key inspection report - care quality commission · stoke-on-trent staffordshire st6 6jn the quality...

Key inspection report

Care homes for older people

Name: Hill Top Manor Care Home

Address: High Lane ChellStoke-on-TrentStaffordshireST6 6JN

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:

Yvonne Allen 1 9 0 8 2 0 0 9

Care Homes for Older People of 39

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 Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified.

Internet address www.cqc.org.uk

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


Information about the care home

Name of care home: Hill Top Manor Care Home

Address: High Lane ChellStoke-on-TrentStaffordshireST6 6JN

Telephone number: 01782828480

Fax number: F/P01782828490

Email address: [email protected]

Provider web address: www.fshc.co.uk

Name of registered provider(s): Four Seasons (DFK) Limited (wholly owned subsidiary of Four Seasons Health Care Limited)

Type of registration: care home

Number of places registered: 80

Conditions of registration:

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

Under 65 Over 65

old age, not falling within any other category

0 80

physical disability 10 0

Additional conditions:

The maximum number of service users who can be accommodated is: 80

The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 80, Physical disability (PD) 10

Date of last inspection

Brief description of the care home

Hill Top Manor is a care home that can provide nursing care for people both male and female requiring long, short or respite care. The majority of people cared for by the home are frail elderly people but the home can also accommodate people above the age of 18 who require intermediate care. The home has a separate dedicated intermediate care unit for up to 19 people with its own facilities. The home is a two-


Brief description of the care homestorey purpose built building situated in Chell, a small residential suburb within the Potteries conurbation. It is situated on a main road and provides easy access to local shops and amenities. It is within walking distance of bus routes and the home provides ample parking space. There are well-tended gardens that are accessible to people who live in the home. The home provides care for up to 80 people on two floors. There is lift access between floors. The majority of rooms at the home are single but there are four companion rooms available. Many of the rooms have en-suite facilities. There are a number of communal rooms, three dining rooms, an activity room and adapted bathing facilities. There is a central kitchen and laundry. Fees charged by the home range from 348.00 to 694.96 per week.Additional charges are made for hairdressing, private chiropody, private dentistry, newspapers and magazines, private transport and special toiletries.


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 overall quality rating for this service is 1 STAR. This means that the people using this service experience ADEQUATE quality outcomes. Prior to the inspection visit we had gathered information about the service. The information we gathered led us to bring the planned Key Inspection forward. This was because we had received some concerns and complaints about the service. These concerns came from various sources such as people who have relatives living in the home and professionals who are involved in the funding of care at the home. The inspection visit took two days to complete. On the first day we were joined by the Infection Control Nurse Specialist from the Primary Care Trust (PCT). She carried out an audit of infection control. We have made references to this audit in our inspection report and we have been informed that the service has been sent a copy of the full audit report by the PCT.


On the second day of the inspection visit there were three inspectors present - Yvonne Allen, Peter Dawson and Linda Clowes. At the end of this day we gave verbal feedback to the Registered Manager and Regional Manager and outlined the areas where we have made recommendations and requirements for improvement. We also outlined the areas where we have identified that the service are doing well. At this time we also left an immediate requirement. We returned to the service after 48 hours to check compliance and found that the requirement had been addressed. During the inspection visit we handed out surveys for people to complete. This was so that we could identify what people think about the service. The surveys were given out to a percentage of people who live in the home, their relatives and staff who work at the home. By the end of the inspection we had received most of these surveys back and comments from these have been included in this report. The service also completed a self-assessment tool known as the Annual Quality Assurance Assessment (AQAA). Completion of the AQAA is a legal requirement and it enables the service to under-take a self assessment, which focuses on how well outcomes are met for people using the service. It was completed to a good standard and gave detailed information about the services offered. References to the AQAA have been included in this report. The ways in which we gathered evidence to make our judgments were as follows - We looked at any information we had received about the service since the last Key Inspection. We spoke with people who live in the home. We spoke with the staff who work at the home. Discussions were held with the Registered Manager and Regional Manager. We examined relevant records and documentation in the home. We walked around the home and visited all the units. We observed staff interaction. We assessed all the Key standards and all the outcomes and have made some good practice recommendations and legal requirements for improvement.


