Care homes for older people - cqc.org.uk · The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to

Key inspection report

Care homes for older people

Name: Saltshouse Haven Nursing And Residential Home

Address: 71 Saltshouse Road Kingston Upon HullEast YorkshireHU8 9EH

The quality rating for this care home is: one star adequate 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: Date:

Beverly Hill 2 9 0 4 2 0 1 0

Care Homes for Older People Page 2 of 35

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 stars - excellent• 2 stars - good• 1 star - adequate• 0 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. They reflect the things that people have said are important to them:

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.


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 Inspection report

Author Care Quality Commission

Audience General public

Further copies from 0870 240 7535 (telephone order line)

Copyright © Care Quality Commission 2010This 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.

Internet address www.cqc.org.uk

http://www.tso.co.uk/bookshop


Information about the care home

Name of care home: Saltshouse Haven Nursing And Residential Home

Address: 71 Saltshouse Road Kingston Upon HullEast YorkshireHU8 9EH

Telephone number: 01482706636

Fax number: 01482376216

Email address:

Provider web address: www.bupa.com

Name of registered provider(s): BUPA Care Homes (CFHCare) Ltd

Name of registered manager (if applicable)

Type of registration: care home

Number of places registered: 150

Conditions of registration:

Category(ies) : Number of places (if applicable):

Under 65 Over 65

dementia 0 150

old age, not falling within any other category

0 150

physical disability 0 150

Additional conditions:

A maximum of 5 people under 65 years of age may be accommodated in the intermediate care facility in Preston Lodge.

A maximum of 7 people under 65 years of age, excluding those people referred to in condition 1 & 3, may be accommodated in PD, DE or TI categories.

Registration includes one younger disabled person Preston Lodge, two younger disabled in Coniston Lodge

Date of last inspection 2 5 1 1 2 0 0 9


Brief description of the care home

Saltshouse Haven is a large care home with nursing, caring for people with a wide range of needs including dementia and physical disabilities. It is part of the BUPA group of care homes, is situated in a residential area and is close to public transport routes into the city of Hull. The home has six separate lodges; all connected by footpaths and covered walkways. Since the last key inspection in July 2009 Sutton Lodge, which was for nursing care and intermediate care, has closed. The main lodge contains the laundry, kitchen, staff training, administration and management functions. Four lodges are individually named and can accommodate up to thirty people in each. Preston Lodge and Meaux Lodge provide residential care, Coniston Lodge provides nursing care and Bilton Lodge provides support for people with dementia care needs. All Lodges have ground floor, single bedroom accommodation, a large communal lounge/dining area with a built on conservatory and a smaller quiet room for those people that wish to smoke. The home is nicely decorated and well equipped. Well-maintained, landscaped grounds surround each lodge and there is ample car parking facilities. Information about the home and its service can be found in the statement of purpose and service user guide, which are available from the manager of the home. A copy of the latest inspection report for the home is on display in the reception area of the main lodge. The homes' weekly rate is dependent on need and ranges between £363.50 to £609. People receiving nursing care will have a specified amount deducted from the total, as this will be paid for by the Health Authority for the nursing part of their care. People will pay additional costs for optional extras such as hairdressing and private chiropody.


SummaryThis is an overview of what we found during the inspection.

The quality rating for this care home is: one star adequate service

Our judgement for each outcome:

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 quality rating for this service is 1 star. This means that the people that use this service experience adequate quality outcomes. This inspection report is based on information received by the Care Quality Commission (CQC) since the last key unannounced inspection on 24th July 2009 and random inspections on 25th November 2009 and 27th January 2010. Due to the size of the home we completed site visits to the home with two inspectors on 28th and 29th of April 2010. Since the last inspection one of the lodges has closed. This leaves four individual lodges with space for thirty residents and each has a unit manager. There is also a general manager for the whole home. The way we inspect means that the home as a whole receives one quality rating. People may experience a differing quality of care in each of the lodges but the quality rating may not fully reflect this. The company is


