Care Home: Whitchurch Christian Nursing Home

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What the care home does well Despite the poor quality rating that this service has achieved, residents we spoke with during the inspection were satisfied with the care and support they receive and said they were well looked after. The information that is produced about the home ensures that residents and their families will know what the home has to offer. The pre-admission assessments undertaken will mean that placement is only offered to residents whose needs can be met. Residents social care needs can be met in a variety of meaningful ways because a range of activities are arranged. They will be encouraged to make choices that affect their daily lives and will be provided with a well-balanced and nutritious diet. What has improved since the last inspection? There has been a significant deterioration in the quality of this service since the last inspection. The management and administration has failed to address a number of the requirements made after the last inspection. What the care home could do better: We have had to repeat five of the requirements made after the last inspection and have therefore extended the timescales for complaince. These five requirements are in respect of care planning processes, risk assessments, staff supervision, ongoing review of staffing levels, and the use of bed rails. We have also issued the following requirements: - all staff to attend safeguarding of vulnerable adults training - a review of the premises and equipment in the home - a review and improvement of infection control and hygiene standards - all staff to receive mandatory training and yearly updates - all notifiable events to be reported to the Care Quality Commission (Regulation 37 forms). We have asked the registered provider to submit their Improvement Plan and also to provide us with regular robust monthly reports on progress. Key inspection report Care homes for older people Name: Address: Whitchurch Christian Nursing Home 95 Bristol Road Whitchurch Bath & NE Somerset BS14 0PS     The quality rating for this care home is:   zero star poor 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: Vanessa Carter     Date: 1 5 0 6 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 37 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Whitchurch Christian Nursing Home 95 Bristol Road Whitchurch Bath & NE Somerset BS14 0PS 01275892600 01275832675 whitchurch@trinitycare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Trinity Care (Whitchurch) Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 50 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 50 The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Whitchurch Christian Care Home provides nursing care for up to 50 residents over the age of 50. The home was purpose built in 1997, and is now owned by Trinity Care (Whitchurch) Ltd, part of the Southern Cross Healthcare group. The home is situated in a suburban position, and is easily reached by car and bus. There are 46 single and 2 double rooms. All are fitted with en-suite facilities. The Care Homes for Older People Page 4 of 37 Over 65 50 0 1 3 0 8 2 0 0 9 Brief description of the care home accommodation is arranged over two floors. A passenger lift provides easy access to all areas of the home. There is a pleasant enclosed garden to the rear of the building. The fee levels and further information about the home can be obtained from the home manager. Care Homes for Older People Page 5 of 37 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: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last inspection of this service was undertaken on 13 August 2009 and our overall judgement about the quality of the service provided for the people who live in the Whitchurch Christian Nursing Home was that people received an adequate service. Because of this quality rating we planned to visit the service again within 12 months. There were a significant number of improvements that needed to be made and we asked for an improvement plan to be devised to address each of the issues. We expected Southern Cross Healthcare to monitor how this improvement plan was progressed. In February 2010 we asked the home manager to submit their annual quality assurance assessment (AQAA), and had to remind the manager again in March to complete this. The AQAA is a self assessment document that focuses on how outcomes are being met for the residents who live in the home. The assessment had been completed with a sufficient amount of detail. Care Homes for Older People Page 6 of 37 Prior to the inspection visit we also sent survey forms to the home to be distributed to residents and staff members. We received a total of 15 completed forms back and these gave us useful information about what it was like to live and work in the home. The home manager was present for both days of the inspection, however was retiring at the end of that week. During the inspection we toured the building and we looked at records kept by the home, including care records and those that are kept in respect of the running of the home. We spoke to residents, relatives and staff on duty, including registered nurse, care staff and anciliary staff. We observed the interactions between the staff and the people who live in the home. We asked residents what it was like to live in the home. The overall quality rating for this care home has been determined as poor. This is because their are significant failings in the management and administration of the service. We were impressed with the loyality of the staff team and residents we spoke with during the inspection were content, and satisfied with the service they receive. Care Homes for Older People Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking 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 8 of 37 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 9 of 37 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 information that is produced about the home ensures that residents and their families will know what the home has to offer. The pre-admission