms, for the social benefits and to promote exercise in going there. We saw that a number of people chose to eat in their rooms or in lounge chairs, their choices to do so being respected. We could see that the home had established working relationships with the various GP practices in Salisbury, and with the mental health and adult care services. A persons relative said they were impressed by the quality of liaison they had seen between the home and GP and hospital services. Records demonstrated that staff were prompt in recognising and responding to health concerns and accidents. When specific monitoring was required, for example of a persons fluid intake, this was undertaken efficiently. A nutritional screening tool had been introduced and was completed for all people. The care staff kept brief, objective notes of their care interactions, which demonstrated that they worked in accordance with care plans. We watched at lunchtime when staff gave some people their medicines and patiently helped them with taking these. Two locked medicine trolleys were in use, so that accepted safe practices could be followed. Medicines were administered promptly. Each person was allocated a key worker, a member of staff who aims to support their individual needs through spending one-to-one time with them. In all the care records we looked at, we saw that people had specific key worker time at least monthly. As a result, staff were identifying and pursuing the kinds of engagement to which people responded positively. Care staff told us they regarded activity provision as an integral part of their role. Some staff spoke about seeking to involve all residents, every day, in some activity, describing games, discussion topics and reminiscence sessions. There were photographs to provide some evidence of specific activities. We saw that family visits were facilitated at any time, and relatives told us they always felt welcomed. There were a variety of places where people could receive visitors as alternatives to bedrooms. There were facilities for visitors to make hot drinks. Care Homes for Older People Page 8 of 39 The main meal of the day was a two-course lunch. There were two choices of main course. People made a final choice at the point of service. Additionally, people could choose alternatives if they did not want either main choice. Meals were served on good quality crockery and the dining rooms provided a pleasant ambience, whilst tray service was also good. People were unhurried and were offered discrete assistance to eat, if they wished. All people we observed at lunch appeared to enjoy their meals. The home provided both fresh and convenience vegetables and there was plentiful provision of fresh fruit. Cakes were baked in-house. The chef had information in the kitchen about special diets, and had a good personal knowledge of the resident group. The home had received no complaints through its formal complaints procedure. There was a record of minor complaints and how they had been addressed quickly. This is good practice, because it demonstrates that peoples dissatisfaction at any time is acknowledged as important. Relatives that we spoke to said they had been given clear information about how to raise concerns or make a formal complaint. All described the management and staff as approachable. We saw that people living in the home made use of communal areas, some having clear favourite sitting places and some liking the freedom to move around. Bedrooms presented as individual, with personal items around. Carpets throughout the home were good quality, and Eileen OConnor-Marsh said their practice was to replace carpets quickly if they began showing deterioration. Standards of cleaning around the home were very high, with no unpleasant odours. An environmental health officer had visited the kitchen within the preceding year and awarded it five stars [top rating] for food safety practice. The home has benefited from a stable care staff team, most of whom have gained NVQ [National Vocational Qualification] to level 2 or 3. Those without NVQ were working towards it. We saw that staff were readily available to people, and people resident in the home told us that staff were there when they needed them. A recognised training company was used for delivering most of the mandatory training courses. There was a training plan that showed staff were required to undertake refresher courses as they became due. We found that staff we spoke with were well motivated towards training. They were proud both of their achievements and the effect they saw training have on their practice. Many were involved in distance-learning, based on work books and weekly tutor visits, in medication practice, dementia care, nutrition, infection control, and palliative care. Staff were expected to move on from one subject to the next. Eileen OConnor-Marsh, as provider, maintained a daily presence in the home, and was therefore as well known to people there as any of the staff. She has fostered a team approach to management, with a regular meeting of all the unit managers and deputy managers. Lisa Mulholland carried out routine monitoring of standards in the home, including health and safety, cleanliness, maintenance, and regularity of key worker meetings with residents. Audit records showed that shortfalls identified this way were highlighted for prompt attention. There were regular staff meetings. What has improved since the last inspection? During the inspection we identified that storage of medicines, in a stock cupboard, in the medicine trolleys and in a fridge, was potentially compromised in terms of temperature and security. These shortfalls had been corrected by the time of our second visit, and a controlled drug cupboard compliant with current legislation had been installed. Care Homes for Older People Page 9 of 39 The home was on the point of introducing forms to assist with capacity assessments in the light of the Mental Capacity Act. Arrangements were in hand with the homes usual training organisation to provide staff training in issues around the Mental Capacity Act including deprivation of liberties. There had been considerable redecoration in both the older and newer buildings over the past year. The environment had been further enhanced by provision of a conservatory and secure patio area, extending choice for people in the home, and their visitors. Some of the senior staff in Tower House and its sister homes have been developed as team leaders. They have gained the Registered Managers Award and begun to take on more delegated roles, including supervision of more junior staff. This supervision was regular and followed a standard format, with constructive outcomes. What they could do better: Two relatives we spoke to said they were not aware of care plan contents and would like to be more directly involved. We found care plans were not signed by the people they were about, or by relatives or other advocates. To obtain such overt agreement would demonstrate transparency and shared aims, and give people the opportunity to question care plan aims and how these were being met. Many care plans, in identifying needs to be addressed, were prefaced due to dementia, but this was not necessarily a primary factor. We would like to see more person-centred planning, that recognises how an individual experiences their