reviewing the way the home is currently registered to address this. Throughout the days we spoke to people that lived in the home to gain a picture of what life was like at Saltshouse Haven. We also had discussions with the registered manager, a member of the company's quality management team, staff members, relatives, two health professionals and a social care professional. Information was also obtained from surveys received from two residents, two relatives and staff members. Comments from the surveys and discussions have been used in the report. We fed back our findings of the inspection to the area manager and senior staff team. We looked at assessments of need made before people were admitted to the home, and the home's care plans to see how those needs were met while they were living there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. We also checked with people to make sure that privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. We observed the way staff spoke to people and supported them, and checked out with them their understanding of how to maintain privacy, dignity, independence and choice. The providers had returned their annual quality assurance assessment (AQAA) within the required timescale. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We would like to thank the people that live in Saltshouse Haven, the staff team and management for their hospitality during the visit, and also thank the people who completed surveys and had discussions with us. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the services are not being put at significant risk of harm. In future if a requirement is repeated it is likely that enforcement action will be taken.


What the care home does well:

The home provides a well planned and purpose-built accommodation for people. There was plenty of communal space, which was light and airy and nicely decorated. The grounds were well maintained and provided people with areas to sit and enjoy the fresh air. People were only admitted to the home after a full assessment of their needs had been completed. This enabled people to be sure the home was able to meet their needs. Staff were clear about how they promoted peoples' independence and choice. The staff members knew the residents well and were observed speaking to people in a courteous manner. People described staff as 'friendly', 'superb' and told us they did a 'good job'. There are activities provided on each of the lodges and people have the opportunity to participate if they choose. On the whole people enjoy the meals provided by the home, the menus provide choices and there are alternatives available. The home tries to deal with complaints quickly and always tells the Care Quality Commission or the local authority of any reportable incident. This enable us to monitor situations and check how the home is dealing with them. The company has a good training and induction programme. However, staff changes on the nursing lodge means that there is a shortfall in some of the skills required and an overall shortfall of people trained in first aid. Despite the lack of formal staff supervision, staff told us they felt supported and could talk to their line manager about any problems knowing they would be sorted out for them. The home manages peoples' finances well.

What has improved since the last inspection?

The management of medication has improved and senior staff in the home are continuing to audit it, to ensure any minor issues are picked up and addressed straight away. Staff told us they manage to find time to read care plans and this helps them to know the residents needs and provides them with information when they return from annual leave. There have been very recent improvements in the recruitment of nurses to the the nursing lodge. A lodge manager, deputy manager and a staff nurse are now in place and further recruitment is underway. This means there will be less reliance on agency nurses and more continuity of care for people.

What they could do better:

Care plans need to be more personalised and updated when changes are made to the


care people receive. Also people must have clear wound care management plans so nursing staff know exactly the treatment regime they are to follow. There had been an issue in the past when pressure-relief monitoring charts were not completed as thoroughly as they should be. At a random inspection in November 2009, this had improved but there has been some slippage again. It is very difficult to audit that the care has been provided if monitoring charts are not completed thoroughly and staff should take care to complete them when the pressure-relief task is completed. Staff must follow instructions for treatment from health professionals. This will ensure that peoples' health and welfare are not compromised. There is a good system of identifying when shortfalls occur in care practices and documentation but ther is no follow up to check that the tasks have been carried out and the shortfall addressed. It would also be useful if the home canvassed the views of visiting professionals to the home so that any problems they encounter can be quickly sorted out. There has been slippage in formal staff supervision. Care staff should be provided with a minimum of six formal supervision sessions a year so they are able to discuss issues of concern and so that their practice can be monitored. New lodge managers should complete the more in-depth safeguarding of adults training specifically for the managers' role in referral and investigation. This will ensure they have up to date knowledge of local procedures. There should be a system in place to verify the training and skills of agency nurses. This will provide management and the residents with confidence that peoples' needs can be met. The home must have more staff trained in first aid and must audit the training and skills of the newly recruited nursing staff, to ensure they have the skills required to meet the more complex needs of the residents on Coniston Lodge. There has been slippage regarding the robust recruitment practices required to ensure full checks are in place prior to the start of employment. Care staff were routinely employed following the return of an initial check against the register barring people from working with vulnerable adults but prior to the return of a full criminal record bureau check. This must only be in exceptional circumstances and not routine practice. The home needs to put in place a system to routinely check the suction machines on the nursing lodge to ensure they are clean and working effectively, and ready for use in an emergency.

