Key inspection report - Care Quality Commission · The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services

Key inspection report

Care homes for older people

Name: Saltshouse Haven Nursing And Residential Home

Address: 71 Saltshouse Road,

Kingston Upon Hull,

East Yorkshire,

HU8 9EH

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.

The quality rating for this care home is:

One star adequate service

Lead inspector: Date:

Bev Hill 2 4 0 7 2 0 0 9

This report is a review of the 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

Care Homes for Older People Page 2 of 37


We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by:

• Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice

• Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983

• Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services.

• Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money.

Reader Information

Document Purpose 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 dateof 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: Saltshouse Haven Nursing And Residential Home

Address: 71 Saltshouse Road, Kingston Upon Hull, East Yorkshire, HU8 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): Mrs Dianne Karen Parker

Type of registration: Care Home with Nursing

Number of places registered: 150

Conditions of registration

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

Under 65 Over 65

dementia 150 150

mental disorder, excluding learning disability or dementia

150 150

old age, not falling within any other category

150 150

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: 1 5 0 7 2 0 0 8

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 is based in six separate lodges; all connected by footpaths and covered walkways. The main lodge contains the laundry, kitchen, staff training, and administration and management functions.


The other five lodges are individually named and can accommodate up to thirty people in each.

Preston Lodge and Meaux Lodge provide residential care. Sutton Lodge has both nursing beds and intermediate care placements, with input from the Primary Care Trust health professionals. All thirty placements in Coniston Lodge are for 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 from £359.50 to £580 depending on the care required. People receiving nursing care will have an amount ranging between £106.30 and £146.30 deducted from the £580 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.


Summary

This 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 Individual needs & Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct and Management of the Home 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 15th July 2008. Due to the size of the home we completed site visits to the home with two inspectors on 9th July and 24th July 2009. There was a gap in between the two days due to an outbreak of diarrhoea and vomiting at the home, which was then closed for a period to all but essential visitors. The home is very large with one registered manager for the whole service, although there is a designated person in charge in each of the lodges. However, 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. Senior managers should consider the possibility of registering each lodge separately. 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, staff members, relatives and a social care professional. We spoke to a health professional on the phone. Information was also obtained from surveys received from residents (some of which had been completed by their relatives), staff members and health and social care professionals. Comments from the surveys and discussions have been used in the report. We looked at assessments of need made before people were admitted to the home, andthe 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 always ensured that peoples' needs were assessed prior to admission. This enabled staff to be sure the home could meet the persons' needs and gave them direction in how to care for them. Staff consistently kept the assessment under review. 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. Residents described staff as reliable, efficient and approachable, 'they look after us well', ‘I like all the staff’, ‘the girls are efficient and help when they can’, ‘staff are reliable and very good’, ‘everything is provided for me’, ‘they do well in caring for my father’ and ‘the majority of staff are kind and caring and make mum feel at home and normal’. A relative stated in a survey, ‘it is a lovely second home for people. It has become an extended family quickly for the resident and their family. Nothing is too much trouble. I would never have got through this awful time without the love, kindness and 200 percent care of the staff’. Generally the home provided a good range of activities for people, although an activity co-ordinator shortage on one of the lodges had affected some provision. Saltshouse Haven provides a pleasant environment for people. Each lodge is clean, warm, well presented and has plenty of communal space. The company ensures a process of continual redecoration and refurbishment of the home. The manager responds quickly to complaints and investigates them well. She always tells the 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. Staff members say they receive the training required for them to complete their jobs. The manager is very well organised and knowledgeable. Although there are some issues with particular lodges the manager works quickly to try to address shortfalls when they become apparent. In between the two days of site visits to the home the manager had already produced an action plan, and started to implement it, to address some of the issues we highlighted on the first day. The home manages peoples' finances well.

What has improved since the last inspection?

General care plans have become more detailed and personalised to ensure staff have full information about residents' needs and how to meet them. Care plans for people accessing intermediate care services have been produced so staff have a better picture of how they need to support people during their rehabilitation. Monitoring charts for food and fluid intake have improved but there are still recording shortfalls when staff complete pressure relief.


Care staff are now receiving formal one to one supervision, although the amount of supervision per year for each care staff needs to increase. Staff members are more aware of what constitutes abuse of vulnerable adults and have received training in how to safeguard people. Care staff are no longer routinely employed following the return of a povafirst check butprior to the return of a full criminal record bureau check. In the exceptional circumstances when this does occur, the staff member is paired with another until the full check is returned.