dementia, what positives remain in their life, and what needs may not be primarily related to dementia. There was also scope for developing the evaluation of care plans, in order to ascertain to what extent they meet their goals. We considered it a shortfall that, where a care plan directed a specific number of checks at night, there was no recording mechanism to show when these checks had been made. We also saw it as a compromise to privacy that care records were sometimes left in too public a place in the older part of the home. We noted some points for attention in respect of medications practice. A number of people were prescribed medication to use as required or with a variable dose. Staff need to have clear written guidance on how to make a decision to administer a particular medicine at a particular dose. The arrangements for handling and recording prescribed medicines applied to the skin needed some improvement. There were two standard record books in place for keeping the extra records needed for controlled drugs. More attention to detail in these records was needed in order to keep a full account of these medicines. Some entries were muddled and not at all clear. We explained the proper way to keep these records. For a significant number of residents, there was no care plan for social care needs. Building on key worker knowledge and life history information, it is necessary to devise such plans for all. This would identify in what ways people may be supported to be more physically or mentally stimulated. It would be a basis on which to plan individual and group activities more coherently, and to evaluate them. We also considered Care Homes for Older People Page 10 of 39 occupation needed to be provided for as much as activities. We noted that all toilet brushes were standing in receptacles, sometimes in liquid. Toilet brush holders should be of suspended design, to minimise the risk of harbouring infection. A routine internal audit of areas presenting high risks to infection control could identify and rectify these kinds of issues. Care staff received infection control training, but housekeepers did not. They need to be trained so they understand the rationale behind the precautionary measures they are required to take, and to be proactive in identifying infection control risk factors. Lisa Mulholland said she saw all accident records, but they were not endorsed to show that she did so, neither was there a monthly or quarterly summary of the records. This would assist analysis to show if any emergent patterns needed closer scrutiny. 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 11 of 39 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 12 of 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a detailed and individualised assessment and admission process. People are given good information and are able to get a flavour of the home before accepting a place. Evidence: We looked at the assessment and admission documentation concerning the two people that had most recently been admitted to the home. A standard assessment form was in use. In each case this gave evidence of a detailed assessment process. The forms showed where and when people were visited, and who else had given information, such as family members and hospital nursing staff. As good practice, the assessment form considered the reasons why a care home placement was being considered, and what the implications might be for the person concerned. This kind of insight was reflected in the homes statement of purpose, which recognised overtly that admission to a home might be accompanied by feelings of loss, anxiety or compromise. Care Homes for Older People Page 13 of 39 Evidence: Comprehensive information was gathered about peoples physical and mental health needs, backed by additional written assessments that the home required from care managers and health professionals. The total amount of assessment detail accumulated thus gave a whole person picture of the individual. This provided a sound basis both to inform a decision that the home could meet a persons needs, and to draw up a care plan, so staff were informed from the start about how to provide care and support to a newly admitted person. In addition, family members or other advocates were asked to provide written information about peoples preferences, such as food likes and dislikes and how they liked to be addressed. There was a combined statement of purpose and service user guide, presented in a readable way, including pictures. A relative of one of the people recently admitted confirmed having been given this, and a copy of the previous inspection report, when they initially made enquiries of the home. They had visited, and they considered the whole assessment and admission process had been extremely well handled. The homes AQAA described encouraging extended visits for prospective residents, where possible, to include a meal with their relative at the home before admission. Relatives of another person told us they were able to arrange to take their relative to spend time at the home when considering it as a possible placement. They had experienced it as a pleasant atmosphere, and considered that staff were accomplished at helping their relative to feel at ease, both during that visit, and through the settling in process: We appreciate how the transition period was eased. The fact the home had been agreeable to also take the persons cat was seen as an especially helpful feature of the admission. The family considered they had been given good information to help their decision-making, and were aware that the admission was backed by comprehensive assessment on the part of the home and external social work personnel. Records showed that allocated key workers arranged introductory meetings with people newly admitted very quickly, in order to establish the nature of that working relationship. Care Homes for Older People Page 14 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples personal and health care needs are met through care planning and liaison with external agencies. Peoples right to privacy is upheld. They are treated with respect but care planning could be more person-centred. There were generally suitable arrangements for handling medication but the inspection identified some weaknesses that need some action and more attention to detail so as to reduce risks with medicines. Evidence: The home uses a commercially available care planning format, so there is consistency in how the care planning process is approached and documented. A long term needs assessment draws on initial assessment information and subsequent reviews. From this, specific areas of need are identified, and separate care plans are developed for these. Residents that we spoke to were generally not aware of the nature of care planning or recording, and whilst plans had a space for people to sign agreement, these were usually endorsed unable to sign. We recommend that where people cannot sign agreement to their plans, a relative or other advocate should be invited to do so. This would demonstrate transparency and shared aims, and give people the Care Homes for Older People Page 15 of 39 Evidence: opportunity to question care plan aims and how these were being met. Two relatives we spoke to said they were not aware of care plan contents and would like to be more