If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4.

The report of this inspection is available from our website www.cqc.org.uk.

You can get printed copies from [email protected] or by telephoning our

order line 0870 240 7535.


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


Choice of home


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.


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 continues to ensure that peoples' needs are assessed thoroughly prior to admission. This ensures that staff and the resident can be sure that the home is able to meet their needs.

Evidence:

We looked at eight care files in detail during the visit, some of which were for people recently admitted to the home. In all cases the home continued to ensure that people had their needs assessed prior to admission. Initial assessments were completed by each lodge manager or sometimes the overall general manager. The home always obtained assessments and care plans completed by care management teams for people funded by the local authority. People admitted for nursing care on Coniston Lodge have an assessment completed by a nurse employed by the primary care trust regarding the level of nursing care they require. This will determine the health authority's financial contribution to the persons'


Evidence:

care. Health professionals also completed continuing health care assessments for people requiring extra funding for specific health needs. The information gathered in assessments completed by the home or visiting professionals was used when formulating care plans for people. The assessment documentation used by the home prompted staff to keep it under review and update it when significant changes occurred. The home does not provide intermediate care services so standard 6 does not apply.


Health and personal care


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.


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.

Although the overall care provided to residents has improved, the documentation underpinning the care must be more detailed. This is especially in relation to wound care, pressure relief monitoring and the personalising of care plans. The management of medication has improved, which means that people will receive the medicines as prescribed for them.

Evidence:

Care plans were examined in each of the four lodges. The home continues to use documentation called, 'Quest', which enabled the staff to work seamlessly from assessment of needs to planning of care. The documentation also provided separate recording sheets for health and social care activities. There was a separate care plan written for each identified need and also evidence of short term care plans for specific areas. Some of the care plans were comprehensive, included preferences for care, encouraged independence and gave clear guidance to staff. However, there were others that could contain more personalised information about how people wished to be cared for.


Evidence:

Residents on the nursing lodge did not have wound care plans. This meant that there was no clear record of the dressing required nor the frequency it must be changed. One of the residents required extensive dressings and pain management in advance of them being changed. Clear care planning is essential to ensure consistent and effective wound care management. There has been particular nursing staff shortages on the lodge resulting in the use of agency nurses for many of the shifts day and night. Despite attempting to use the same nurses as often as possible, it has directly affected some management processes and care practices within the lodge. However, a new manager has been in post for two weeks, a deputy manager for six weeks and recruitment is well underway for other nursing positions, so the shortfalls should be addressed in time. By the time we arrived for the second day of inspection, all three residents had good plans of care for their wound care management. There had recently been a care plan audit completed by the company's quality audit team and it was clear they had highlighted the issues that needed improvement such as updates when needs changed, inputting more individualised care and the need for wound care plans. It was encouraging that the company's audit was picking up shortfalls, however, these need to be actioned in a more timely way. Care plans had a monthly review page after each section so staff could comment on the continued effectiveness of the plan. Care plans were signed by the resident or their representative when possible. Food and fluid intake charts were completed but monitoring charts for people requiring pressure relief had some gaps. We were assured that these were recording, rather than care deficits. This has been an intermittent problem noted at previous inspections and staff need to ensure that monitoring charts are completed consistently and in line with the persons' care plan. Staff told us in discussions that they now made time to read the care plans and they evidenced that they knew the residents' needs well and tried to maintain privacy and dignity. One staff member stated, 'when we are washing people we speak to them so they feel at ease - keep people covered'. Risk assessments were completed and held in the care file next to the related care need. This made for ease of access and the care file flowed well. Risk assessments covered a range of needs, for example, falls, moving and handling, bed rails, nutrition, pressure areas, and for behaviours that could be challenging to others. The risk assessments were reviewed each month. Residents had access to a range of health professionals for advice, guidance and