What they could do better:

Staff need to read and use the care plans fully to ensure guidance in them from senior staff and health professionals is followed. This will ensure care is not missed. One resident also needs to have a behaviour management plan in place so staff can follow it consistently and help to manage the behaviour safely. Lessons must be learnt from care issues highlighted in complaints and safeguarding of adults investigations and ensure the same issues are not repeated. A checking system also needs to be put in place to ensure that personal grooming tasks have been completed so that residents are well presented in line with their wishes. Staff must respond promptly to requests to use the toilet so that people's dignity is not compromised. The nursing lodges must be adequately staffed with nurses to ensure they have the time to complete nursing tasks and supervise the care provided. An activity coordinator should be recruited quickly for Bilton lodge. One relative has noticed that the reduced social stimulation has had an impact on their loved one. Recording of care must be improved so staff write down when they complete pressure relieving tasks, when they bathe someone or when they are monitoring specific health needs. It is difficult to evidence care has taken place if staff do not record it properly. The way the home manages medication must be improved so that it is ordered more efficiently, stored at the correct temperature, administered at the right time as per procedures, and recorded properly in line with pharmaceutical guidance. The home could listen more to the views of residents about the meals provided and in light of comments in the report each unit manager should speak to residents and their relatives to try to establish where the shortfalls arise and address them. This will mean that resident’s views will be listened to and actioned. Care staff should receive a minimum of six supervision sessions per year. The environment for people receiving intermediate care services could be improved to ensure people have dedicated space and therapy rooms to aid their rehabilitation. The water temperature for bathing and washing should be as near to 43 degrees as possible. It was noted to be several degrees lower than this which could be cool for some people. This will ensure an ambient water temperature for people.


The way the quality of the service is monitored and managed could be improved so that the shortfalls we picked up during the visits will be picked up routinely by staff and managers.

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.

http://www.cqc.org.uk/


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

These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them:

People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need.

People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home.

People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money.


Judgement:

People using the 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 are only admitted into the home following a comprehensive assessment of their needs, which is constantly kept under review. This means the home has full information about people to enable them to decide if they can meet their needs. People admitted for intermediate care are supported to regain their independence but staffing issues have impacted on aspects of their care and they do not have designated space to assist in the process of rehabilitation.

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 ensured that people had their needs assessed prior to admission. Initial assessments were completed by the manager or other senior staff and the home always obtained assessments completed by Care Management Teams for people funded by the local authority. The information gathered in assessments was used when formulating care plans. The assessments were kept under review and updated when significant changes occurred. One health and social care professional stated, 'I think the pre-assessment before placement works very well in ensuring that the correct placement is identified. Good communication with all levels of staff I find' and 'we feel they work in partnership with us and will promote the residents' best interests appropriately'.


People admitted for nursing care 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' care. The home provides intermediate care services on Sutton Lodge. The service is time limited and focuses on rehabilitation with input from health and social care professionals. It is used to prevent people being admitted to hospital and to facilitate early discharge from hospital. The service is funded by health and social services. People admitted for intermediate care have their needs assessed by health professionals prior to admission and they also produce a plan of care. Health professionals such as doctors, nurses, occupational therapists, physiotherapists and dieticians provide expertise but care staff members within the unit provide the day to day care. As the care plans produced by health professionals have a limited focus on health needs, since the last inspection full care plans have been produced by the home. This ensures that nurses and care staff providing the day to day care have clear guidance on how to meet peoples' needs. There continues to be no designated area within Sutton Lodge for intermediate care services, which means that for the permanent residents there is a constant turnover of people in and out of their home. Communal areas, such as lounges, dining areas and bathrooms are shared with permanent residents. There is no rehabilitation kitchen or therapies room for people admitted for intermediate care to be assessed for, or to practice, their independent living skills throughout their stay in preparation for a return to their home. Since the last inspection there had been an increase in the number of beds used for intermediate care from fifteen to eighteen. Fifteen of the bedrooms are located at one side of the 'H' shaped building and three at the other side, which encroached into permanent residents bedroom areas. It was noted by the inspector that people admitted for intermediate care tended to stay in their bedrooms. This coupled with the reducing number of permanent residents meant that people could be isolated in the home with fewer people to talk to. People's experience of intermediate care services was generally good but staffing levels have impacted on aspects of their care. Two people on the lodge told us they had to wait too long for staff to support them to use the toilet and this resulted in, 'accidents'. One person stated they know now to ring, 'well in advance'. This is an example of the person adapting to the service rather than the service meeting their needs. This in unacceptable and must be addressed. One visiting health professional comm. ented, 'the staff are caring and hard working on Sutton Lodge but they are understaffed'. Staff confirmed this stating there was not enough time to spend with residents and they told us the nurse on duty can be busy admitting people for intermediate care for most of their shift, 'only one nurse means a very busy shift'. We were told that although carers were very good and were positive about their work, the nurses were unable to supervise properly. They felt that staffing numbers were affecting the standard of work and, 'pressures of the unit means that things can be missed'. Nurses found it difficult to take their breaks. We observed the telephone ringing constantly, which meant the nurse on duty was interrupted in their tasks, including administering medication, often for minor issues that could have waited.