directly involved, much as they knew that assessments or reviews, in which they had been involved, demonstrated the priority areas being addressed by the home. One of the relatives, who was a frequent visitor to the home, said they had no doubt the home knew the residents needs extremely well, as a result of which, the carers have a brilliant way with them towards X and treat her well. Care plans were accompanied by associated risk assessments, to identify nutritional needs, falls risks and the nature of risk to pressure areas. For example, for one person we saw that the pressure area risk assessment was to be reviewed regularly, with regular turns instituted whenever the assessment score exceeded a certain level. A turn chart was being completed, to show these care directions were being carried out. Documentation in the care plan showed the person was using pressure-relieving equipment supplied by the district nursing service, who were also visiting regularly. For the same person, a nutrition care plan explained to staff why this was an issue, and gave guidance on encouraging a sufficient diet. Many care plans, in identifying needs to be addressed, were prefaced due to dementia, but this was not necessarily a primary factor. For example, support to continence needs might be needed partly due to disorientation or loss of memory function, in which case this should be explained, but equally for some would be a mainly physically-based need, related to age. The repetition of due to dementia tended to uphold a stereotypical view of dementia being necessarily associated with problems, without considering the individuals individual experience of dementia, including their remaining abilities. Care plans also concentrated on a rather clinical approach to ensuring basic physical care needs were met, without recognising that the primary aim of continence support, to use the same example, should be for the person to be comfortable and for their dignity to be preserved. Thus we identified that there was scope to develop a more person-centred approach to defining and meeting needs. This might not result in big differences in actual care directions, but would shift the context to one of individualised care. Consideration also needs to be given to evaluation of how successful care plans are in meeting their aims. The care plan format in use had an evaluation column, which should be used to ascertain where planned care interventions had worked well or not so well. We could see that the home had established working relationships with the various GP practices in Salisbury, and with the mental health and adult care services. A persons relative said they were impressed by the quality of liaison they had seen between the home and GP and hospital services. We joined a handover between care shifts, when Care Homes for Older People Page 16 of 39 Evidence: staff coming on duty learnt of any current health-related issues receiving attention. Records, including notifications to us about incidents requiring medical attention, demonstrated that staff were prompt in recognising and responding to health concerns and accidents. When specific monitoring was required, for example of a persons fluid intake, this was undertaken efficiently. Care plans highlighted where people had specific conditions, such as diabetes or parkinsonism, and how that impacted on care needs. A nutritional screening tool had been introduced and was completed for all people. Care plans drew attention to peoples needs regarding use of spectacles and hearing aids, with appointments made externally or in the home, according to individual wishes and ability. People living in the home appeared comfortable in how they were dressed. They received evident support to hair, make-up and nail care. Records showed where people had declined the offer of assistance to any aspect of their care. Peoples relatives that we spoke to said the people they visited always presented as well cared for. One of them said their relative had commented on the kindness that staff showed them. We observed that staff usually knocked on peoples doors before entering, and showed awareness in other ways of peoples privacy. People we spoke to said staff always respected their privacy and dignity. For the few people sharing rooms, care plans included directions on how to preserve privacy. Peoples preferences for baths or showers were recorded, as well as any individual issues about opposite gender carers. The care staff kept brief, objective notes of their care interactions, which demonstrated that they worked in accordance with care plans. However, we considered it a shortfall that, where a care plan directed a specific number of checks at night, there was no recording mechanism to show when these checks had been made. We also saw it as a compromise to privacy that care records were sometimes left in too public a place in the older part of the home. People living in this home were dependent on the staff to handle and administer their medicines for them. We noted that staff supported two people to self-administer a cream and an inhaler. In such circumstances a written risk assessment should be made to make sure this was safe for everyone in the home. The medicine records must be marked to indicate what is self administered, and when staff have handed over any medication to people to look after, so that use of the medication can be monitored and stock accounted for. Care staff who had undertaken medication training were responsible for handling and administering all medicines to people living in the home. Staff we spoke to demonstrated knowledge about peoples needs relating to medicines but there was sometimes a lack of basic knowledge about some treatments and certain issues about Care Homes for Older People Page 17 of 39 Evidence: safe handling of medicines. Staff described the regular support they received from district nurses for more specialist medicine administration. Care records also showed regular contact with various other health professionals. We spoke to the registered provider about any cultural or other diversity issues affecting medication for people living in this home as these can sometimes affect treatment with some medicines. The provider told us that there was nothing related to medication they have identified for anyone in the home at the moment. We watched at lunchtime when staff gave some people their medicines and patiently helped them with taking these. Two locked medicine trolleys were in use, so that accepted safe practices could be followed. We pointed out that it was not good practice in one case to take just a pot of medicines to another floor without the records or medicine packs. Medicines were administered promptly. We discussed the times medicines are administered and the importance of making sure there are correct intervals between doses, particularly a minimum of four hours for products containing paracetamol. The times the pharmacy printed on the medicine charts just allowed for this four hour period but in some cases there was no tolerance for administration times running late as can often happen in a care home. We also pointed out that some medicines in use have more specific directions about when and how the dose should be taken but the pharmacy had not included this on the medicine chart or labels we saw. This sort of information