What the care home does well:

The standard of care planning was found to be good. Individual care plans are comprehensive and contain risk assessments with detailed reviews. People are encouraged to be involved in the development and reviews of their care plans. Where this is not possible then their next of kin or advocate will be involved. This helps to ensure that people's individual choices and preferences are included in the activities of daily life. Access to other professionals is promoted and people living in the home benefit from the services of Specialist Health Care Professionals. This helps to ensure that individual health care needs are assessed, monitored and met. There is good multi disciplinary team working on the Intermediate Care Unit. This helps to ensure that the specific rehabilitation needs of people on this unit are met. These are comments which were received from people who live at the home and their relatives - "The home understands individual needs well and respects the needs and routines of the resident." "The home does the following well - training staff, covering shortages and employing new staff and supporting staff, residents and relatives." "They uphold and maintain residents' dignity and self esteem by giving holistic care." "They look after the needs of the residents." "The home does its best for the comfort and satisfaction of the residents, viewing everybody as an individual and important." "There is a homely feel with good caring staff." "The home provides continual professional care for all residents." "The home provides a piece of mind for relatives when they are not visiting residents. They know that the people in their care are well looked after." "Provides a good standard of care." "Staff are at hand if we have any worries or concerns." "Staff are friendly and caring." "The medical care is very good and the explanation about medicines etc is very good. Keeping residents clean and well fed. Medical staff on hand at all times." "The staff are very supportive of relatives, understanding how they feel about their loved ones. The staff are helpful with hospital appointments etc."


What has improved since the last inspection?

The service has developed strong links with the Tissue Viability Support team and these Nurse Specialists now come out to visit people who live in the home on request. This means that people who live in the home, and are at risk of developing, or have a pressure ulcer, receive expert advice and treatment for this. Staff are also supported and have help with preventing the development of and managing pressure ulcers. The service has reviewed its medication policies and procedures and these have been improved since the Random Inspection was held. However some medication procedures still require tightening up as highlighted in the section below.

What they could do better:

The recording and monitoring of peoples' intake of fluids is poor. Fluid intake charts are not completed correctly and indicate that people are not offered fluids throughout the night. Some records indicate that some vulnerable people, who are unable to give themselves a drink, have gone as long as sixteen hours without the offer of a drink. Also the fluid intake charts are not totalled at the end of each 24 hour period so that it is difficult to identify whether or not people are adequately hydrated. Also concerning, is where fluid intake has been poor for an individual person, no action or follow up has been recorded nor communicated between nursing staff in order to address this. This means that vulnerable people living in the home are at risk of becoming dehydrated. We made an immediate requirement at the time of the inspection visit for records relating to fluid intake to be improved so that individual hydration can be better monitored. Complaints which we received prior to the inspection visit have highlighted cleanliness issues at the home, especially in relation to the Intermediate Care Unit. Together with the Infection Control Nurse Specialist, we identified that cleanliness and infection control is not good and leaves people vulnerable to contracting infections. This is mainly focused on the Intermediate Care Unit but is not limited to this area. The Nurse Specialist has identified areas in need of improvement and sent an audit to the service containing recommendations. In this audit she states that - "Whilst the issues identified individually may not appear serious, taken together this is a gross breach of standards which affects quality of care and peoples' safety". We have made requirements and recommendations for the service to improve in this area. This will help to ensure that people who live in the home are kept safe. We also identified a need to review and improve Social and Therapeutic activities in the home in order to make them more person centered. People also told us that they would like more trips out. The service will also need to review its Quality Assurance programme in order to ensure that the areas we have identified as poor or adequate are efficiently audited and improved. Although some improvements have been made to the medication process we identified that prescribed creams are not being signed for by the person who is administering these. Plus also it is difficult to carry out an audit of the numbers of medicines kept in


the home at any one time. The service should make improvements in these areas in order to help keep people safe. Overall the staff training and development programme is good. However the areas of concern we have identified throughout this report highlight a need for further staff training. These areas relate to cleaning and infection control, communication and record keeping in relation to fluid intake, and awareness and understanding of dementia care. This further training will help staff understand and meet the needs of people living in the home and will help to keep people safe. These are comments received from people who live at the home, their relatives and staff who work there - "The home could do more to stimulate the residents. For instance more activities and outings." "They could put two nurses on the Intermediate Care Unit since the bed capacity is now 20." "They should make sure that there are enough staff to meet the needs of the residents." "They should give more support and motivation to staff members." "Possibly more activities." "Get more staff." "More trips and activities needed for the residents." "They should take us on more regular outings."