Staff told us there should be two nurses and four carers in the morning, one or two nurses and three carers in the afternoon and one nurse and two carers at night. We looked at staff rotas for two weeks prior to the first day of the site visit, the 9th July, to see how many nurses had actually been on shift and then checked the next two weeks to see what was planned. We found only one nurse had been on shift all day for five of the days during the first two weeks and one nurse was planned all day for four days in the two weeks up to 23rd July. The rest of the days had two nurses in the morning and one nurse in the afternoon. Due to an outbreak of diarrhoea and vomiting our planned second day site visit had to be postponed until the home was cleared for visitors. During this time the manager put in place a system to ensure administration staff in the main lodge took all phone calls between 9-10am, other than urgent ones, and the nurse would collect the calls and return them after 10am. This simple solution meant nursing and care staff could concentrate on completing tasks with residents without interruption.


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 takeaccount of their spiritual and cultural wishes.


Judgement:


People experienced differing levels of care throughout the home. Care staff did not consistently follow care plans and some instructions from health professionals. Peoples' dignity was not consistently maintained and medication practices fluctuated. These issues could affect the safety and well being of residents.

Evidence:

We looked at eight care files in detail and three behaviour management plans during the site visits. The home used 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. The care plans contained information about the needs identified at the assessment stage and gave guidance to staff in how to meet them. They identified preferences, likes and dislikes and referred to maintaining privacy and independence. One health professional spoken with told us that the home had, 'a good Quest system of care planning' and 'care plans had much improved with information easier to access'. They also stated the staff were supportive of a particular relative and perceptive of their needs. Care plans were evaluated monthly and signed by the resident or their representative when possible. However we noted that not all care plans were updated after the evaluation even when needs had changed. For example one care plan stated the person was administered their medication orally but, swallowing difficulties had necessitated


the insertion of a tube into the persons stomach and they received all their nutrition and medication through this means to prevent choking. There was a discrepancy in another persons' care plan which stated they were unable to manage their own inhaler but the medication administration record stated the person was self-medicating with it. Several of the care plans identified particular needs but staff were not following them in practice. For example there were instructions from health professionals for staff to happly hip protectors to two residents as a precaution against injury should they fall butthese had not been applied. Similarly one of the residents was assessed as needing a convene sheath to assist with their continence needs but this was not insitu. The same person had a very high risk of developing pressure sores but they were not sitting on a specialised cushion. One persons' care plan stated they must be weighed weekly but indicated they were actually weighed monthly. Another stated the person had to complete exercises but there was no evidence these were being done. Generally the care plans contained the right information but the staff were not following them. Staff members spoken with told us they were busy and had very little time to read the care plans. They had handovers at the exchange of shifts but reliance on only verbal means of gaining knowledge about residents without backing this up by reading care plans has meant that care has been missed. Staff record in care files basic information about the days tasks. Some improvement is required in this area to ensure all the care provided is documented. For example it was noted in one care file that the person had sore areas and that cream had been applied and that their eyes had also been weeping. There was no follow on during the next few days to report on the conditions and whether there had been improvements. There wassome recording discrepancy as to why a persons' catheter was not replaced and staff had stopped recording the wound care they were completing when the page was filled up. We were assured the wound care did continue and there was evidence the sore was healing. Food and fluid intake charts were completed but monitoring charts for people requiring pressure relief were not consistently completed. For example one person had a severe sacral sore and their care plan stated they required two hourly pressure relief. The monitoring chart recorded a turn at 23.50 on 7th July and the next recorded turn was 06.10am on the 8th July. Another persons' pressure relief chart recorded the care at 07.30am, 08.20am and 22.30pm on the 8th July and 02.30am, 07.00am and 11.30am for the 9th July. Again the care plan states two hourly pressure relief. We were assured that these were recording rather than a care deficits. Staff need to evidence that care plans are being followed and care is provided. Risk assessments were completed and there was evidence that residents had access to a range of health professionals for advice, guidance and treatment. 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. The risk assessment for selfmedication was very basic and needs to be a full analysis of whether the person knows what their medication is for, how often and when they need to take it, and that they are able to keep it safe and secure. The behaviour management plans generally gave staff guidance, although some tasks were rather vague. For example, 'give reassurance'. It would be helpful to staff to know