Evidence:

treatment. A visiting health professional told us that care staff had nursed a specific resident very well. We found from a discussion with another health professional and examination of one of the care files that staff had, on two occasions, not carried out specific instructions. These related to a change in nutritional regime for one person despite information faxed through to the home, and an update in nutritional supplements for another. It is important that staff promptly carry out treatment prescribed by health professionals in order to ensure the health and welfare of residents. It was also expressed that the staff were not always prepared with ready information needed by visiting health professionals, for example information about the residents' weight. As information about weight loss or gain could affect treatment plans it was essential this was available. There was also a positive comment that the staff appear to know the residents needs well. On the whole we found that the care people received had improved since the last inspection. There were no comments to the contrary during the two days of the site visit. Comments from discussions were, 'they don't rush us', 'they knock on the door and always check in the night', 'it's better than being at home - I feel safe here and everything is done for you', 'I like the home - they look after us well', 'I feel he is well looked after - I come every other day', 'very caring and enthusiastic to achieve what is expected', 'they help me to wash and dress and help with creams', 'she is happy and content at the home', 'on the whole the care given is how we wish it to be' and 'I love it and am very settled'. We received one survey from a resident and two from relatives. Both relatives stated they were happy with the care provided. When asked what the home could do better, the resident commented, 'could answer buzzers more quickly' and 'sometimes there does not seem to be enough carers on'. There has been a general improvement in the management of medication. We completed a random inspection in November 2009 and found medication practices had not improved in key areas. The home received a Statutory Requirement Notice that required them to improve practices within a designated timeframe. A follow-up inspection in January 2010 found the home to be compliant with requirements. The company's quality audit team have been closely monitoring the management of medication on each of the lodges and has kept the Care Quality Commission and the local authority informed when their audits find any shortfalls. There are still some delivery issues to sort out with the supplying pharmacy and prescribing amounts with


Evidence:

a GP surgery but the manager has meetings in hand with them. This had affected the supply of two residents medication. The use of agency staff on the nursing lodge had also affected the smooth administration of medication, as on one occasion they were unable to locate medicines yet there was evidence they had been received into the home. This had caused the resident to miss two doses. There were some minor recording errors mentioned to the operations manager during feedback.


Daily life and social activities


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.


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 quality of life had improved for residents by the provision of social stimulation in all the lodges, respecting and maintaining individual choices and by action to address any nutritional issues.

Evidence:

Each lodge had an activity coordinator and there was evidence of a range of activities provided. These were determined by the needs of the residents, for example, small group sessions and one to one support. We observed people enjoying a game of dominoes with staff. There was a weekly activity plan on each of the lodges and staff recorded the number of people that had attended but not always their names. It would also be useful to record how successful the activity was and whether the residents enjoyed it. This would help for future planning. Activities recorded for Bilton Lodge were, crafts, nail and hair care, gardening, a film afternoon, reminiscence, sing-a-longs, a tea party, games such as dominoes and cards, and one to one sessions with people. Coniston lodge activities included, a clothes party, one to one chats, quizzes, exercises, games, current affairs, bingo, reading newspapers and magazines and an entertainer to play the organ. Other lodges had similar activities arranged and there were also visiting


Evidence:

entertainers and an exchange of library books. The lodges indicated that there were church services but a resident spoken with on Preston Lodge stated they used to go to church but had no opportunity now and they were not aware of any church services in the home. This needs to be checked out and people made aware if services take place and staff should look into any support residents may need to attend church and whether this is possible for them. Those staff members spoken with were aware of peoples' needs and how to ensure that people were able to make choices about their lives, 'talking to people is very important', 'we will open the wardrobe and ask people what they want to wear - hold up items', 'we have to get people to go as much as they can for themselves', 'we ask people things like what to wear, what to do, what to eat and whether they want to stay in their room' and 'it's fine for people to have a lie-in, there are no restrictions on times'. People were encouraged to make choices where possible, for example, in personalising their bedrooms, managing their own finances and, in some instances, managing parts of their medication. Routines were flexible about rising and retiring and a key worker system ensured that relationships between residents and staff were developed. Relatives were welcomed at any time. One resident told us how their relatives had painted and decorated their bedroom for them and installed their own furniture and carpet to make it like home. A resident spoke of really enjoying a glass of Bailey's every night and another resident chose to have two hamsters in their bedroom. Generally people liked the meals provided. We saw breakfast being served as people wandered into the dining rooms throughout the morning. One resident spoken with told us they could have a cooked breakfast every morning if they liked. There were choices at each meal and referrals to dieticians made as required. Comments were, 'it's very good food', 'we make choices the day before', 'the food is great' and ' the food is very nice and warm - they come around the day before and ask what we want'. A relative told us they had been offered a meal and it was quite nice. There were one or two comments about the food that indicated not everyone was completely happy, however, the home was very large and there were avenues for residents or their relatives to take their suggestions forward. Tables were individually set out and had condiments and menus on them. Care staff received prepared food from the main kitchen in bain-maries and served it themselves, which enabled them to provide portions in line with their knowledge about residents' needs and wishes.