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.

People have their individual needs assessed by a suitably trained person from the home prior to admission and can be assured that these needs will be met. People are given information about the home and, wherever possible, are given the opportunity of visiting prior to admission. This means that people can make an informed decision about moving in to the home.

Evidence:

In their AQAA the Providers tell us that - "Residents and Relatives are encouraged to look round and view the facilities available to them. Potential residents are welcome to come to the home over a period of time, to meet other residents, sample a meal, or to observe and take part in activities. There is a trial period of at least one month for all new admissions. Our Service User Guide can be made available in varying formats. A copy is given to all enquirers visiting the home or can be posted if preferred. Our Statement of Purpose is comprehensive and is available to all enquirers visiting the


Evidence:

home. We make our previous inspection report available to enquirers. The Company has an informative and easy to use website". We looked at how people have their needs assessed prior to admission. We saw that individual care plans contain detailed pre admission assessments. We also spoke to people about their involvement in the admission process. We met with one person who had brought her mother in for respite care. She told us that her mother would not settle very well and that she had to take her home the previous night and bring her back again that next morning. She was pleased that the manager and staff had been so accommodating. She also told us that she had been given information about the service in the form of a brochure including the Statement Of Purpose and Service User Guide. She said "I am pleased with everything so far, everyone seems very helpful". We observed the manager talking to this lady, explaining that she could "take her time" with the admission process to ensure that her mother settles in well. The service offers a separate unit which is dedicated to caring for people with intermediate care needs. This is a twenty bed unit which has single rooms with en suite facilities, communal rooms and a physiotherapy room. People come into this unit directly from hospital for short term care with a view to either going back home or moving on the another care setting. People can stay from a week through to six weeks and have a planned programme of care designed to meet their rehabilitation needs. There is good multidisciplinary team working in place on this unit. Later in this report we have identified that this intermediate care unit does not meet with current cleanliness and infection control guidelines. When we discussed this with the manager of the service she explained that the unit has a "very quick turnover of people" and that this does not always give sufficient time between one person going out and another coming in to thoroughly clean each bedroom. The manager told us that she has recently changed the policy on admissions to the unit allowing more time for cleaning to take place.


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.

People have their personal care needs planned and regularly reviewed. Individual health care needs are assessed and monitored but the recording and monitoring of fluid intake is inadequate and the current system cannot guarantee that vulnerable people receive sufficient hydration. The current medication system used in the home cannot be easily audited and does not always guarantee that people are receiving their medication as prescribed.

Evidence:

In their AQAA the providers tell us - "The pre admission assessment (CHAP) is completed fully which enables staff to develop a comprehensive person centered care profile. This enables staff to provide the individualized care the residents require. Comprehensive internal audit and monitoring resulting in robust action plans to address identified shortfalls. The company expects our medication audits to show 100% compliance, with the regional manager being required to validate regularly. Group, regional and local Clinical Governance meetings are now a routine part of our


Evidence:

processes." We looked at individual care plans and identified that there is a good care planning format in place which is completed well in detail which is regularly reviewed with detailed summaries. Plans contain risk assessments, some of which are signed by relatives and we saw an example where all fourteen aspects of a care plan had been signed in agreement by relatives. Risk assessment are comprehensive and included assessments of nutrition, moving & handling mobility including support needed support needed with clear instructions for the use of hoists and other moving and handling equipment. People are weighed monthly or more often as required. The service had had a problem with their scales and an error was seen where the weight of a person had been recorded as 34kg for many months then 40kg change in one month and remains so. The service have recently purchased new scales. People have access to health care specialists as and when required such as visits by the general practitioners (GP), the tissue viability nurse specialists, the infection control nurse specialists, chiropodists, opticians, dentists, palliative care nurse specialists, dietitians, speech and language therapists (to assess ability of swallowing). On the Intermediate Care Unit there is a team of Physiotherapists and Occupational Therapists to help with mobility and rehabilitation. The multidisciplinary team work closely together to help people convalesce, regain their Independence and prepare for moving on. Although we saw plenty of fluids available to people around the home, the records of individual fluid intake, which are vital for some people, to ensure adequate hydration and well being, were generally poor. We saw a number of examples where daily intake charts were not totalled and checked by nursing staff and there was no evidence of night staff offering drinks to people. Examples of the total fluid intake for some people in a twenty four hour period are as follows - 450 mls, 650 mls and 730 mls. One of these people had a urinary catheter in place and would need more fluid intake than this in order to ensure the catheter was working efficiently. There were instances seen where, according to fluid intake records, people did not have drinks from early evening on one day to 9AM or 10AM the following day. We left an immediate requirement for fluid balance charts to be completed correctly in order to maintain a record and demonstrate that people are receiving enough fluids. Nor were there any records of follow up of people whose hydration had been poor. We