assessments undertaken will mean that placement is only offered to residents whose needs can be met. Evidence: The Statement of Purpose sets out the aims and objectives of the service, the facilities available in the home, details about the manager and the staff team. A copy of the document is kept in the main reception area of the home and is readily available for residents/family/visitors. The document has not been reviewed for many years and will now need to be updated to reflect changes in the management structure. There is also a service user guide and a copy was available in the main reception. We did not see any copies of these guides in residents bedrooms. We spoke to a number of residents and asked them whether they had been given information about the home My relatives arranged everything so I am not sure. In our completed survey forms, Care Homes for Older People Page 10 of 37 Evidence: nine residents each stated that they had been given enough information about the home to make an informed choice. Each resident admitted to the home will be provided with a statement of terms and conditions in respect of their stay. A contract for payment of fees will be set up with privately funded residents. For those who are part-funded by a local authority or are entitled to continuing healthcare funding from the primary care trust, a schedule of payments will be set up between Southern Cross and the responsible authority. Pre-admission assessments will be undertaken before people are offered a placement in the home to ensure that the staff team have the necessary skills, there is capacity to meet the persons needs and any necessary equipment that the potential resident requires is available. Those assessments we saw had not been signed or dated therefore it was difficult to verify that they had been completed prior to admission. Information is recorded about the individuals personal care needs, physical and mental health, mobility, eating and drinking, communication, continence and medication regimes. The assessment provides a clear indication of the residents individual care needs and is used as a basis for preparing care planning documentation. The home is able to care for up to 50 people who have nursing and personal care needs. One of the beds is block purchased by the local authority and is used as a respite bed, providing short term care for residents who then return to live in their own home. We spoke to one person who has used this facility on many occasions in order to give their main carer a break - really enjoy the stays and am very well looked after. The carer added an invaluable resource that I could not do without. I can not praise the service enough. Care Homes for Older People Page 11 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning and risk assessment documentation needs to be clearer to ensure that residents needs are met in the way that has been agreed. However, residents are satisfied with the care and support that they receive and say they are well looked after. Improvements to the management of medications will ensure systems are safe and residents get their medications as prescribed by the GP. Evidence: We looked at the care planning documentation for four people, including a recently admitted resident. The other three each had differing needs, and had lived in the home for a long time. Based upon the sample of plans that we looked at, we have determined that care planning skills is lacking. The plans are based upon the assessment of needs that had been completed. In all four plans we found that the information recorded was not consistently up to date or accurate. For example one residents eating and drinking plan did not state that there was a significant risk of choking - this means that there were no clear instructions for staff to follow to reduce that risk. For another person their mobility plan had not been revisited to reflect a marked change in their ability to move about independently. These shortfalls could Care Homes for Older People Page 12 of 37 Evidence: potentially mean that residents would not receive the care and support that they require. Care plans are reviewed on a monthly basis, but it was not evident who had been involved in the review. Any changes to the residents care plan should be clearly written on the front sheet and not just in the review section, as new needs may be missed. We did note that a re-assessment of the care needs of long term residents and new care planning documentation had been prepared. We asked for this to be done when we visited last year. Care plans are supported by a number of risk assessments in respect of the likelihood of developing pressure sores, nutrition, manual handling tasks, continence and falls. Dependency assessments are completed for each person and reviewed on a monthly basis, however this information is not used to determine the staffing levels required to meet the collective needs of residents living in the home. Manual handling risk assessments are undertaken and a safe system of work is devised which should provide the staff team with clear instructions on how each resident should be moved or transferred from one place to another. Those we looked at did not contain sufficient information, for example when a hoist is required this should state the sling size to be used. The instructions for one person stated that were able to move independently from bed to chair, however needed two carers and a walking frame, plus needed help to raise their legs up on to the bed. We asked the home to improve practice in this area last year. The registered provider must ensure that robust risk assessments of manual handling tasks are carried and staff are provided with clear and detailed instructions about any manual handling tasks they need to perform. This is a repeat requirement and further non compliance may lead to enforcement action. In addition to the standard risk assessments, specific risk assessments are completed where required. We were told that one had been completed for a resident who chose to use their wheelchair without the footplates, but that staff would put the