Evidence:

A recent audit had indicated weight loss in some residents so the menu's had been altered, staff made aware of the issues and support arranged for specific residents.


Complaints and protection


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.


Judgement:


People are able to make complaints in the knowledge that they will be addresed. Not all staff in management positions have received the more indepth safeguarding of adults training specific to their management role. This may mean that they do not have full knowledge of local procedures. The risk of insufficient care has been partially addressed by staff recruitment and the auditing of training needs. However, plans now need to be carried out fully out to enable confidence that health and wefare is not compromised and residents placed at risk.

Evidence:

The home had a complaints policy and procedure that continues to be displayed in the main reception and in each of the lodges. We also saw complaints forms at the entrance to each lodge. Documentation evidenced that complaints were recorded and every effort made to try and resolve them quickly at lodge level but some were escalated to the general manager to address. There has been a reduction in complaints about care issues. Staff spoken with knew how to deal with any concern and what documentation to use. This was also confirmed in staff surveys. Residents spoken with said they knew how to make a complaint and identified specific staff they would speak with if they were unhappy about anything. One resident


Evidence:

mentioned that they had made a complaint recently but had not had any response yet. This was mentioned to the manager to check out. One relative spoken with was also not sure of the complaints process so it may be useful to highlight this at the next residents/relatives meeting or in the next newsletter. Comments were, 'I would tell the staff or my family' and 'I don't bother complaining - I would go to them if I'm unhappy'. The home uses the multi-agency policy and procedures for safeguarding vulnerable people from abuse and consistently sends any alerts through to the safeguarding team for a decision about how to proceed and whether to investigate. We spoke to a local authority investigating officer, who was present at the home during the second day of the site visit. They confirmed that there had been a reduction in complaints about care issues that had previously been escalated to safeguarding of adults investigations. They had recently investigated concerns that there was a shortfall in the care for people with percutaneous endoscopic gastostromy sites. Apparently the tubes were becoming blocked. However, the cause was identified as a specific medication issue but there was also a training need identified. See the section on staff training. The majority of staff had received training in how to safeguard vulnerable adults from abuse. In discussions staff were clear about what constituted abuse and what to do should they witness any abuse or poor practice. New lodge managers should complete the local authority training, specifically for managers, regarding their role in the referral and investigation of safeguarding adults from abuse procedures. Severe shortages of qualified nurses on Coniston lodge and the reliance of agency nurses to manage shifts has had an impact on some care issues. There has also been a lack of specific skills in the agency staff, which has resulted in the out of hours district nursing service contacted for some nursing tasks to be completed. The inconsistency of nursing staff, the shortfall in agency staff skills and the lack of good clear wound care plans placed the residents at risk of harm and of receiving insufficient care. However, it is acknowledged that the shortfalls are mostly addressed with the recruitment of qualified nurses in the roles of lodge manager, deputy manager and lodge nurse. Further recruitment is underway for more qualified nurses. Training needs are to be identified for the nurses. We will continue to monitor the home until the staffing and training issues have stabilised and we can be sure the residents needs are being fully met.


Environment


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.


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.

The home provided a clean, warm and well maintained environment for people.