is in the Patient Information Leaflets available for each medicine dispensed. There was a copy of the British National Formulary as a suitable reference book. The copy in the home was from March 2008 and Eileen OConnorMarsh undertook to obtain a more recent version. Two people were prescribed very small volumes [less than 5ml] of a liquid medicine which staff measured in a 25ml medicine measure. This is not a suitable method to accurately measure such doses and a proper oral dose syringe marked in 0.5ml divisions from 1 to 5ml must be used. There were suitable arrangements for keeping records about medication received, administered and leaving the home or disposed of [where no longer needed] for each person living in the home. Accurate, clear and complete records about medication are very important in a care home where during a day a number of different staff will administer medicines. This helps to make sure that people are not at risk from mistakes with their medicines and that there is a full account of the medicines the home is responsible for on behalf of the people living there. However, we noted some points for attention - Care Homes for Older People Page 18 of 39 Evidence: Staff need to make sure they always record the actual dose given, where the prescription allows a variable dose [one, or two, tablets for example]. There was no information in the allergy box on the medicine charts, yet care plans for two people indicated they had allergies to particular groups of medicines. A number of people were prescribed medication to use as required or with a variable dose [or both might apply to one medicine]. Staff gave us some explanation about how they would use some of these medicines and in some cases it was said the person would be able to state their need for a particular medicine. Staff need to have clear written guidance on how to make a decision to administer a particular medicine at a particular dose in order to meet identified needs in a consistent way. This must include consideration of the provisions of the Mental Capacity Act 2005 and whether the person is able to state their need for a particular medicine or dose and consent to this. This was sometimes mentioned in care plans but not in sufficient detail. We discussed straightforward ways to achieve this. The arrangements for handling and recording prescribed medicines that are applied to the skin, such as creams and ointments, needed some improvement. We looked in care plans and found these were too generic, using the term waterproof cream for most people. Eileen OConnor-Marsh explained that with regard to pressure area care plans, the direction to use a barrier cream on a newly observed red mark was intended merely as a short term holding measure, pending referral for urgent attention and treatment directions by a district nurse. However, clear records are needed about any cream, ointment or topical product applied, and must consider the questions - what, when, where, why and how much? We publish information about this on our website which should be followed. We looked in two bedrooms where creams or ointments were in use and kept. Some containers had no pharmacy label with directions for use or name of person supplied for. None had opening dates and so changing regularly after fixed periods in use was not possible. One pack was out of date. One cream was not included on the current MAR chart; it was not clear if this should be in use. In one room the creams were stored right by the toilet pan, which was not hygienic. There is a need to risk assess storage in en suite bathrooms as being safe for everyone in the home including the consideration that other people living in the home may go into the bedrooms. A local pharmacy supplied many medicines in special packs called a monitored dose system. The packs we looked at indicated that people had received their medicines as prescribed and these agreed with the record charts. Some medicines could not be supplied in these packs. We could not carry out audit checks for these medicines as on the whole staff did not write the date on the packs when the first dose is taken, as is Care Homes for Older People Page 19 of 39 Evidence: good practice. This also allows proper stock rotation of certain medicines that have a limited shelf life after opening. We pointed out there was no opening date on two liquid medicines where the manufacturer stated a specific period for use after first opening. We did see that an eye drop container had an opening date and was still within the right period to use. The pharmacy should be able to provide standard information about recommended discard dates after first opening. We also discussed other monthly recorded checks that should be made of medicines that are not regularly used to make sure that these are properly accounted for and new supplies are only ordered when needed so as to reduce wastage. We looked at the arrangements for storing medicines. Two medicine trolleys were used, one in each building, and there was a large cupboard for reserve stocks. The locations of the trolleys when not in use posed issues of security and temperature control. As a result of our observations, they were relocated before the conclusion of the inspection to more suitable sites. With regard to the cupboard, we advised using a thermometer to check the right temperature is kept as it felt very warm during the inspection. The maximum temperature to routinely store most medicines and keep the right potency is 25 degrees. Mrs OConnor-Marsh has since confirmed that an initial period of checking, during winter months has shown a consistent 19 degrees. Some medicines had to be kept in a fridge and records showed these had been stored at the right temperature. The medicines however, were kept separate from food only by being kept in a lidded compartment in the door of the fridge, and were not secured such that only authorised staff could access them. This shortfall was made good during the course of the inspection. We drew attention to one particular eye drop that did not need fridge storage when in use, but the unopened bottle must be kept in the fridge. A person who had been admitted recently made some use of prescribed oxygen. The necessary precautions for storing oxygen were not being followed. On our advice the medical gas supplier was contacted and the correct signage and other precautions were in place at the time of our second visit to the home. Similarly, a controlled drugs cabinet that meets the Misuse of Drugs [Safe Custody] Regulations 1973, which was on order from the supplying pharmacy when we first visited, had been delivered and correctly installed by our second visit. There were two standard record books in place for keeping the extra records needed for controlled drugs. More attention to detail in these records was needed in order to keep a full account of these medicines. Some entries were muddled and not at all clear. We explained the proper way to keep these records. Some entries in the book did not agree with the medicine chart, raising the question as to which record was correct. Two staff signed each administration but Care Homes for Older People Page 20 of 39 Evidence: there were no regular recorded stock checks as is accepted best practice. We looked in particular at the records for one person who was prescribed a pain relieving