footplates on when they were moving the resident. We observed staff moving the resident without checking that the plates were in place. We looked at this assessment, no control measures were in place to reduce the risk and there was no agreed plan. In speaking to staff members we are of the opinion that there is limited understanding of risk assessment processes. We looked at wound care planning documentation for two people. We saw that the tissue viability nurses had been contacted for advice and an account made of the advice given. The wound care plans contained details about the medical products to be used and stated how often dressings were to be renewed. A written progress report was made about the wound each time it was attended to and we did see some evidence of wound photography in order to monitor progress - this could be done Care Homes for Older People Page 13 of 37 Evidence: more often to make it a better monitoring process. On a daily basis the staff are checking that pressure relieving equipment is functioning correctly but there was no information recorded about what pressure settings were correct. Feedback we collected from residents about the care and support they received included the following - I am so well looked after here, I have only been here since May. I get all the help I need but the staff are always so busy, it is very nice here and all is OK. Despite the shortfalls in care planning and risk assessment processes, we gained assurance by talking to residents, relatives and staff members, that residents receive the care and support that they need. A daily account is recorded for each resident. Many of the entries only provided a very basic overview of the care that resident had received that day. Significant medical events were recorded and evidenced the actions taken. It was difficult to evidence where staff are making best interest decisions on behalf of those residents who do not have the capacity to make decisions about their daily personal care. This was discussed with qualified nurses who are currently the only members of the staff team who complete entries in residents care records. A visiting healthcare professionals record is kept when the doctor, podiatry, speech and language therapist, tissue viability specialist and physiotherapists, for example, visit. Most of the residents are registered with the doctors from the Whitchurch Medical Centre and the GP visits the home on a weekly basis and does a ward round. In addition GPs will be asked to visit residents on an individual basis as and when necessary. Those residents who returned our survey forms said they received the medical support that they needed. During our conversations with the qualified nurses we were assured that they are knowledgeable about the health status of the residents in their care. Care staff were able to tell us about the care needs of the residents they were looking after. The home has not made any changes to the systems in place for the ordering, receipt, storage and disposal of medications. The majority of medications are supplied in a prepared dosage system made up by the pharmacist, but some medicines, and any liquids are supplied in packets or bottles. We looked at the medication administration records (MAR charts) on one unit and we noted the following - prescibed creams and ointments are not being signed for as being administered, nutritional supplement drinks prescribed by the GP are not signed as given, and for one person who was poorly and receiving regular pain killing medication, they hadnt received any since the previous day. The nurse in charge (who had not been on duty for several days) reviewed this immediately. We saw signage displayed where oxygen therapy was Care Homes for Older People Page 14 of 37 Evidence: being used or cylinders were being stored. Last year we were told that it was Southern Cross policy that all trained staff were to complete a medication competency training pack. We spoke to two qualified staff during the inspection and neither had completed the training. The home provides placement for people who have end of life care needs and will continue to look after residents when they reach the terminal stages of their illness and are dying. The home has links with the local hospice and the registered nurses have the necessary skills and competencies to administer adequate pain relief medication when required. The home has a supply of pressure relieving equipment, moving and handling equipment and specialist profiling beds to aid peoples comfort when they are confined to bed. We discussed the documentation and records completed in respect of residents resuscitation status and in three out of four instances found the records to be inadequate. The residents GP is the only person who can make a decision to withold resuscitation (DNR) in the event of a sudden collapse. Clearly documentated evidence signed by the doctor must be retained by the home to verify this agreement and also include the names of others who have been consulted. The home must not record family decisions and see this as a DNR decision. Care Homes for Older People Page 15 of 37 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. Residents social care needs can be met in a variety of meaningful ways because a range of activities are arranged. They will be encouraged to make choices that affect their daily lives and will be provided with a well-balanced and nutritious diet. Evidence: There are two designated Activities Organiser who organise a range of different activities throughout the week or spend time with an individual on a 1:1 basis. Information about the activities that are organised are advertised upon the activities board in the main reception area along with many photographs of previous events and activities. During the course of the inspection there was a chair exercise session and a reminiscence session. Examples of other activities that are arranged include music events, flower arranging, quizzes, visits by the hairdresser, and a friday fellowship meeting. Coffee mornings, cream teas, fetes and festivals are celebrated throughout the year along