Evidence:

looked at daily notes and these did not indicate a cause for concern where people had not taken sufficient fluids. Neither was there any record of an action plan to address this or records of whether this person had been referred to the doctor. We spoke with the nurse in charge who agreed that there should have been "better communication between nurses" and we raised this concern with the manager of the service. Good wound care records are in place, including body maps, grading, treatment, photographs and recording when dressings are changed. The service also enlists the help and advice of the Tissue Viability Nurse Specialists who come out to the home to assess people. We had carried out a Random Inspection Visit at the service in September 2008. We did this as a result of concerns raised about the management of medication within the home. During this inspection visit we identified areas in need of improvement and we made some legal requirements and good practice recommendations. The service sent us an improvement plan outlining how their medication system would improve. We were pleased to note that, although we have now identified further areas for improvement, the previous requirements and recommendations have been addressed. We looked at the process for the receipt, storage, administration and disposal of medication. This included looking at the Medication Administration Record (MAR) sheets. The folder with the MAR charts contained a policy for the Control and Administration of Medication. There was a list of names and signatures for people who were approved to administer medication. However, the name of the nurse responsible for medication and administering medication on the lunchtime medication round was not listed. We pointed this out to the nurse and she added her name and signature to the list while we observed. We saw protocols for "as required" (PRN) medication for each person. We monitored prescribed pain relief for one person but were unable to follow an audit trail for this as the quantities received and any left over from previous periods had not been recorded. We have, therefore, made a recommendation as part of this report that the quantities of each medication held in the home is recorded as required by regulation. We identified that prescribed creams were being stored in people's bedrooms and were being administered by care assistants. The MAR charts, however, were being signed by the nurses in charge of the medication round. It is imperative that the person who administers any prescribed treatment signs to confirm this. We have, therefore, recommended that the home introduces a system for accurate recording of


Evidence:

prescribed treatments. The service will need to ensure that people responsible for the administration of prescribed treatments are suitably trained and their practice is regularly monitored to confirm competency. We have made a recommendation regarding this issue as part of this report. This is what people told us about the care they receive in the home - "The service provides a piece of mind for relatives when they are not visiting residents. They know that the people in their care are well looked after." "The medical care is very good." and "They keep people clean and well fed and medical staff are on hand at all times." "We are happy with the care our nan receives." "They provide a good standard of care." This is what staff told us about the care in the home - "The home does its best for the comfort and satisfaction of the residents, viewing everybody as an individual and important." "We look after the needs of the residents." "We uphold and maintain residents' dignity and self esteem by giving holistic care." "The home understands individual needs well and respects the needs and routines of the residents."


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:


The social and therapeutic needs of people are assessed and met adequately although this could be improved by making activities more person centered. The activities of daily life in the home are flexible and varied. People can be assured that their dietary needs will be assessed and met. However improvements are required to ensure that people receive adequate fluid intake.

Evidence:

In their AQAA the Providers tell us - "We employ an experienced and enthusiastic Personal Activities Leader who has spent time developing life histories for our residents. There is a variety of activities provided, the programme having been developed following discussion with the residents. There are regular outings for residents in a group or one to one. Some residents have access to groups e.g. The Stroke club. Advocates are used should a resident require assistance. Individual care files are developed and evaluated in conjunction with the resident and their families/close friends where possible." We looked at the programme of activities and entertainment in the home.