patch to be changed every seven days. The records we saw were muddled and incomplete with differences between the record book and medicine chart. We were concerned that records showed a three week interval between patches applied. At the time of the inspection we could find no explanation about this in any records and staff we spoke to were not sure why. We also strongly recommended that good practice is followed in revising the storage and recording arrangements for a particular liquid medicine. At our second visit, Eileen OConnor-Marsh had researched and acted on the guidance on our website about management of controlled drugs, and medicines which are advised to be treated as controlled drugs, and had carried out an investigation concerning the particular issues identified above. The homes medication policy and procedures, which directed staff about how the service expected medicines to be handled and administered, needed the addition of a section about controlled medicines. They also need to take into account the issues raised at this inspection. We were disappointed to find that despite all the medication training, staff had not picked up and addressed the type of issues identified during the inspection. The homely remedies protocol needed revision about what medicines were listed and to include more information about contraindications and warnings for specified treatments. Staff told us none of these medicines were in fact stocked at the time of the inspection. Care Homes for Older People Page 21 of 39 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is some planning to bring variety and meaning to peoples lives, but with scope for a more personalised and consistent approach. Meals served are good quality. People receive good support to maintain contact with the community and significant others. Evidence: At initial assessment, people and their families were asked for guidance about likes and dislikes and preferred activities. A start had just been made on seeking a greater amount of information by way of life history sheets. This is intended to help staff acquire more of a whole person view, to promote engagement with individuals based on knowledge of, for example, previous occupations or where people had lived. This will be especially helpful to key workers, and where a person has an advanced dementia. Each person is allocated a key worker, a member of staff who aims to support individual needs through spending one-to-one time with them. In all the care records we looked at, we saw that people had specific key worker time at least monthly, and that staff were identifying and pursuing the kinds of engagement to which people responded positively. However, a persons relative told us they did not know who the key worker was. They wished to pass on information about a pastime that they had found their relative responded to. Care Homes for Older People Page 22 of 39 Evidence: Care staff told us they regarded activity provision as an integral part of their role. On each shift, one care worker was designated to ensure some activity took place. A notice board showed a basic structure, as a guide to what events were to be promoted on different days. This said there was a music club on a Thursday. When we asked about this on a Thursday, some staff did not know about it, but in due course three staff produced a supply of percussion instruments and created a clearly enjoyable session with a group of residents in a day room. Other sitting rooms seemed used more for resting and sleeping, although they were provided with a wide choice of music, and we saw an offer to some people to watch a film on dvd, which they declined. We considered there to be an over-use of colouring as an activity, using wax crayons and often books aimed more at children. One person told us they had no interest in the colouring book they had been provided with, and they were unable to exert sufficient pressure on the crayons. They said they missed their previous life at home and would prefer to do proper things like folding linens or dusting. Some staff spoke about seeking to involve all residents, every day, in some activity, describing games, discussion topics and reminiscence sessions. Eileen OConnor-Marsh has told us by letter that some clients [sic] set the tables daily, under supervision make a cup of tea, wash up the cups, with staff tidy their rooms and those that wish to even help prepare vegetables, fold the ironing and polish items in their bedroom and one client frequently makes a cake. There were photographs to provide some evidence of specific activities, but a running record of who participated in what, every day, would provide the home with a picture of who was being successfully engaged and where there were gaps in provision that might be tackled. Such an approach would be facilitated if one member of the senior staff were to have a lead role in overseeing how the daily delegated role is carried out, and how individual social needs care plans were devised and delivered [see below]. The home was able to show that people have benefited from support to go out into the gardens or into town, for individual needs or group-based events. Some people in the home were able to tell us of their appreciation of such opportunities. Entertainments in the home and trips out were occasionally organised, and days such as Halloween and Christmas time got due recognition. However, there was little evident provision for occupation as opposed to activity. People who chose to remain in their rooms confirmed they were checked on frequently but appeared to have little to do, although we were told that the decline of opportunities that were offered was respected as personal choice. However, for a significant number of residents, there was no care plan for social care needs. Building on key worker knowledge and life Care Homes for Older People Page 23 of 39 Evidence: history information, it is necessary to devise such plans for all. This would identify in what ways people may be supported to be more physically or mentally stimulated. It would be a basis on which to plan individual and group activities more coherently, and to evaluate them. Many relatives are likely to be keen to be consulted on ways individual lives might be made more fulfilling. Where social support care plans did exist, some were effective in describing peoples likes and dislikes, and in their guidance on how to encourage involvement. One person had direct staff support to attendance at an external day resource. The homes AQAA described a weekly club morning that has been devised, and development of interests such as cake decorating. Two people had been supported by staff to enjoy a holiday in Bournemouth. Peoples spiritual needs were recognised and they were supported to retain active religious involvement if they wished. We saw that family visits were facilitated at any time, and relatives told us they always felt welcomed. There were a variety of places where people could receive visitors as alternatives to bedrooms. There were facilities for visitors to make hot drinks and one of the sitting rooms, with attached kitchenette, had been successfully used for family parties. Bedrooms had telephone points and one person had a telephone installed for maintaining family contact, whilst another had a mobile phone. We saw in one persons key worker