with birthdays. We were told that the number of trips out from the home to places of interest have been scaled back because the number of residents who can cope with such an event has diminished. One person spoken with during the inspection said I like to take part in everything because it breaks the day up and gives me something to do. Another said I only go along to those things I enjoy. I also like to spend my time reading quietly in my room. The activities organisers will Care Homes for Older People Page 16 of 37 Evidence: spend time with residents finding out what they would like to be doing - for one person they helped to organise raised beds for vegetable growing so that the person could continue with their hobby. It is evident that residents are able to choose whether to participate in activities or not and we heard them being asked what they wanted to do, whether they wanted to join in and where they wanted to go. People are asked what time they like to get up, go to bed and where they want to have their meals served. So far only the manager and one of the trained nurses have attended mental capacity act (MCA), and deprivation of liberty safeguards (DOLS) training and there was uncertainty about when the rest of the staff team are going to be offered this training. The whole of the staff team need to be aware of when they may have to make best interest decisions for the residents they are looking after. The home has a four-week rolling menu plan, and these are displayed in the main reception area. There is a choice of two main midday meals but alternatives can be provided upon request. The menus consisted of a range of different meals including red meat dishes, fish, chicken, vegetarian dishes and a full roast meal twice a week. Those residents we spoke to during the inspection were complimentary about the meals they were offered. Those residents who had completed our survey made a range of comments - there could be more choice of dinner. Everything is the same, the food is good and the pureed diets are not always catered for appropriately. Care Homes for Older People Page 17 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Any issues, concerns or complaints that are raised with the manager are not consistently recorded and this means that trends may not be identified or issues addressed adequately. Greater emphasis needs to be placed upon staff awareness of safeguarding issues and any concerns should always be reported following the agreed protocols. Evidence: The homes complaints procedure is displayed in the main reception area and is included in the service user guide. We looked at the complaints log maintained by the home manager - three complaints were recorded. It was difficult to track the actions taken as a result of the complaints as the information was not kept in any order. We noted that one of the complaints had not been resolved at home level and the complainant had deemed it necessary to raise concerns again with head office. We spoke to the manager about one document that did not appear to be attached to any of the three complaints to question why action required for a member of staff was to attend further training. The document was not signed and we were told that the member of staff has not yet attended the two training sessions that were referred to. The home manager told us that a weekly surgery is held where residents or families can call in and discuss any issues they have. We asked to see the records that are kept of these meetings and were told that no notes are kept. The manager stated that complaints, concerns or niggles are dealt with in this informal manner. Whilst the Care Homes for Older People Page 18 of 37 Evidence: weekly surgerys are good practice, the abscence of records being kept means that any trends in the issues being raised will not be identified. The Care Quality Commission has been contacted on one occasion in the last year by a family who had concerns about a number of issues in respect of their relatives care manual handling, management of continence, meals, answering of call bells, cleanliness of the bedroom, staffing levels, and respect and dignity. These issues were dealt with following Bath and North East Somersets safeguarding protocols. As an outcome, the home manager was asked to address the issues. Some of them have again been referred to in this report. Residents we spoke with during the course of the inspection said that they felt they would be able to raise any complaints or concerns they may have with the staff and we received the following comments - the staff are helpful, mustnt grumble and some people will complain about anything. In general everything gets sorted here. Improvements should be made in the way that any comments, concerns or complaints are recorded and handled, so that they can identify any trends in the issues raised and demonstrate what actions they have taken to resolve issues. The home has a Safeguarding of Vulnerable Adults (SOVA) policy and guidance is available for the staff to follow if any safeguarding issues are suspected, alleged or witnessed. Some of the staff we spoke with during the inspection confirmed they had in the past received SOVA training, but others who were part time said they had not had any training. Staff were aware of their responsibilities in safeguarding the residents in their care and would report any concerns to the home manager or a senior member of staff. Information is displayed in the main reception area detailing how staff or visitors can raise concerns directly with Bath and North East Somerset Council. We looked at the homes training matrix and noted that safeguarding training for the staff team was overdue for the majority of the team. Care Homes for Older People Page 19 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whitchurch Nursing Home would benefit from being upgraded in some areas to provide a more pleasant environment for the residents. Redecoration and replacement of some carpets and furniture is needed. More specialist nursing beds would be more appropriate for the numbers of very ill residents admitted. Hygiene and