Evidence:

The service employs two activity co-ordinators who each work 20 hours. We met one of them and she explained how the programme of activities is planned around meeting the needs of people. The activities are listed on the activity room door as follows - Monday - Hairdressing. Individual needs - newspapers, discussion therapy. Tuesday - Hairdressing. Movement to music. Wii games. Wednesday - Hairdressing. Individual needs including crafts, take residents around grounds. Thursday - Gardening. 2pm Movies. Firday - Picture Quiz. 2pm Entertainer - music. The activity co-ordinator told us that they do not work at the weekends usually. She showed us her own records of individual activities and this did include some one to one time for people who do not or are unable to join in group therapy sessions. The co-ordinator also explained to us that she is trying to put together a "Life story book" for each person living in the home. We saw letters left for relatives asking for assistance with this. This will help to make activities more person centered. People have very mixed feelings about the provision of activities at the home - A relative of a person living on the ground floor unit told us "Mum goes to the hairdresser once a week and joins in with some of the activities. She has recently enjoyed painting some of the plant pots which you can see outside." Another visitor said - "more trips out are needed or just more walks around the garden my relative would enjoy this." Another person told us - "Activities need improving. I would like more trips out" Comments received from the surveys we sent out included - "The home could do more to stimulate the service user. IE: More activities and outings" "The home could do better by taking us on regular outings" "Could possibly provide more activities" The same number of people had ticked on the surveys that they felt the service does


Evidence:

provide activities which they can take part in. We discussed the above with the manager who explained that it is very difficult to take people who need the use of a hoist on trips out due to health and safety legislation. Visitors are welcome at any reasonable time to the main home but visiting times are somewhat restricted on the Intermediate Care Unit. The manager explained that this is because people living on this unit need time set aside for physiotherapy and occupational therapy. She did confirm that should any visitors be unable to come at set times then arrangements can be made for alternative visiting times. The service assesses the spiritual and religious needs of people and these are provided for by way of visits from the local Clergy and Church Services held in the home. People told us that the meals served in the home are of a good standard and that they have a choice of main menu. "The food here is very good" "Oh yes we have plenty to eat and drink - they are always coming around with one thing or another" We observed some of the meals being served and these appeared wholesome, nutritious and well presented. People have their nutritional needs assessed. They are weighed regularly and a care plan is put into place when required. Where indicated people are prescribed nutritional supplements and referred to a dietitian. Special diets are catered for by the service and likes and dislikes are documented so that people receive a suitable diet. An area of concern, which has already been highlighted in this report as being in need of improvement, is the monitoring and recording of peoples' intake of fluids.


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 who live in this home are able to raise any concerns they might have and will be listened to. The service investigates complaints but does not always take action to make the necessary improvements. People are safeguarded from harm or abuse by the policies and procedures adopted by the service.

Evidence:

In their AQAA the Providers tell us - "All complaints are handled as per the comprehensive company policy. All complaints are taken seriously with the culture being that complaints and comments are viewed as a way to improve. Investigations are timely and thorough. Outcomes from complaint investigations are communicated to all relevant members of the team in order to promote learning and prevent re occurrence. The home reports all safeguarding issues without delay to ensure the safety of those involved. Our complaints procedure is available in a variety of formats and languages." The service has a complaints procedure in place which is displayed on the walls at the entrance to the home and is contained in the Service User Guide. This outlines the procedure to follow in order to raise concerns with the service including written


Evidence:

complaints. The procedure gives a timescale in which the service will investigate complaints. We, the commission, have received three complaints from relatives of people who live in the home since the last Key Inspection and these were directed to the service to investigate. When we looked at their log of complaints we identified that the manager of the home had carried out investigations and had responded back to the complainants accordingly. The Health Authority have made us aware of four complaints about the service, two of which are included above. They have highlighted the same themes and trends linking complaint issues. We looked at the log of concerns and complaints and identified that the service has investigated complaints according to their procedure and has responded to people within the given timescales. We also identified that the service carries out complaint investigations thoroughly and produces comprehensive reports based on obtaining evidence from all sources. When we spoke to people living in the home they told us that they know who to raise concerns with if they have any. On the surveys we sent out we asked people if there is someone who they can talk to if they are not happy and they all indicated that there is. People also commented "Staff are at hand if any worries or concerns". Some of the complaint issues have been raised on more than one occasion and we identified that action is not always taken to improve the areas of concern. This is with particular reference to the cleanliness of the Intermediate Care Unit. This is highlighted by the Infection Control Nurse Audit carried out during the Key Inspection visit. Future quality auditing could focus more on whether improvements have been made as a result of the complaints received. We looked at the procedure for keeping people safe in the home. The service has a policy on Protection Of Vulnerable Adults (POVA) and all staff are made aware of this on induction training. There is also a Whistle blowing policy in place which allows and protects staff to raise concerns about poor practice within the home. Staff told us that they receive training in Safeguarding Adults and when we looked at


Evidence:

training records we could confirm this.