Evidence:

The company has a redecoration and refurbishment plan and there is a continual process of renewals. The home provides purpose built, single storey accommodation in four lodges. A fifth lodge, that was used for a mixture of intermediate care services and nursing care closed last year. The sixth, and main lodge, contains the central facilities of laundry, kitchen, staff training, administration and management functions. Preston Lodge and Meaux Lodge provide residential care, Bilton Lodge provides support for people with dementia care needs and Coniston Lodge provides nursing care. All Lodges have ground floor, single bedroom accommodation, sufficient bathing and showering facilities and large communal lounge/dining areas with a built on conservatory. There is also a small kitchen for staff to use, which is entered from the dining area. The lounge areas are provided with wide screen televisions, music centres and comfortable furnishings. There is also a smaller quiet room for those people that wish to smoke at the entrance to each lodge. The home continues to be nicely decorated and well equipped throughout. Well-maintained, landscaped grounds surround each lodge and there is ample car parking facilities. Each lodge has a key pad entry system to enhance security.


Evidence:

We visited each of the lodges and generally areas were clean and fresh. Domestic and care staff work hard to maintain standards. One bedside table had liquids spilled on it, that had been there some days, and was very sticky. Also one of the bedrooms had a malodour. These points were mentioned to the staff so they could address them. Relatives inform staff if they find bedroom cleanliness falls short of expectations and this is quickly sorted out. People spoken with were happy with the home in general and with their bedrooms. Surveys stated the home was fresh and clean either, 'always or usually'. People told us they were able to bring in personal items and small pieces of furniture with which to personalise their bedrooms and this was seen to varying degrees. Some people had installed telephones to keep in touch with family and friends. One resident told how their relative had decorated and carpeted their room for them and they were very pleased with the result. The laundry was well equipped with industrial washing machines and driers. Each lodge has colour coded bags and all clothes are marked by the home to aid identification.


Staffing


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.


Judgement:


Shortfalls in staff consistency in one of the lodges and the reliance on agency staff to manage the lodge has affected care for some residents. Although the company has a good training programme, there were noted shortfalls in first aid on all the lodges and, due to the turnover of nursing staff on Coniston Lodge, shortfalls in specific nursing skills. This could place residents at risk of insufficient or delayed care.

Evidence:

There were sufficient care staff on duty in the residential lodges to meet assessed needs and each lodge had designated ancillary staff and an activity coordinator. There were catering, laundry, administration and maintenance staff based in the main lodge. The staffing difficulties have arisen in the nursing lodge, where, due to recruitment difficulties, there has been a reliance on agency nurses to manage shifts. This has caused inconsistencies and some shortfalls in care practices. However, the recruitment of a lodge manager, deputy manager and another nurse has improved the continuity of care. There is still a shortfall of nursing hours but permanent staff, and some agency staff, are filling the gaps until the recruitment process is complete. The clinical services manager had responsibility for auditing the training needs of staff and arranging induction for new staff, and ongoing training for all staff. New staff


Evidence:

members complete a comprehensive induction and foundation training programme when they first start at the home and they complete several shifts as supernumerary staff. The company had a good staff training programme in place that offered access to mandatory training and some subjects linked to the needs of the people using the service. It was noted that there were gaps in first aid training in all four lodges, which needs to be addressed. In the past there have been courses specifically for nurses to ensure they completed their registration requirements and that they had sufficient nursing skills to meet the needs of residents in their care. The nursing staff changes on Coniston Lodge means that not all the nurses have specific skills required. A primary care trust nurse has arranged specific training in the management of gastrostomy sites but other training in areas such as, male catheterisation, venepuncture, the use of syringe drivers, wound care updates and management of supra-pubic catheters is required. The home used agency staff to provide nursing care to residents. There was no system in place to verify their skills and the training courses they had completed. When the home requested nurses, they stated the residents specific nursing needs, however, there were instances when the agency nurses were unable to complete specific nursing tasks and the out of hours district nursing service had to called. This could lead to a delay in treatment for the resident. Nurses in charge of shifts must have the required skills to meet the residents nursing needs. Community health professionals such as the tissue viability nurse and infection control nurse have provided advice and guidance, and staff have contacted McMillan nurses for additional support when required. The home can access training courses facilitated by the local authority. The clinical services manager told us that fifty-one care staff had completed a national vocational qualification in care at level 2 or above with additional staff working towards the qualification at level 2 and 3. This equated to 63% of care staff trained to this level and has exceeded the standard. This demonstrated the company's' commitment to supporting staff to gain a qualification in care. There were positive comments about the staff team in surveys and in discussions with people. These were, 'on the whole very affable', 'they are honest girls - I prefer them to speak their mind, it's ok when we get to know everyone as the girls become themselves','the staff are alright', 'I feel he is very well looked after - very kind staff',