infection control standards fall far short of acceptable practice. Evidence: The home is a purpose built two storey building with level access from the large car parking area at the front of the home. The inner front door is secured and the door bell is linked into the call bell system. Visitors to the home are able to shelter in a vestibule until the door is opened. During office hours the receptionist/administrator is on hand to open the door promptly. The administrators office, the home managers office and the main dining room lead off from the main reception area. There are several staircases and a shaft lift up to the first floor making the home fully accessible to people with impaired mobility. The corridors throughout the home are wide allowing easy wheelchair access. The decorative state and carpetting in the ground floor reception area and corridors is shabby and tired looking and we were told that this is to be upgraded - there are no definite plans for this work to be completed as yet. An area of the ceiling and wall on the first floor needs attention following a previous water leak, as the damage and mildew looks unsightly. Last year we asked for the carpet in the upstairs corridor to be replaced and this was done. Care Homes for Older People Page 20 of 37 Evidence: There are several communal areas throughout the home. One large lounge room and two smaller quiet rooms, the dining room and the activity room provide sufficient space for the residents who live there. One of the lounges is referred to as the church lounge and is used for the fellowship gathering each week. There are also a number of seating areas at the ends of corridors. We noted during our look around the home that a number of the older type armchairs were stained and looked unpleasant - these chairs are not covered with easily cleanable coverings and their suitability should be reviewed. Other newer chairs that we saw were comfortable and appropriately covered. At the rear of the home there is a very pleasant secluded garden area - there are covered seating areas where people can sit outside in the sunshine. The hanging baskets and tubs have been planted out by some of the residents and the activity staff. There are four bathrooms with assisted baths (two with swivel bathers and two with parker baths). One of the parker baths was noted to be in need of a good descouring it was also leaking, but we were told that it had recently been serviced and new parts awaited. We pointed out that the underside of one of the swivel bather seats needed a good clean. There are two shower rooms - the shower room on the upper floor has been out of action for some time - the room smelled offensively and was being used as a storage place for nursing equipment. There are seven toilets located throughout the home, they too were being used to store wheelchairs and laundry skips for example. The waste bins we saw in all bathrooms and toilets were missing their lids, one toilet had a stained and damaged seat (this was replaced during our visit), and we saw dirty raised toilet seats on the floor in one bathroom. Separate from the bathroom and toilet facilities, there are a number of sluice rooms. There was no clinical waste bin in one of the upstairs sluices and in another clean nursing products were being stored. We asked for these to be moved and stored in a cleaner environment. We also found that the sluices were used to store otherinappropriate items and these were disposed of after we brought it to the attention of the manager and domestic staff. There are 46 single bedrooms with ensuite facitilies, and two shared rooms with an ensuite facility, one on each floor. Screening is fitted between the beds to give the residents privacy. A tour of the home included seeing all bedrooms - residents are encouraged to make their bedroom their own and can bring in small items of furniture, pictures and photographs of their family. One person we spoke with during the inspection said it is very important to me to be able to see my husband everyday. It makes me feel as if he is still with me. We were told that when bedrooms become Care Homes for Older People Page 21 of 37 Evidence: vacant they will be redecorated and/or recarpetted if needed. Rooms will be deep cleaned when they become vacant and before a new resident is admitted. Since the last inspection the number of specialist profiling beds or nursing beds has been increased and we were told that there is a rolling programme of replacement of the ordinary divan beds. The specialist beds are required for people who are confined to bed or who have multiple or complex health problems. Nursing staff must ensure that for those residents who are still using divan beds, they are still appropriate and meeting their needs. New flat screen TVs have recently been installed in each of the bedrooms. We spent time with the domestic staff and were concerned that they do not work to daily/weekly/ monthly cleaning schedules. There has been a slight increase in the number of domestic hours allocated per week and there is now a third member of staff covering three days a week. We looked at Southern Cross policies regarding cleaning equipment and there seemed to be no adherence to this. Some of the equipment that the staff were using was damaged and arrangements were made to replace these whilst we were there. The staff said that they had not received recent training in the control of substances hazardous to health (COSHH) and this included a new member of staff who had been working in the home for two months. Cleaning practices currently do not adhere to safe hygiene and infection control procedures - the same cleaning cloths and mops are used for many different areas. This is not acceptable and could potentially place residents at risk of ill health. During the course of the inspection we found out that earlier in the year there had been at outbreak of sickness. This event was not reported to the Care Quality Commission, the Health Protection Agency or The Environmental Health Department. During this outbreak both residents and staff were affected. Apart from the shower room