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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service.

The standards of cleanliness and infection control measures adopted by the service cannot guarantee the safety of people living in the home.

Evidence:

In their AQAA the Providers tell us - "We employ a full time Maintenance Person who is supported by our Regional Estates Team. We refer to a comprehensive Estates Manual which ensures that all routine checks are on a service schedule and that these are undertaken regularly in line with policy. Records and certificates are available for inspection. We hold three monthly Health and Safety meetings resulting in actions to address any areas of risk. The home is kept clean and tidy and the house keeper directs her team to ensure all areas of the home are well maintained. We have an annual programme of refurbishment supported by an appropriate budget." On the first day of our inspection visit we were joined by an Infection Prevention and Control Specialist Nurse from the NHS Stoke On Trent Primary Care Trust team. She had joined us as a result of the concerns received by the PCT in relation to cleanliness issues within the home. She carried out an audit of the premises. The results of this audit have been sent to the service for their attention. As previously highlighted some of the concerns about levels of cleanliness in the home have been raised by more than one person and on more than one occasion. These


Evidence:

concerns have been mainly focused on the Intermediate Care Unit. We walked around the home and found the following - Seven rooms on the Intermediate Care Unit, seven rooms on the upper floor, eight rooms on the rest of the ground floor and all sluices and communal bathrooms were inspected. As a result of the audit carried out by the Infection Control Nurse and the observations made by inspectors during the visit the following concerns have been identified - Unsatisfactory standards of hygiene in relation to - Toilet seats and toilet raisers. Some of the mattresses. Some of the Pressure relieving cushions. Bed frames, including unsatisfactory records of the cleaning of beds. Toilet cleaning brushes including the storage of them. Sinks in bedrooms. The cleaner's room does not contain a sink. The sinks contained within clinical rooms are not compliant with standards of infection control. Approximately half of the liquid soap dispensers for staff to use were empty. Cluttered sluice rooms, a shortage of urinary catheter stands and the poor condition of the bed pan washers. Items stored on the floor in sluice rooms. Badly stained and chipped work surfaces in the Intermediate Care Clinical room. Plastic medicine tots were washed in the sink and left draining. The drip trays located under water and juice fountains were stained and full of water.


Evidence:

Tables and dining chairs had a build up of fluid and food spillage on the underside. This was also evident on bed tables in some rooms. Many easy chairs contained food crumbs and debris. Commodes were not of a satisfactory standard of cleanliness. In one room a person's prescription maintenance catheter supplies were being stored on the floor next to the toilet in the en suite room and the flooring is lifting away by the toilet. There was evidence of high dust in many places. Liquid splashes were evident on walls in many rooms and around the sink area in all the en suite rooms. Another room had extensive dust and spider webs in the en suite window sill. The housekeeper was not able to show any evidence of organized cleaning routines. There was no audit trail of cleaning available. Although there was an extensive set of procedures they were not easy to follow and did not provide evidence of work completed. The Infection Control Nurse Specialist states "Whilst the issues identified individually may not appear serious, taken together this is a gross breach of standards which affects quality of care and peoples' safety". As an example of how these come together to affect this, the Infection Control Nurse Specialist has outlined issues from just one room (room 14), there are further examples of this. "Bed frame stained, easy chair food debris under cushion, foot stool torn, bed table encrusted with dried food, wheel chair stained and dirty, pillows not covered, wall by the door stained, pro-pad mattress overlay badly stained, no liquid soap in dispenser for staff hand washing, wash bowl stored wet on top of the bin in the toilet, plug hole in sink dirty mouldy and wet, skirting corners dirty, bed frame chipped, toilet seat raiser dirty. The resident in this room had a bandaged foot resting on the floor with no covering, no slipper or shoe." The NHS Stoke on Trent Primary Care Trust have, in their audit report, identified specific recommendations for improvement to infection control at the home. A copy of this has been sent to the Providers of the service.


Evidence:

The registered Provider shall ensure that the care home is conduced so as to promote and make proper provision for the health and welfare of people who live in the home. This is with particular reference to standards of hygiene and infection control at the home.


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:


People are cared for by a staff team who caring and helpful. However it cannot always be guarenteed that staff collectively have the knowledge and skills required to keep people safe.