Evidence:

'all the staff are very nice - I can't grumble at all', 'the staff are very nice - if you are nice to people they are nice to you' and 'the carers are wonderful - they do a good job and they are helpful'. However, other people stated, 'when you buzz for help the only thing that annoys me is when staff finally come, they always have an excuse' and, 'the staff are ok but sometimes they wash me at 2pm - they are busy'. The person wished for support earlier in the morning. This was mentioned to the manager. It was clear from discussions with staff and from surveys that they enjoyed their job, despite its description as, 'challenging'. Those spoken with said they had a good team and took pride in caring for people. Comments were, 'overall the home is one of the best I have worked for but it has to be more efficient with communication', 'I do like coming to work' and 'it's a friendly place - good staff, good team work and we get feedback from residents'. One person did write that they would like to see more staff and improvements in how information is disseminated. Other staff told us that handovers could be longer when they have returned from annual leave, as there is a lot of information to catch up with. There used to be handover sheets but the reliance now is mostly on a verbal exchange. Recruitment practices were examined and checks were carried out prior to the start ofemployment. It was noted that staff were employed after a check of the register barring people for working with vulnerable adults but prior to the return of the full criminal record bureau check. This must only occur in exceptional circumstances and not be routine practice. The manager stated that the care staff always worked with another staff member until the return of the full CRB.


Management and administration


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.


Judgement:


We are unable to test the fitness of the acting manager until the application process for her to be registered with the Care Quality Commission has been completed. Shortfalls in staff supervision, quality audit actions, wound care planning, some staff training and staff recruitment need to be addressed to be sure peoples' welfare is not compromised.

Evidence:

There has been a recent change in management for the home and the new post holder has yet to apply for registration with the Care Quality Commission. However, the manager is a qualified nurse and has previous experience of managing nursing and residential homes. She has completed her Registered Managers Award and keeps herself up to date with relevant training/briefing sessions. The regional manager, as the 'responsible individual' visits the home and the manager has avenues of support she could use when required. The company also has a quality


Evidence:

group that has been completing audits on systems, and providing guidance to staff on how to improve practices and documentation. The home is very large and continues to be difficult to manage as one unit. There are four individual lodges with space for thirty residents and each has a unit manager. The way we inspect means that the home as a whole receives one quality rating. Shortfalls in one of the lodges may affect the quality rating of the home as a whole. The company has been reviewing the way the home is registered and is considering registering each lodge as a single home. Staff spoken with and surveys received from them indicated the lodge managers were supportive of them, 'they are always there to explain things' and 'we are very happy with our new manager she is organised and delegates'. They also told us that they were getting to know the new, overall manager and confirmed that she visited the lodges each day to check that there were no issues she needed to be aware of. One person mentioned that it would be nice to have more positive feedback when she visits their lodge so they know everything is ok with their work. Another senior staff member commented that they received, 'good support' from the new home manager. Staff also had the opportunity to speak with the area manager and regional manager when they visited. The home has an up to date quality assurance award from the local authority's quality development scheme. 'Investors in People' status has also been achieved and is ongoing. The home has a quality assurance system that consists of audits and questionnaires. The audits cover a range of topics and it was clear that shortfalls have already been identified in some documentation, for example in care plans and wound care management plans. The auditor gave clear directions on what was required to rectify the shortfalls. However, there did not appear to be a system of checking that the shortfalls had been addressed, as there were no wound care management plans in the three care files we examined. Previous audits in medication management had identified where practice needed to be improved and further training had been completed. Also audits around nutrition had identified some weight loss and resulted in menu changes, staff discussions to heighten awareness and an increase in individual one to one time for one resident during meals. Surveys were sent to residents in February 2010 but the views of visiting professionals have not been obtained yet, nor of relatives this year unless they assisted a resident to complete theirs. However, the manager is available to speak with relatives and completes a daily, walk around the home. She is also available monthly on Saturdays to speak with relatives. Staff surveys were completed in 2009. Meetings for staff and