already referred to, there were no unpleasant odours noted during the inspection and the bedrooms, communal rooms and corridors appeared to be clean and tidy. In the last year concerns were raised with us by the family of one resident, who amongst other things had concerns regarding cleanliness. We visited the laundry. This is located across the car park and used linen will be transported across to the facilities in linen skips. Special sealed red bags are used for soiled or infection linen and these will disintegrate in the washing machine, meaning that laundry staff do not have to handle soiled linen. Working practices do not adhere to safe hygiene and infection control measures - staff do not cover their uniforms when dealing with dirty laundry and will then be dealing with laundered items. Laundry staff have also not had COSHH training either and they handle laundry products. One product is corrosive and they do not use any personal protective Care Homes for Older People Page 22 of 37 Evidence: equipment (PPE). The PPE that is available, does not give the necessary protection. Care Homes for Older People Page 23 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are not arranged according to the collective needs of the residents who live in the home and therefore there is the potential that people will not receive the full level of care that they need. Recruitment procedures for new staff are safe and induction training for new staff has been improved. Ongoing staff training is severely lacking which infers that the organisation does not support the development of its staff team. Evidence: The home continues to employ staff in both the care and anciliary teams who have worked at Whitchurch Nursing Home for many years, but there have been a number of new staff recruited since the last inspection. The turnover of staff however is not excessive. Those staff spoken with during the inspection were very committed to their role and the care of residents living in the home. The staff team are very supportive of each other, will cover extra shifts as and when necessary. Agency staff are only used as a last resort. This means that residents will be cared for by staff with whom they are familiar. All shifts are covered by registered nurses and care assistants and we were told that day time shifts are staffed by two registered nurses and eight care assistants, and over night there is one registered nurse and four carers. This ratio of staff to resident numbers is unchanged from last year, and despite being advised in the improvement plan submitted by Southern Cross after last years inspection, and again during the SOVA investigation, staffing levels have not been reviewed. The Care Homes for Older People Page 24 of 37 Evidence: manager told us that in order to change this staffing level a report has to be submitted to head office to agree the funds. We were told this last year when we were advised that a staffing levels dependency tool was being developed. Nothing has been done about this. Staffing levels are not arranged to take into account the dependency levels and care needs of all the residents who live in the home. There is a process in place to determine the dependency level of each resident and this is reviewed on a monthly basis, but the information is unused. Comments we received on our survey forms included at times call bells take a long time to be answered, I would love it if the staff had time to just sit and chat with me and if you want help at certain times you just have to sit and wait it out. All the residents we spoke to were very complimentary about the staff team - they work very hard and are so helpful and the staff effort is excellent and they really do care. Care staff are supported in meeting residents daily living needs by a team of administrative, housekeeping, catering, laundry and maintenance staff. The numbers of housekeeping staff has seen a slight increase. In the AQAA the home manager informed us that approximately half of the care staff have either already achieved at least an NVQ Level 2 qualification or are working towards the award. This is a reduction on last year. Whilst this meets the minimum requirements, this information should be considered along with the requirements for staff to receive adequate mandatory training. We looked at the staff files for six staff members who have been recruited to the staff team since the last inspection. These verified that the home operates a thorough recruitment procedure and expects written application and attendance for an interview. Two written references are obtained that verify any previous experience and CRB (criminal records bureau checks) and ISA1st (independent safeguarding authority checks) are always completed prior to employment commencing. Improved measures are in place to ensure that all new recruits complete the induction training programme. The Southern Cross induction-training programme is in line with the Skills for Care guidelines and includes a two day corporate induction that addresses manual handling and fire awareness training. We spoke to two care assistants who had completed the programme. A computer database (the staff training matrix) is maintained that shows when training sessions were last attended. The current matrix, dated 14 June 2010, evidenced that for nearly all staff their mandatory training courses were well overdue. This state of affairs was confirmed as correct by the home manager. In reference to Care Homes for Older People Page 25 of 37 Evidence: the quality review audit completed by Southern Cross in January 2010, these shortfalls had been picked up at this time. There needs to be urgent attention paid to ensure that the staff team have the necessary skills and competencies to carry out their jobs safely. Staff we spoke with during the inspection said that they had had training in the past but they did not know when their updates were due. Mandatory training consists of fire safety, food hygiene, moving and handling, health and safety, abuse and POVA, infection control, nutrition and medication safe handling. The staff team must all receive the appropriate