Evidence:

In their AQAA the Providers tell us - "We value all team members. We use minimal agency staff, preferring to support and retain our own competent staff for the benefit of the residents. There is a comprehensive induction and training programme for all staff and regular staff supervision and annual appraisals are held. All staff receive an Employee Handbook. We refer to a comprehensive HR manual which ensures that all personnel issues are dealt with professionally and in compliance with the prevailing employment laws, working time directives, and care home regulations. Regular audits of personnel files are carried out." Review rates of pay annually to ensure that they remain fair and competitive in the local job market." The service is managed by a qualified and experienced manager who has been approved as Registered Manager by the Commission.


Evidence:

The care staff team consists of thirty-two permanent staff made up of registered nurses, senior care assistants and care assistants. We looked at a sample of six staff personnel files (two nurses and four care assistants) all of whom were recent recruits. Three of the staff were from overseas. We confirmed that the service was taking up recruitment checks that included the taking up of Criminal Record Bureau Enhanced Disclosures (police checks) and appropriate references. We were unable to confirm the full employment history for the overseas staff or identify that police checks had been carried out in their country of origin. The Operations Manager and Registered Manager told us that their central Human Resource Section at Four Seasons carry out these checks. As we were unable to confirm details further back than four years for any of these staff we will refer this matter to our Provider Relationship Manager to clarify at a corporate level. All new recruits had undertaken or were currently undertaking Induction Training. We spoke with several staff on the day who confirmed that they had undertaken thorough recruitment training to prepare them for their role. We monitored the Training Matrix and found that all mandatory training was in place. The Annual Quality Assurance Assessment (AQAA) informs us that 52% of care staff have attained a minimum of National Vocational Qualification (NVQ) Level 2 in Care and that several are presently working towards this award. All staff spoken with told us that they have 'lots' of training to help them in their job. We were informed that there are a high proportion of people who suffer confusion or dementia and recommend that further dementia care training be included in the Training Programme in order that staff at all levels may respond appropriately to people who have dementia care needs. We confirmed that staff at all levels receive regular supervision which is an effective way of raising the quality of care delivery. We were told that staff "can expect to receive supervision every three months". Staff we spoke to confirmed that they attended for regular supervision. This is what people told us about the staff who work in the home -


Evidence:

"The staff are wonderful, they are great to us I am more than happy." "The staff are very caring and helpful to both the person staying in the home and their family. Nothing is too much trouble for them." "Good caring staff." "Staff are at hand if any worries or concerns." "Staff are friendly and caring." "The staff are very supportive of relatives, understanding how they feel about their loved ones being in the home." Staff who work in the home told us - "The home provides regular training for the staff which enables them to give excellent care to people." "The home could do better by reducing the number of care staff calling in sick particularly during weekends." "The home is good at - training staff, covering shortages and employing new staff, supporting staff, relatives and residents." "Two nurses are needed on the Intermediate Care Unit instead of one as the bed capacity is now 20." "The home could do better by - making sure that there are enough staff to meet the needs of all the residents." "The home could give more support and motivation to staff members." Under the section on Health and Personal Care we have identified that there is a lack of staff communication regarding the recording and monitoring of peoples' fluid intake. This may also indicate a lack of staff awareness of the importance of this. Further training may be required in this area. Under the section on the Environment we have identified an inefficient cleaning regime


Evidence:

an a lack of attention to detail in relation to the control of infection at the home. This may also indicate a need for further staff training in this area.


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:


People feel that the home is generally managed well and that the manager is accessible and supportive.In some areas management and quality assurance has not been effective, and, therefore, it cannot always be guaranteed that the home is run in the best interests of the people who live there.

Evidence:

In their AQAA the providers tell us - "The current home manager has been in post since March 2002 and holds the following qualifications - Registered General Nurse, ENB 998, Nll Care of the dementia patient and their carers. D32,34 National Vocational Assessor,Verifier. Registered Managers Award. Four Seasons Regional Management structure ensures that Registered Managers have a manageable number of homes in order that effective quality and monitoring can take place. All complaints or concerns are addressed and residents and relatives have confidence in the home's management. There are good accounting procedures to ensure that the residents' finances are managed safely. The home employs a full time Administrator who is