what type of reassurance or distraction works well to calm the particular person. Also staff had been monitoring the behaviour of one resident for some time and the information now needs to be collated into a comprehensive behaviour management plan that details the types of behaviour and what works well to manage it, what approaches staff have to use and scripts for them when dealing with difficult situations. One resident had been confused and experiencing increasing bouts of agitation. She was moved to another lodge and the staff team had worked very well in supporting her and providing her with a calm environment and she was now much more settled. People had a different experience of care throughout the home and we were not confident that peoples' dignity was maintained across the whole home. For example twopeople on one of the lodges told us they had to wait a very long time to use the toilet and this had led to them having, 'accidents'. We observed a person on another lodge sitting at the breakfast table in a disheveled and unclean state with dried tea stains on his clothes, food around his mouth and hair un-brushed at the back. Yet other people were smartly dressed and one inspector noted, 'one person we spoke with had a well kept appearance with his hair and beard combed'. In discussions and surveys people said, 'the care is very good', 'I am happy with the care and attention', 'the personal care is good', 'on the whole its a good standard', 'need more toilet checks in the afternoon as we've found mum soaking wet', 'the staff need training courses in caring' and 'everything is provided for me'. We received twelve surveys from residents and nine stated they received the care and support they required, 'always', two people said this was, 'usually' and one, 'sometimes'. Again medication practices varied across the home. There were no issues noted in the two nursing lodges other than late administration of some medication due to staff constraints. However, there were issues around storing, administration, recording and stock control across the other three lodges. The home received requirements for medication at the last inspection in July 2008. Some of these are repeat requirements and action must be taken to address them. Areas that require improvement are: - Two signatures and full instructions are required when handwriting onto the medication administration record (MAR). This is to ensure mistakes are not made. When medication is omitted codes should be used consistently to indicate why. One person had missed five doses of their medication with no reason why. Medication must be given at the times prescribed. One person told us they had to wait until midnight for their medication. People must not be allowed to run out of medication. One person missed ten days of important medication and another had run out of their laxative. Staff must be more proactive in contacting the GP when people are not taking their medication for any reason. One person missed the last dose of the day most days, as they were usually asleep. The GP may be able to alter the time but needs to know the full dose is not being administered. Medication must be consistently signed into the home and amounts carried forward from one MAR to the next for medication not dispensed in a cassette.


When medication is completed it must be returned to the pharmacy to avoid mistakes. One person had cream in the trolley but this was not recorded on the MAR and staff were unsure if it was still being used. Staff must follow policies and procedures when administering medication and sign the MAR when they witness the medication has been taken. We observed staff leave tablets in a pot in a person's bedroom for them to take later. The medication storeroom temperature on one of the lodges was consistently between 25-30 degrees centigrade. Medication must be stored in accordance with manufacturer’s instructions and must not be stored above 25 degrees. The medication trolley must not be left unattended. We observed a staff member leave the trolley and although it was locked there were boxes of medication and eye drops on top of the trolley.


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:


Generally people received social stimulation in line with their wishes and needs. However, due to a staffing issue on one of the lodges, residents with more complex needs associated with dementia did not have their needs fully met. This could lead to boredom and a further deterioration in cognitive abilities. The provision of meals for a section of the home has not met with residents' expectations. This could affect their well being, and in some cases their health, and needs to be addressed.

Evidence:

There were activity coordinators on four of the five lodges. The coordinator on Bilton lodge had left and had not been replaced yet. There was evidence of a range of activities on each lodge, some of which were small group sessions and others were one to one support. For example in June on Preston lodge, people had participated in gardening, bingo, quizzes, skittles, one to one games and chats, craft work, a wine and music session, chair exercises, reminiscence, feeding the birds, visiting entertainers andwalks around the grounds. There had been trips out for some people to local shops, East Park, the Deep and one person enjoyed a pub lunch. The activity coordinator was observed to visit each resident in turn and chat to them and later set up a game of dominoes with one resident. A newsletter kept people informed and each lodge had a notice board of planned activities.


We observed an activity on Bilton lodge during the second day of our inspection. Residents on Bilton lodge have varying degrees of dementia care needs and some people require a lot of support. People participating certainly enjoyed the lively music and staff supported some to dance and encouraged the sing along. People were observed tapping their feet and hands and clapped when it had finished. We checked the activity records for June and July and found that the activities recorded were limitedand repetitive. They did not fully meet the needs of people with dementia. Staff told us that lots of other types of stimulation went on but was not written down. The lodge had acquired two rabbits called Rosie and Henry and the residents enjoyed watching them and at times stroking them. Each bedroom door had memorabilia inside a case with which the occupant could recognise and identify with. This was very effective as, during the visit, one resident was prompted to tell us about their youth and badminton playing days. One relative did comment that the loss of an activity coordinator on Biltonlodge had been felt, 'staff don't have time to do them like the previous activity coordinator did - you can see a real difference in mum when she is stimulated with suchactivities'. Other comments from relatives stated the home needed a minibus as, 'transport was difficult' and 'they could do with more days out'. An, 'at a glance' monthly record would establish who participates and who does not. This might enable staff to establish shortfalls and tailor activities more in keeping with peoples' dementia care needs. Those staff members spoken with were aware of peoples' needs and how to ensure that people were able to make choices about their lives. In surveys staff told us they treated people as individuals and constantly tried to find ways to improve the service. People were encouraged to personalise their bedrooms, manage their own finances and some residents also managed 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 and most spoken with stated they were kept well informed. One relative did state in a survey that communication between the staff and the relative could be improved. There was a mixed response to the meals provided. Some people were happy with the meals, 'in general the food is quite good', 'good food', 'they do the food well', 'the food is lovely - we have a choice of menu' and 'the food is quite good'. However, other people commented, 'its uneatable, cold and unappetising', 'sometimes its not appropriate for example pork chop', 'I'm not happy there is toomuch veg', 'its mostly the women that complain about the food' and 'the meals he receivesare not very good at all'. We received twelve surveys from residents and four people stated they liked the meals, 'always', four said, 'usually', and two each said, 'sometimes' and 'never'. Clearly the home is not getting it right for a section of the residents and, as mealtimes can be the highlight of some peoples' day, this does need to be addressed.