training to ensure that the residents who live in the home, get the care and support that they need from well trained and competent staff. One staff member said they were attending falls awareness and management training the following day. Care Homes for Older People Page 26 of 37 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The abscence of effective management systems and the lack of robust quality assurance monitoring means that the home is not run to the expected standards. The potential for the residents who live in the home to not always receive a quality service is raised and this is not acceptable. Evidence: The current home manager Mrs Daveda Evans has been the registered manager since 2002, however she will be retiring from the post at the end of the week. A new manager has already been appointed but will not take up their duties until the beginning of July. In the interim, the management of the home will be overseen by two senior nurses and senior Southern Cross personnel. Since the inspection that was completed in August 2009, there has been little improvement in the management of this home and of the 11 requirements made only half had been addressed. Two of the requirements were being made for second time. This is not good enough and further non compliance may result in the need for enforcement action being taken. Care Homes for Older People Page 27 of 37 Evidence: It is Southern Crosss policy to use a variety of quality assurance mechanisms according to their statement of purpose. Regulation 26 visits completed by a senior manager or a home manager from another care service, should be completed on a monthly basis however there were only records made available of three such visits in the last year. The records of these visits did not evidence any robustness in the monitoring process. We were also provided with a copy of a full internal audit and quality review, where Southern Cross has scored the home against the national minimum standards. The overall rating of their own audit was that the home was performing poorly and an action plan was prepared with timescales. The manager was unable to tell us when the audit had been completed or when the timescales were reached. Again we have found sufficient evidence to prove that the quality of this care service is not being rigourously monitored and any action plans are not being followed up to improve outcomes. The home will be asked to prepare an improvement plan to address the shortfalls and we expect Southern Cross to monitor the improvements and to inform us on a monthly basis by submitting a copy of their regulation 26 visit reports. Residents can leave money in safe keeping to pay for extra services such as chiropody, hairdressing and newspapers, and good accounting systems are in place to show all transactions in and out of each residents account. We did not check a sample of accounts on this inspection and have no evidence to suggest that the systems that were in place last year are not robust. All staff spoken with during the inspection said that they do not have regular formal 1:1 supervision sessions with a senior member of staff. We were told that staff supervision is shared between the home manager and the senior nurses, however the manager has not been ensuring that regular supervision is being undertaken with the staff team. One carer stated I thought I didnt have supervision because I am only part time. There is little opportunity for qualified nurses to work alongside care assistants therefore any training and development needs may not be identified and met. The general view was that there was no time for staff supervision, that care staff had their job to do and registered nurses has their tasks to complete. A number of the records we asked to look at during the inspection were not available, or were only kept on the computer and therefore not available for all staff to access. We were not able to see resident or relative meetings, and only the last staff meeting notes were available. Some records could not be found or we were told that staff who were not on duty had the information with them. This is not acceptable and further evidences a lack of effective management and leadership. Care Homes for Older People Page 28 of 37 Evidence: We asked the manager about regulation 37 notifications - these are forms that they have to send to us to tell us about events that have happened in the home. Since the last inspection we have only received one. The manager could not explain why regulation 37 forms had not been sent to us but did confirm that there have been many notifiable events. During the inspection we looked at moving and handling risk assessments - these had been completed for each resident. A safe system of work is devised following the manual handling risk assessment but these were not always clear and did not contain enough information. Some safe systems of work were out of date and had not been reviewed inspite of a change in the residents needs. We spoke to staff who all had said they had enough information about how to move each individual and were provided with up date information in shift handover meetings, however the records must be an accurate account. Where bed rails are used to maintain a residents safety whilst they are in bed, a risk assessment should be completed prior to their use. This is so that the likelihood of any additional risks being posed as a result of bed rail use, are considered. The home manager must ensure that a full risk assessment is completed before bed rails are used and that consent for their use is gained. This requirement is being made for a second time. Monthly environmental audits are completed in respect of water temperatures, the staff call system, hoists, the profiling beds and all wheelchairs. We did not check the records on this inspection however a look at other checks completed by the maintenance team evidenced there to be good checks and recording in place. Southern Cross expects the home manager to sign off these checks each month - this had not been done. The weekly monthly and quarterly fire checks were all in order. Care Homes for Older People Page 29 of 37 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 Each person must have a 13/10/2009 plan of care covering all their care needs and setting out the specific action required by the care staff. Repeated requirement. This is so that care staff know how the person wants to be looked after. 