Evidence:

supported by the Regional Support Administrator and our central office personnel. Advocates are used should a residents require assistance. There are robust Health and Safety systems in use. Staff training is comprehensive and mandatory training is up to date." The management structure for the service consists of the Registered Manager and the Deputy Manager. The Regional Manager also visits monthly or more frequently to offer support and guidance. During these visits the Regional Manager conducts a small inspection of the service, copies of which are made available for inspection. The registered manager has held this position for many years and has the necessary qualifications, skills and experience to manage the home. The manager also has close links with health care professionals and Social Services within the local area, thus enabling people who live in the home to have access to help and support when required. The Company has a comprehensive Quality Assurance system which involves regular quality auditing of all areas within and services offered by the home. We identified that audits are analyzed and the results are made public and displayed within the home. Action plans are also produced from these audits. These include actions to be taken for improvements, where indicated. One area which had been audited on 21/01/09 by the service was a domestic (cleaning) "Team Audit Process." This was not comparable to the findings of the inspectors and the Infection Control Nurse at the time of the visit. Also the audit does not ask the specific questions which would lead to the checking of areas of infection control, which we have identified as needing improvement. People are encouraged to manage their own finances wherever possible. However there is a secure facility provided for the safekeeping of monies and valuables. We looked at the maintenance of peoples' money within the home and were informed that the system has not changed since last inspection. The Service has a Health and Safety Policy Statement in place and the registered manager is responsible for ensuring that this is adhered to.


Evidence:

Staff are aware of this Policy and have regular training updates in mandatory health and Safety areas. In sections of this report we have identified areas which have not been well managed. These areas are namely the recording of peoples' intake of fluids, including a lack of communication and monitoring of this, and a lack of general cleanliness and control of infection. The overall management and quality assurance of the above areas has proved ineffective and is in need of urgent review and improvement in order to ensure that people are kept safe. People who live in the home, their relatives and the staff who work there feel supported by the manager and this is what they told us - "You can always go to Kath if you have any problems and she will sort them out for you." "The manager is very good and we are supported with our training needs." "The manager has been very helpful with settling mum into the home."


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 26 12 12 (a) The registered Provider shall ensure that the care home is conduced so as to promote and make proper provision for the health and welfare of people who live in the home. The arrangements for standards of cleanliness and infection control at the home must be reviewed and improved in order to comply with the Health and Social care Act 2008.

11/10/2009

2 26 13 13 (3) The registered person shall make arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The arrangements for general cleaning of the home and infection control highlighted as poor must be reviewed and improved in order to ensure that people

11/10/2009


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

living in the home are kept safe.

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 8 It is recommended that, where people's fluid intake has been inadequate, then this is recorded and communicated and that action is taken to address this. This is to help ensure that people are kept adequately hydrated.

2 9 The service will need to ensure that people responsible for the administration of prescribed treatments, such as creams and lotions, are suitably trained and their practice is regularly monitored to confirm competency. This is to ensure that the people receive their medication safely.

3 9 It is imperative that the person who administers any prescribed treatment signs to confirm this. This is in respect of prescribed creams and lotions. Therefore, the service should introduce a system for accurate recording of these prescribed treatments. This is to ensure that people receive their medication as prescribed.

4 9 The quantities of each medication held in the home should be recorded as required by regulation. This will allow for an audit trail to be carried out at any time.

5 12 Therapeutic activities should be made more person centered in order to ensure that peoples' individual needs are met.

6 16 Future quality auditing should focus more on whether improvements have been made as a result of the complaints received. This is in order to ensure that appropriate action is taken to help avoid other people raising the same concerns.

7 30 It is recommended that nurses and care staff are given training updates in the importance of good communication and record keeping. This is especially in relation to the recording and monitoring of adequate hydration. This will help to keep people who live in the home safe from


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

dehydration.

8 30 It is recommended that domestic staff are given up to date information and training on best practice cleaning regimes and infection control. This will help to keep people who live in the home safe from contracting infections.

9 30 It is recommended that further dementia care training be included in the Training Programme in order that staff at all levels may respond appropriately to people who have dementia care needs.

10 33 It is recommended that Quality Auditing is reviewed in order to be able to identify and take action to improve the areas of weakness highlighted in this report. This will help to ensure that people have their needs met and are kept safe within the home.


Helpline:

Telephone: 03000 616161

Email: [email protected]

Web: www.cqc.org.uk

We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website.

Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified.

key inspection report - care quality commission · stoke-on-trent staffordshire st6 6jn the quality...

Documents