record how they were supported to a high level in maintaining an external significant relationship, with a good deal of understanding on the part of the key worker. People confirmed to us that they got up and went to bed when they chose. People were encouraged to take meals in the dining rooms, for the social benefits and to promote exercise in going there. One persons relative told us the staff had been successful in gradually introducing their relative to shared meal times and greater social integration generally. The resident concerned told us they liked staff giving this encouragement, whilst having the option of the privacy of their own room at any time. They said they usually enjoyed their meals. We saw that a number of people chose to eat in their rooms or in lounge chairs, their choices to do so being respected. The main meal of the day was a two-course lunch. There were two choices of main course. People were asked during the morning which they would prefer, but made a final choice at the point of service. Additionally, people could choose alternatives if they did not want either main choice. Meals were served on good quality crockery and the dining rooms provided a pleasant ambience, whilst tray service was also good. Care staff serving meals were attentive to individual preferences. People were unhurried and were offered discrete assistance to eat, if they wished. They were offered choices of sauces and condiments. All people we observed at lunch appeared to enjoy their meals. The home provided both fresh and convenience vegetables and Care Homes for Older People Page 24 of 39 Evidence: there was plentiful provision of fresh fruit. Cakes were baked in-house. A variety of breakfasts were available. The chef told us he worked six days per week, including weekends. For his days off he left simple meals for care staff to prepare. He had information in the kitchen about special diets, such as sugar-free and vegetarian. He had a good personal knowledge of the resident group and said he received good feedback about the meals provided. He described his contact with one particular person, and efforts made to meet their preferences; the person concerned described their meetings in a similar way. The menu was varied, but concentrated on meals that were familiar to the majority of people in the home, for example, we saw a choice between faggots and a fish dish. One person particularly liked curries and the chef said he ensured they were offered to them regularly. Care Homes for Older People Page 25 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is good provision for receipt of and response to complaints. Staff and management understand and exercise responsibilities in respect of keeping residents safe. Evidence: The home had received no complaints through the formal complaints procedure, but we saw how the process would be recorded and tracked within set timescales. There was a record of minor complaints and how they had been addressed quickly. This is good practice, because it means any patterns emerging can be recognised, and demonstrates that peoples dissatisfaction at any time is acknowledged as important. Relatives that we spoke to said they had been given clear information about how to raise concerns or make a formal complaint. All described the management and staff as approachable. One person told us they had never found it difficult to voice any concerns, and when they had done so their views were taken seriously and responded to appropriately. Family members also told us the home was efficient at informing them of any incidents or accidents affecting their loved ones. Staff were all trained in abuse awareness, training records showing this was repeated at least two-yearly. The homes policy on responding to suspected abuse fitted with the locally agreed inter-agency safeguarding procedures. The brief No Secrets guide to these procedures was readily available within the home, as well as being issued to Care Homes for Older People Page 26 of 39 Evidence: each member of staff. Some people living in the home could present behaviours that challenged others. We looked at how this aspect of care needs was assessed for one person. There was a risk assessment, which identified known trigger factors and interventions that had been found to be successful. It had resulted in a care plan that described the behaviours that could be presented, and gave guidance to staff on how to respond. Both documents appeared to be of good quality, but it would be preferable for them to be counter-signed by an external health or social care professional, such as a psychiatrist or care manager. This would demonstrate joint responsibility and accountability for the actions of staff in what could be difficult situations. The home was on the point of introducing forms to assist with capacity assessments in the light of the Mental Capacity Act. We were concerned that care records for one person, earlier in 2009, showed the home had been almost compromised by difference of opinion between a persons family and a prescribing doctor. We discussed how decisions made at the time could have been better recorded. Arrangements were in hand with the homes usual training organisation to provide staff training in issues around the Mental Capacity Act including deprivation of liberties. The home had a policy of not using bed rails, which can present a number of risks. Care Homes for Older People Page 27 of 39 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is homely, safe and well-maintained. There are good standards of hygiene around the home, which might be further enhanced by training housekeepers in infection control. Evidence: We toured the entire home and found a high quality environment. The older part of the home benefited from large room dimensions with various shapes and architectural features. In the newer building, uniformity was countered by creative design and use of older, individual pieces of furniture. The upstairs day room in the newer building, also used as a dining room, had plentiful natural light. The lounge in the older building was a more cosy room, with a coal effect fire. There was also a large downstairs day room in the newer building, which had ready access to a new separate conservatory and secure patio area. There were plans to create an extended level walking area. We saw that people living in the home made use of communal areas, some having clear favourite sitting places and some liking the freedom to move around. One person had established a sitting place in a dining room, where they had personal things around them. They told us an additional light had been put in place for them there, to aid their knitting hobby. Many communal areas were ornamented with dolls. A number of residents and staff said these were not to their taste. Bedrooms presented as individual, with personal items around. Eileen OConnor-Marsh Care Homes for Older People Page 28 of 39 Evidence: said only a few people took up the option of bringing pieces of their own furniture with them, although several had televisions. There was a uniform tidiness to bedrooms, particularly where individuals spent little time in them by day. Carpets throughout the home were good quality, and Eileen OConnor-Marsh said their practice was to replace carpets quickly if they began showing deterioration. There was a preference