One staff member said in a survey, 'residents complain about the food but the kitchen staff do their best'. 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. There were choices at each meal and referrals to dieticians made as required.

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.

Peoples’ legal rights are protected, including being able to vote in elections.


Judgement:


Complaints are logged and audited and people feel able to complain. However, in the last year recurring themes related to care practices and staff philosophy have led to safeguarding of adults referrals. This has meant that the wellbeing of some residents has not been protected as robustly as it should be.

Evidence:

The home had a complaints policy and procedure that was displayed in the main reception and in each of the lodges. We saw complaints forms at the entrance to each lodge, although some staff members spoken with were unaware that this is where they were located. Documentation evidenced that complaints were recorded and every effort made to try and resolve them. Investigation reports completed by the manager were detailed. However, to improve, the complaints form should detail whether the complainant was satisfied with the outcome of any investigation. Staff told us they tried to deal with niggles quickly and that management dealt with more formal complaints. The homes annual quality assurance document (AQAA) stated that the home had received eighteen formal complaints in the last year, fourteen of which had been upheld. In surveys eight residents stated they knew how to make a formal complaint, whilst four were not sure, and nine people said they knew whom to speak to informally if they were unhappy about something. Residents spoken with named particular people they


would complaint to if needed and one relative spoken with stated, 'we don't often have complaints but if we do we go to the unit manager or carers'. All thirteen staff surveys stated they knew what to do, and how to record it if someone complained to them about the service. Although complaints about care issues had been investigated and addressed some of the problems reoccurred, which indicated resolution was only partial or time-limited. The local authority had received some complaints about care issues, which were escalated to safeguarding of adults referrals. We spoke to the local authority investigating officer, who was present during the second day of the site visit. They advised that there had been several complaints received in December 2008 and January 2009 that had recurring themes of insufficient personal care to people and a good caring philosophy that was not adhered to by all care staff. They had completed seven investigations and was progressing with a further six. However they had noticed an improvement over the last few months and stated that the manager was addressing the issues. The manager confirmed that recruitment of new staff over this time frame had impacted on care practice and in response she had initiated a redistribution of experienced staff throughout the lodges. All staff had received training in how to safeguard vulnerable adults from abuse. In discussions they were clear about what constituted abuse and what to do should they witness any abuse or poor practice. The manager had completed a, 'train the trainer' course so was able to facilitate the training to the staff team. She was very clear about her referral and investigation role and had demonstrated this by sending appropriate alerts through to the local authority. The homes AQAA also stated the manager had made twenty-eight safeguarding referrals in the last year. These related to a range of issues such as care of residents, incidents between residents, concerns about staff and visitors and inappropriate hospital discharges, for example people discharged with pressure sores or no information for the home about wound care plans. The outcome of investigations led to retraining and supervision for some staff members, dismissal of three staff and the forwarding of their names for possible inclusion in the protection of vulnerable adults register, updating of care plans for some residents and discussions with relatives. A minor injury to one resident during a fire evacuation drill has led to a change of fire training practice.


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 the 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 were provided with a comfortable, clean and homely environment with opportunities to personalise their own bedrooms. The temperature of water for bathing could be considered cool for some people and thermostats should be adjusted accordingly.