Evidence:

residents/relatives take place and a newsletter is completed quarterly providing people with information about staff changes, events and local news. There has been no change to the way residents' finances are managed and they were not assessed at this inspection. Financial information was recorded on a computerised system. Money left for safekeeping for any resident was maintained in one specific account. Each person usually receives interest from the account, on a monthly basis, according to the amount of money each of them has in the bank. Each person has their own individual account record and receipts were issued for monies in and out. People were able to access their money when they needed to. Residents or the person managing their finances were invoiced for hairdressing and chiropody services should they receive them. Staff supervision records indicated that not all care staff received the required minimum of six formal one to one sessions each year. Formal staff supervision has slipped over the last year and staff were receiving varying amounts. The acting manager is aware of this and is to put in place a supervision plan to ensure it is re-started fully. This was a recommendation from the last inspection and will remain in the report. Accident books were filled in appropriately and audited for patterns, and risk assessments were carried out for the home in general and for individual residents' needs. Maintenance certificates were in place and up to date for all the utilities and equipment within the building. Regular fire drills and, alarm and fire equipment checks, are carried out. The home notified the appropriate agencies of incidents that affected the health and welfare of people living in the home. There needs to be a checking system in place for the suction machines on the lodge providing nursing care. Both machines were found out of their carrying cases and under a sink in the treatment room. They would need to be cleaned prior to any use and tubing had been compromised. This could have been an issue if they had been needed in an emergency.


Are there any outstanding requirements from the last inspection?

Yes £ No R

Outstanding statutory requirementsThese 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


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 People requiring dressings to treat their wounds must have clear plans of care in place. This will ensure that nursing staff have clear guidance about the dressing required and the frequency of changes. Wound care plans must be produced in a more timely manner.

31/05/2010

2 8 13 Staff must follow instructions for treatment from health professionals. This will ensure that peoples' health and welfare is not compromised.

31/05/2010

3 18 12 People must be protected from poor or insufficient care by consistent staff, skilled nurses and good care planning. This will ensure peoples' health and welfare is not

30/06/2010




action

compromised and staff have the skills and competence to care for people.

4 29 19 Full criminal record bureau checks must be in place prior to the start of employment. The practice of employing care staff after an initial check against the barring register but prior to the full return of the CRB should be in exceptional circumstances and not be routine practice. This will help to ensure only appropriate staff work with vulnerable people.

31/05/2010

5 30 18 Nurses must receive the training required to care for people with specific nursing needs. This will ensure that peoples' assessed needs are met by staff within the home and provide nurses with the confidence and skills required to support people fully

31/07/2010

6 30 18 There must be a programme in place to ensure staff receive training in first aid. This will ensure that each lodge has a first aider on each shift with the skills

30/06/2010




action

required to deal with emergency situations.

RecommendationsThese 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 include more personalised information about preferences for care. This will help staff to have a better understanding of how people prefer to be supported.

2 8 Pressure relief monitoring charts, obviously in place for a reason, should be completed consistently when a task has been completed. This enables a clear audit trail of care. The monitoring chart should also be clear about the frequency of pressure relief, any restrictions on positions and a comment on skin condition after each task would provide important information that may affect the care regime.

3 18 New lodge managers should complete the more in-depth safeguarding of adults training specifically for managers role in referral and investigation.

4 27 The recruitment drive for permanent nurses for Coniston Lodge should be completed as swiftly as possible, as the reliance on agency staff may lead to further shortfalls in care practices.

5 30 There should be a system in place to verify the training and skills of agency nurses. This will provide management and the residents with confidence that peoples' needs can be met.

6 31 The acting manager needs to apply for registration with the Care Quality Commission so their fitness to be the registered manager can be tested.

7 33 There should be a system in place to follow up actions required from quality audits. This would ensure that tasks are completed.

8 33 The views of professional visitors to the home should be gathered as part of the quality monitoring system. This will enable any issues to be addressed quickly.


RecommendationsThese 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

9 36 Care and nursing staff should receive a minimum of six formal staff supervision sessions each year. This will ensure their practice can be monitored and that the staff member is able to discuss issues of concern as well as their training and development needs.

10 38 There should be a system in place to monitor the suction machines for cleanliness and effectiveness. This will ensure that they are suitable for use in an emergency.


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