to promote homeliness by an absence of signs, for example, toilet doors were not identified. Eileen OConnor-Marsh said there had not been orientation issues, but signage would be used if necessary to assist individual assessed difficulties. Bedroom doors had clear numbers. Standards of cleaning around the home were very high, with no unpleasant odours. There was a team of housekeeping staff that worked in Tower House and the three other nearby homes in the same company. Each property received daily attention, then twice a week the home had a full domestic team, which enabled deep cleaning to take place, for example, having time to pull out beds in individual rooms. An environmental health officer had visited the kitchen within the preceding year and awarded it five stars [top rating] for food safety. The laundry comprised a rented commercial machine, tumble drier, outside line space and an ironing station. Care staff incorporated laundry tasks within their role, whilst domestic staff did most of the ironing. There were individual boxes to ensure return of laundered items to people in the home. People did not raise any concerns about how this aspect of the service operated. The home shared a maintenance person with the other homes in the group. Redecorating tasks were generally contracted out. The home had a maintenance and refurbishment programme and there had been considerable redecoration in both the older and newer buildings over the past year. We found one free standing toilet frame that was badly rusted and stained underneath, which Eileen OConnor-Marsh undertook to dispose of promptly. We also noted that all toilet brushes were standing in receptacles, sometimes in liquid. Toilet brush holders should be of suspended design, to minimise the risk of harbouring infection. A routine internal audit of areas presenting high risks to infection control could identify and rectify these kinds of issues. Care staff received infection control training, but housekeepers did not. They need to be trained so they understand the rationale behind the precautionary measures they are required to take, and to be proactive in identifying infection control risk factors. Care Homes for Older People Page 29 of 39 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have good support from competent, trained staff who are provided in sufficient numbers. People are protected by sound recruitment practices that ensure nobody works at the home until checks on their background are complete. The provider invests in the development of staff, to maintain a specialist and mainly qualified team. Evidence: All staff are employed to work in all the homes operated by the provider. In practice there is a core staff group in the home, but when shortfalls arise in the staffing rota due to sickness, training commitments etc., staff are drafted from the other establishments. This means there is no need to make use of agency staff at any time, and all staff are familiar with the homes policies and procedures. The minimum number of care staff needed to meet peoples needs is set out in a condition of registration as five in the mornings and four in the afternoon/evening. This level was being regularly augmented by additional staff to ensure support to peoples individual needs and to enable staff to work together in providing activities. We saw that staff were readily available to people, and people resident in the home told us that staff were there when they needed them. At night there were two staff on duty, one in each building, plus a member of staff sleeping in. It was extremely rare for the sleepin person to be called out, but their presence was regarded as an additional fire precaution, and they assisted with morning routines until day staff came on shift. We saw attentive and kind interactions between staff and residents, and relatives we Care Homes for Older People Page 30 of 39 Evidence: spoke to commented on their appreciation of the nature of care interactions. Recruitment of staff was centralised for the four homes. We carried out an inspection of a sister home immediately prior to this inspection, when the recruitment process was assessed. We found that employment checks included Criminal Records Bureau [CRB] and Protection of Vulnerable Adults [POVA] checks, two written references and a medical declaration. All potential staff completed an application form, and this was kept by the company, as well as photographic ID. All the staff files we examined contained the appropriate checks. The homes have benefited from a stable care staff team, most of whom have gained NVQ [National Vocational Qualification] to level 2 or 3. Those without NVQ were working towards it. Across the four homes, six senior staff had achieved the RMA [Registered Managers Award] and were being developed in team leader roles, with another person currently working towards completion of the RMA. A recognised training company was used for delivering most of the mandatory training courses. There was a training plan that showed staff were required to undertake refresher courses as they became due. For example, there had been infection control and first aid training in October 2009 and health and safety training was due to be delivered in November. Additionally, the home had a range of training DVDs that could be used as necessary with individual members of staff or small groups. A further programme was for ASET training, organised with Salisbury College. This provided for distance-learning, based on work books and weekly tutor visits, in medication practice, dementia care, nutrition, infection control, and palliative care. Staff were expected to move on from one subject to the next. We found that staff we spoke with were well motivated towards training. They were proud both of their achievements and the effect they saw training have on their practice. Two members of staff were trained as manual handling trainers, and so were able to deliver all the homes needs for this training. Care Homes for Older People Page 31 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their supporters experience an open and competent style of management. The views of people living in the home, and their supporters, are sought and acted on. People have good quality support because the care workers are regularly supervised. The environment is safe for them and staff because of sound health and safety policies and practices. Evidence: Lisa Mulholland has been registered manager of the home for five years. Eileen OConnor-Marsh, as provider, maintains a daily presence in the home, and is therefore as well known to people there as any of the staff. She has fostered a team approach to management, with a regular meeting of all the unit managers and deputy managers. Owing to her regular active role, Eileen OConnor-Marsh did not record specific unannounced registered provider visits. Lisa Mulholland carried out routine monitoring of standards in the home, including health and safety, cleanliness, maintenance, and regularity of key worker meetings with residents. Audit records showed that shortfalls identified this way were highlighted for prompt attention. Care Homes for Older People Page 32 of 39 Evidence: Team leaders were beginning to carry out checks in each others units, for example on medications practice, and each had areas of delegated responsibility