Evidence:

There has been no change to the environment since the last inspection other than progression with the homes' redecoration and refurbishment plans. The home comprises of six separate lodges. The main lodge contains the central facilities of laundry, kitchen, staff training, administration and management functions. The remaining five lodges offer accommodation for up to thirty people in each. Preston Lodge and Meaux Lodge provide residential care. Sutton Lodge has fifteen nursing and fifteen intermediate care placements, although there were eighteen people receiving intermediate care on the day of the visit. All thirty placements in Coniston Lodge are fornursing care and Bilton Lodge provides support for people with dementia care needs. 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 is nicely decorated and well equipped throughout. Well-maintained, landscaped grounds surround each lodge and there is ample car parking facilities. We visited each of the lodges and apart from one large foot cushion in Sutton Lodge that required cleaning, all areas were clean and fresh. One relative did comment in a survey, 'they could do with air fresheners'. However, we did not note any unpleasant


odours during the two days and domestic staff must work very hard to ensure standards are maintained. Apart from a lack of designated intermediate care facilities on Sutton Lodge, the home was suitable to meet the needs of the people using the service. The recommendation made in the last three key inspection reports June 2006, July 2007 and July 2008, 'where intermediate care is provided, dedicated space should be made available for this service group', will remain in this report under standard 6. On Preston Lodge it was noted that the water temperature used for bathing and washing was recorded at 36 degrees centigrade. This could be considered cool for some people as the ambient temperature for bathing and washing should be at approximately43 degrees unless choice dictates a higher or lower temperature. This needs to be checked out with people and the thermostats adjusted. People spoken with were happy with the home in general and with their bedrooms. We received twelve surveys from residents and eleven stated the home was fresh and cleaneither, 'always or usually'. One person said this was, 'sometimes'. One person said, 'there is a tremendous effort to create a lovely garden, which is a calm and peaceful environment'. However, a relative commented that access to the lodge they visited was difficult with a wheelchair, due to having to negotiate to the two-door system and key pad. This was mentioned to the manager. 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 their own fridges and had installed telephones. 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. People were satisfied with the laundry service provided by 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 using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The experiences of some residents regarding, staff availability differs on some of the lodges and has affected their well being. Staff members are recruited appropriately, complete a good induction and have access to a solid training programme.

Evidence:

The experiences of people in the home regarding staff availability differed depending on which lodge they were on and even within some of the lodges. On the lodges providing intermediate care and nursing care there were staffing issues that had affected daily routines and care practices, such as medication and taking people to the toilet. Two residents told us they had to wait a long time to use the toilet and this had compromised their dignity. Staff told us that when other lodges were short-staffed they had to provide cover and this left them short, with less time for people. The lodge providing intermediate care often only had one nurse on duty and their time was taken up with intermediate care tasks and left little time to supervise the general day to day nursing home section of the lodge. The care staff stated they found it hard to meet careneeds due to the staffing levels and things easily get missed. One person receiving intermediate care told us that staff were lovely and the care was very good and a resident praised staff stating they were, 'very happy' with the service. There were generally four care staff, sometimes five, and a manager on duty during theday in the residential lodges and two in each lodge at night. The nursing lodges had care staff and a nurse on duty at night. Each lodge had an activity coordinator, apart from Bilton Lodge. The activity coordinator had left and to date had not been replaced. There were ample catering, domestic, administration and maintenance staff.


In surveys from residents, seven stated staff were available, 'always' and five said this was, 'usually'. Seven also stated that staff listened to them and acted on what they said, 'always', four said this was, 'usually' and, one person said, 'sometimes'. There were positive comments about the staff team from residents, relatives and visiting professionals. Comments were, 'I like all the staff', 'the girls are efficient and help when they can', 'staff are reliable and very good', 'everything is provided for me', 'they do well in caring for my father', 'they look after you well', 'the majority of staff are kind and caring and make mum feel at home and normal', 'they are good to us', 'mum is generally happy here and therefore we are happy', 'the staff are caring and hard working, although understaffed' and 'the staff are approachable and welcoming - they make it feel like mums' home'. One relative told us in a survey that the garden was lovely and the staff, 'did this in their own time and is an example of their caring attitude - they should be commended for this'. Another stated in a survey, 'it is a lovely second home for people. It has become an extended family quickly for the resident and their family. Nothing is too much trouble. I would never have got through this awful time without the love, kindness and 200 percent care of the staff'. In discussions staff told us that some days were busier than others but they always had good handovers of information. They also said it was a nice place to work, although could be a challenge at times. Staff members came across as motivated, enthusiastic about their jobs and keen to improve the quality rating of the home. One said, 'I am proud to be a member of this team'. In discussions staff were aware of residents needs but they did not always evidence that these were met, as discussed in the health and personal care section of the report. In one of the lodges they also told us it was difficult to find the time to read care plans. 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. She is new in post and has begun a process of auditing the nurses training files to get them up to date and ensure certificates are in place. New staff members complete a comprehensiveinduction and foundation training programme when they first start at the home and they complete several shifts as supernumerary staff. There was 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. There were also courses specifically for nurses to ensure they completed their registration requirements. 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 registered manager was able to facilitate training in safeguarding adults from abuseand unit managers had completed various, 'train the trainer' courses in order to cascade training to staff in areas such as moving and handling and infection control. One unit manager is also connected with the falls team project and attends meetings to bring information back to share with the staff team. The home can access training courses facilitated by the local authority and seven nurses completed training in how to manage syringe drivers for pain control in palliativecare. The clinical services manager told us that forty-six 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 51 percent of care staff trained to this level and has exceeded the standard. This demonstrated the homes’ commitment to supporting staff to gain a qualification in care. Recruitment practices had improved and all checks were carried out prior to the start of employment. In the exceptional circumstances when a staff member may be required to start after the return of the povafirst check, but prior to the return of the full criminalrecord bureau check, the staff member is paired with an experienced care worker.