2 8 12 Risk assessments and 13/10/2009 management strategies must be in place to deal with falls, manual handling tasks, and nutritional needs. This is so that staff are provided with specific information on what actions to take. 3 27 18 There must be a review of 13/10/2009 staffing numbers on duty for each shift and this must be based upon the assessed needs of all the people who live in the home. This is so that there are adequate numbers of staff on duty to meet everybodys needs. This must be reviewed as often as is necessary. 4 36 18 The registered person must ensure that staff receive 13/11/2009 Care Homes for Older People Page 30 of 37 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 appropriate supervision. Repeated requirement. This is so that staff performance and training needs are monitored. 5 38 38 You must ensure that bed 13/10/2009 rails are not used unless risk assessed and consent obtained. This is so that you know that the bed rails do not pose additional risk and are an agreed part of the persons care needs. Care Homes for Older People Page 31 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 The registered provider must ensure that detailed and clear care plans are prepared for each resident. They must be kept up to date. Repeated requirement This is so that residents receive the care and support that they need. 15/07/2010 2 8 12 The registered provider must ensure that risk assessments are properly completed in respect of manual handling, bed rail use and other specific identified hazards. Repeated requirement. This is so that any risks can be reduced or eliminated 15/07/2010 3 18 13 The registered provider 15/09/2010 must ensure that all staff receive safeguarding adults training and that this is refreshed on a regular basis. Care Homes for Older People Page 32 of 37 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 This is so that residents are safeguarded from harm or abuse. 4 19 23 The registered provider to 15/12/2010 undertake a review of the premises and produce a refurbishment plan to address the issues in the report. This report to include timescales. This is so that residents will be cared for in a pleasant and smart home. 5 26 13 The registered provider must ensure that there are suitable arrangments to prevent infection and the spread of infection and that the home maintains satisfactory standards of hygiene. This is so that people are not placed at any unecessary risks. 6 27 18 The registered provider must ensure that staffing numbers are appropriate to the assessed needs of all residents. Repeated requirement. This is so that every residents needs can be met in a timely manner. 15/07/2010 15/07/2010 Care Homes for Older People Page 33 of 37 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 7 30 18 The registered provider must ensure that the staff team receive all mandatory training and any other training required. This is so that they have the necessary skills and competencies to meet residents needs 15/09/2010 8 33 24A The registered provider must submit an improvement plan. This is so that we can monitor how you will improve the service and meet your timescales 01/09/2010 9 33 26 The registered provider must ensure that robust monthly quality assurance checks are in place and actions deemed necessary and followed up. This is so that the quality of service residents who live in this home receive, is improved. 15/07/2010 10 36 18 The registered provider must ensure that staff receive appropriate and regular supervision. Repeated requirement. 15/08/2010 Care Homes for Older People Page 34 of 37 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 This is so that staff performance and training needs are monitored 11 38 38 The registered person must 15/07/2010 ensure that bed rails are used unless risk assessed as appropriate and consent for their use obtained. Repeated requirement. This is that no additional risks are posed and they are an agreed part of a residents care needs. 12 38 37 The registered provider must ensure that we are informed of all notifiable events that have happened in the home. This is so that we can monitor how the home has handled events 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 15/07/2010 1 2 1 2 The Statement of Purpose should be reviewed and updated to reflect management changes All pre-admission assessments should be signed by the staff member completing the assessment and dated to evidence when completed. This is in line with good record keeping practice. Wound care monitoring either by mapping or photography Page 35 of 37 3 8 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 should be completed on a more regular basis in order to see progress or deterioration. 4 8 Staff need to ensure that when they make records about residents care, the record accurately when they have made best interest decisions about the support provided during the shift. Staff should be provided with guidance about correct equipment settings so that when they check that pressure relieving equipment is working correctly, they know what they are checking against. Medication administration Charts should be completed when residents receive prescribed creams, ointments and nutritional supplement drinks. Correct documentation must be kept in respect of do not resuscitate decisions All staff should be receiving information about the mental capacity act (MCA) and deprivation of liberty safeguards (DOLS) Information in respect of complaints should be arranged in order to demonstrate actions taken and outcomes. This will make it easier to track and identify any recurrent issues. Notes should be kept of all resident/relative surgeries for the same reason. 5 8 6 9 7 8 11 14 9 16 Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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