across all the homes,for example, activity provision, medications and health and safety. Given areas for development that we identified at this inspection, there is scope for these roles to be made stronger. We saw from minutes that staff meetings took place regularly. They presented as a two-way process between management and staff, covering appropriate wide agendas and leading to agreed changes in working practices. A quality assurance survey of people with an interest in the home was carried out annually. Eileen OConnor-Marsh and Lisa Mulholland discussed the findings and decided on actions to address any issues raised through this exercise. The 2009 survey was in process at the time of this inspection, replies starting to be received. Residents meetings were held quarterly. Minutes showed about ten people attended each time. The meetings were used to share information about prospective changes, such as refurbishment; to remind people of facilities available to them, and encourage their use; and to seek feedback, such as satisfaction with meals. It was part of the key worker function to cover similar ground on an individual level. The home had a policy of non-engagement with peoples personal finances, for example, they do not offer a safe keeping facility. Charges for items such as hairdressing and chiropody were met in the first instance by the home, and added to invoices for fees. Monies might be lent to people on trips out, in which case receipts were kept and amounts added to invoices. Care staff were supervised one-to-one by senior care staff, who in turn were supervised by managers. Individual records that we sampled showed that supervision was regular and followed a standard format, with constructive outcomes. One meeting per year was specifically about peoples training and development needs. They were also appraised annually. A senior carer confirmed she met with her supervisees on alternate months, and experienced a similar frequency for herself. Sometimes management meetings decided issues they specifically wanted addressed through everyones individual supervision sessions. Examples given were policy and procedure issues, and areas of practice such as life history work. There was a range of risk assessments and servicing arrangements appropriate to management of the environment in order to meet health and safety needs of residents and staff. We saw that the fire risk assessment had been amended following Care Homes for Older People Page 33 of 39 Evidence: management attendance at a Fire Service presentation, to include an evacuation plan. As a result of our initial findings, an addition was made to the fire risk assessment concerning the use of prescribed oxygen by a recently admitted person, before the conclusion of this inspection. All care staff undertook training in first aid, food safety and infection control. Individual care records showed that bath or shower temperatures were checked each time they were used. A newly started accident book was not in a good format, although this had been recognised in the home. Appropriate records were being made, and it was agreed a better designed book would be obtained. Lisa Mulholland said she saw all accident records, but they were not endorsed to show that she did so, neither was there a monthly or quarterly summary of the records. This would assist analysis to show if any emergent patterns needed closer scrutiny. Care Homes for Older People Page 34 of 39 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 35 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 For all medicines prescribed 15/12/2009 with a direction when required, or with a variable dose, there must always be clear, up to date and detailed written guidance for staff on how to reach decisions to administer the medicine and at what particular dose, taking into account the provisions of the Mental Capacity Act 2005. This will help to make sure people living in the home receive the correct amounts of medication in a consistent way, in line with planned health and care outcomes. 2 9 13 Where skin preparations are 15/12/2009 kept in bedrooms or en suite facilities, there must be an assessment of associated risks. This will ensure risks are recognised and minimised, Care Homes for Older People Page 36 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action as many of the people in the home are limited in their abilities to identify or control such risks. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 Care plans should be written in person-centred terms and should show evidence of sharing with family members or other advocates, if the person in the home is unable to consent to the terms of their care plan. There should be evidence of how and when night staff carry out checks on people. Always use a proper oral medicine syringe to measure any medicine doses below 5ml. For any medication that is self-administered, this should be recorded in the MAR along with a record of when it has been handed to the person concerned; there should be an assessment of potential risks to the individual or others arising from the responsibility of self-administration of medication. Make arrangements to write the date on containers of any medicines when they are first opened to use, and record the quantity of any stocks of medicines that are carried forward to the next medication cycle. This is to help with good stock rotation in accordance with the manufacturers or good practice directions and to enable audit checks that medicines are being used correctly and the right quantities remain in stock. Make arrangements to keep the allergy box on medicine charts completed with up to date information. Ensure that the medications policy and procedure fully reflect your obligations in respect of the storage, use and recording of controlled drugs. All medicines in the home should be kept within the Page 37 of 39 2 3 4 8 9 9 5 9 6 7 9 9 8 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 temperature range specified by the manufacturer or pharmacy. The temperature of the stock cupboard should therefore be monitored, and action taken if the temperature is found to exceed 25 degrees C. 9 10 11 10 12 12 Care records should never be left where they might be accessed by unauthorised people. Ensure there is a social needs care plan in place for every person. A record of activities offered and of participation should be kept in order to further develop activities and occupational provision. Peoples relatives should be informed about key workers and invited to liaise with them. Seek signed agreement by external professionals to risk assessments and care plans concerning management of behaviours that may challenge. Toilet brush holders should be of the suspension type to minimise risks to infection control. Housekeeping staff should be provided with infection control training. Consider strengthening delegation of specialist lead roles among the staff being developed into more senior roles, to engender consistency and best practice. Accident records should be signed to show they have been seen by a manager, and there should be a routine summary and analysis of accidents that have been recorded. 12 13 13 18 14 15 16 26 26 31 17 38 Care Homes for Older People Page 38 of 39 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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