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 bestinterests. 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 supervisedand supported by their managers.


Judgement:

People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management of the very large home continues to be generally satisfactory overall but there are still continuing shortfalls in documentation, monitoring care practices, and in the amount of supervision staff receive. This could mean residents welfare and safety could be compromised.

Evidence:

The manager is a Registered General Nurse with twenty-plus years experience in the health care sector and she has managed the home for approximately fourteen months. she has completed registration with the Commission, gained a diploma in management in 2005 and also has a health and safety management qualification. She has completed a, 'train the trainer' course in safeguarding adults from abuse and cascades this trainingto staff within the home. Information provided by the manager showed that she regularly updated her skills and knowledge through attending relevant training. She continues to be very organised, has a clear sense of direction for the home and is very resident-focused. The regional manager, as the 'responsible individual' visits on a monthly basis and the manager has avenues of support she could use when required. We found the manager very responsive to suggestions regarding improvements and other visiting professionals clearly agreed, 'the manager is knowledgeable and approachable' and 'I get a positive response when I visit to investigate and feel the manager is addressing problems


slowly. I'm working with Dianne and beginning to see improvements'. The home is very large with one registered manager for the whole service, although there is a designated person in charge in each of the units. However, 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. Senior managers should consider the possibility of registering each lodge separately. Staff spoken with and surveys received from them indicated the manager was firm but fair, 'we are very well supported', 'she will sort out problems for you', and 'she will let you run with something but will support when required'. Disciplinary records and staff meeting minutes showed that the manager was tough on poor practice and initiated re-training when required. 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 but in light of some of the documentation issues highlighted during the site visit, for example monitoring charts, care plan updates, medication and staff supervision, it is clear senior staff on the units may be missing things during their audits or not implementing plans to address shortfalls. At the last inspection one staff member stated that problems were resolved for a short while but often reoccurred and required more consistent follow up to ensure they were resolved permanently. There have been recurring care issues during the last year so this comment may still be relevant and unit managers must be more proactive in identifying problems and resolving them. The manager advised that a, 'diagnostic review' has been implemented to look at each national minimum standard in turn, identify shortfalls and develop action plans to address them. This thorough self-regulation will enhance the quality assurance system and help staff and management to identify shortfalls and address them. Ten surveys for each lodge are sent out each month regarding a different topic, for example activities, housekeeping, privacy and dignity and meals. Surveys are also issued to staff and people accessing the intermediate care services. Surveys are planned, but not implemented yet, for visiting professionals. The manager has initiated a, 'surgery' one Saturday each month in order to speak with relatives that only visit at weekends. There are also plans to visit the lodges and complete observations of practice. Meetings for staff and residents 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 computerized system. Money left for safekeeping for any resident was maintained in one specific account. Each person 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 minimumof six formal one to one sessions each year. 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 regarding fire, moving and handling, bed rails and activities of daily living. 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 system for checking staff responses to fire emergencies at night has been reviewed and a better system put in its place. The home notified the appropriate agencies of incidents that affected the health and welfare of people living in the home. It was noted that some of the bathrooms were used to store items such as wheelchairs, hoists and other equipment making them look cluttered and potentially restricting pathways. There was also an easy chair blocking access to two fire extinguishers on Preston Lodge. One of the bedrooms required a full statutory warning notice on the door, as oxygen therapy took place inside. Some store rooms were unlocked on some of the lodges and bed rail protectors were missing from one bedroom on Sutton Lodge. One staff member was observed pushing a resident in a wheelchair with no footplates insitu and had to be reminded by the inspector to use them. There needs to be a checking system in place for the suction machines on the lodges providing nursing care and it was noted that two people were sharing a lancet devise for blood monitoring. This is not safe practice and was addressed on the day. All these points were mentioned to the manager during the feedback discussion.


Are there any outstanding requirements from the last inspection?

Yes No

Outstanding statutory requirements

These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards.

No. Standard Regulation Requirement Timescale for action

1 13(2) The registered person must ensure that the home does not run out of prescribed items and when transcribing medication onto the MAR two signatures are recorded. This will ensure a checking system is in place and serviceusers receive the medication as instructed by their GP. Previous timescale of 22/08/2009 not met.

31/10/2009

2 13(2) The registered person must ensure that medication is administered to people as per their prescriptions. This will ensure the health, safety and wellbeing of people is protected. Previous timescale of 22/08/2009 not met.

31/10/2009


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.


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.


1 7 12 Care staff must follow instructions in plans of care that are written to meet peoples' assessed needs. This will ensure that people are protected and their wellbeing promoted and also ensure that care is not missed.

13/11/2009

2 7 17 Accurate recording must be completed when pressure relieving tasks are completed. This will help to audit care and ensure it is not missed.

13/11/2009

3 8 13 A behaviour management plan must be produced for a specific resident now that information has been gathered during the last few months. This will ensure staff have full guidance in the type of behaviours the person has and the most effective and safe ways of managing them and supporting her.

13/11/2009


4 8 13 Advice and equipment provided by health professionals must be followed and used. This refers to the use of convenes, hip protectors, pressure relieving aids and completion of exercises. When the tasks are completed it must be recorded. This will help to protect people from injury, promote pressure relief and maintain their wellbeing.

13/11/2009

5 9 13 Adequate arrangements must be put in place for the correct storage and handling of medicines and for the timely and accurate recording of all medicines received and administered. This will help to ensure that medicines are always available when needed so that they can be given correctly in order to protect peoples' health and wellbeing.

13/11/2009

6 10 12 People must be taken to the toilet in a timely manner when requested. Having to wait for lengthy periods with obvious consequences will compromise a persons' dignity.

13/11/2009

7 18 12 The lessons learned from investigations into complaints and safeguarding of adults referrals should be implemented and monitored via quality assurance processes, documentation, staff supervision and training, and observations of

13/11/2009


practice. This will help to ensure poor practice continues to decrease and the wellbeing of residents continues to increase.

8 27 18 There must be sufficient numbers of nurses working the day time shifts in the lodges providing nursing care. This will enable the nurses to carry out their duties effectively and safely.

13/11/2009

Recommendations

These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.

No. Refer to Standard Good Practice Recommendations

1 6 Where intermediate care is provided, dedicated space should be made available for this service group.

2 7 There should be time available, and the opportunity, for care plans to be read rather than just relying on a verbal exchange of information between care staff. This will help toensure they have full knowledge about the people they are supporting.

3 9 The medicine trolley should not be left unattended with medicines openly available to people. This will help to prevent the loss or diversion of essential medicines.

4 9 The GP should be contacted regarding the administration of one persons' medicines as they are usually asleep and miss the last dose each day. This will ensure the GP is aware and has the opportunity to alter the time or dose as required.

5 9 Handwritten entries to MAR charts should be accurately recorded and detailed and signed by two staff members. This makes sure that the correct information is recorded so a person receives their medication as prescribed.

6 9 All medicines received into the home and medication carriedover from the previous month should be recorded. This helps to confirm that medication is being given as rescribedand when checking stock levels.

7 9 Action should be taken to ensure the temperature of the medication storage areas does not exceed that recommended by the manufacturers.


8 10 A system should be in place to check that people are well groomed and dressed in clean clothes. This will help promote general well being and self-esteem.

9 12 An activity coordinator should be recruited quickly for Bilton lodge to ensure stimulation can be improved and support staff in developing the programme currently on offer.

10 12 There should be an 'at a glance' monthly record maintained on Bilton Lodge to establish who participates in activities and who does not. This might enable them to establish shortfalls and tailor activities more in keeping with peoples' dementia care needs.

11 15 In light of comments about some aspects of meal provision, residents and their relatives should be consulted again to try to establish where the shortfalls arise. Catering staff should be informed and action taken to try to resolve the issues. This will mean that residents’ views will be listened to and actioned.

12 16 The residents should be reminded of the complaints procedure and who to see informally, should they have any issues. This will remind residents of the importance of letting staff know quickly if they have any concerns so they can be dealt with.

13 16 The complaints form should detail whether the complainant was satisfied with the outcome of any investigation. This would improve the auditing system and evidence the complaint process had been successful in resolving issues.

14 25 The water temperature for bathing and washing should be as near to 43 degrees as possible. This will ensure an ambient water temperature for people.

15 27 In light of comments made by people receiving nursing care, and by staff members, action should be taken to address the conditions that impact on the completion of the nurses work.

16 33 The plan to send out surveys to visiting professionals shouldbe implemented to enable a fuller view of how the service is managed.

17 33 In light of the shortfalls identified in recording, medication and some care practices, a more robust quality monitoring system should be operated on each of the units. This will help to ensure that care is not missed.

18 36 Care staff should receive a minimum of six, formal supervision sessions per year. It is also recommended that observations of staff practice take place to complement the supervision process. This will ensure staff have the opportunity to speak to their line manager on a regular basis and enable the supervisor to witness at first hand how staff support people.

19 38 More robust environmental checks should be carried out to ensure each unit remains a safe place for residents.


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Key inspection report - Care Quality Commission · The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services

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