Review of compliance - cqc.org.uk · Page 1 of 21 Review of compliance Adiemus Care Limited...

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Review ofcompliance

Adiemus Care LimitedStrathmore House

Region: East

Location address: Friday Bridge RoadElmWisbechCambridgeshirePE14 0AU

Type of service: Care home service with nursing

Date of Publication: November 2012

Overview of the service: Strathmore House is a care home with nursing which provides a service to a maximum of 46 older people and older people with dementia.

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Our current overall judgement

Strathmore House was not meeting one or more essential standards. Action is needed.

The summary below describes why we carried out this review, what we found and any action required.

Why we carried out this review

We carried out this review as part of our routine schedule of planned reviews.

How we carried out this review

We reviewed all the information we hold about this provider, carried out a visit on 8 August2012, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

What people told us

People told us what it was like to live at this home and described how they were treated bystaff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by an Expert by Experience who has personal experience of using or caring for someone who uses this type of service, and a practising professional.

During our inspection of Strathmore House on 08 August 2012 we used a number of different methods to help us understand the experience of people living in the home. This was because some people were living with dementia, which meant that they were not able to tell us their experiences. For part of the inspection we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We spoke with a family member who told us, "I can't speak highly enough about everyone.Staff have been wonderful with [my relative], absolutely marvellous." Another family member told us that, "The dementia and personal care is getting better". A visiting professional said that the staff were, "Very caring" and that they contacted health professionals for advice appropriately. One person told us that they were, "Bored" and, "Lonely".

We observed staff providing care to people. In most instances staff provided care in an

for the essential standards of quality and safetySummary of our findings

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appropriate way but we did observe an example of poor moving and handling practice. Wealso observed some examples of staff not recognising the support that people needed which meant that their dignity was compromised. There were very few examples of people having access to meaningful activities, particularly those people living with dementia.

People told us they enjoyed their meals. One person said, "The food's lovely – no complaints at all." People's nutritional needs were met. Staff, including the kitchen staff, had a good understanding of people's individual needs and how these should be met. They also understood how to recognise signs that someone was at risk from poor nutrition or hydration. Staff were less skilled at providing care to people who were living with dementia. Our observations concluded that there were not enough staff with the right skillsto meet people's needs.

What we found about the standards we reviewed and how well Strathmore House was meeting them

Outcome 01: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run

The provider was not meeting this standard. We judged that this had a moderate impact on people. People's privacy, dignity and independence were not always respected.

Outcome 05: Food and drink should meet people's individual dietary needs

The provider was meeting this standard. People were protected from the risks of inadequate nutrition and dehydration.

Outcome 07: People should be protected from abuse and staff should respect their human rights

The provider was meeting this standard. People were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Outcome 13: There should be enough members of staff to keep people safe and meet their health and welfare needs

The provider was not meeting this standard. We judged that this had a minor impact on people using the service. There were not enough qualified, skilled and experienced staff tomeet people's needs.

Outcome 21: People's personal records, including medical records, should be accurate and kept safe and confidential

The provider was meeting this standard. People were protected from the risks of unsafe orinappropriate care and treatment because records were completed well. People's right to have their confidentiality respected and maintained was protected because records were stored securely.

Actions we have asked the service to take

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We have asked the provider to send us a report within 14 days of them receiving this report, setting out the action they will take. We will check to make sure that this action has been taken.

Where we have concerns we have a range of enforcement powers we can use to protect the safety and welfare of people who use this service. When we propose to take enforcement action, our decision is open to challenge by a registered person through a variety of internal and external appeal processes. We will publish a further report on any action we have taken.

Other information

Please see previous reports for more information about previous reviews.

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What we foundfor each essential standard of qualityand safety we reviewed

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The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate.

We will have reached one of the following judgements for each essential standard.

Compliant means that people who use services are experiencing the outcomes relating to the essential standard.

Where we judge that a provider is non-compliant with a standard, we make a judgement about whether the impact on people who use the service (or others) is minor, moderate or major:

A minor impact means that people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.

A moderate impact means that people who use the service experienced poor care that hada significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.

A major impact means that people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly.

Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary changes are made.

More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety

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Outcome 01:Respecting and involving people who use services

What the outcome saysThis is what people who use services should expect.

People who use services: * Understand the care, treatment and support choices available to them. * Can express their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support. * Have their privacy, dignity and independence respected. * Have their views and experiences taken into account in the way the service is provided and delivered.

What we found

Our judgement

The provider is non-compliant with Outcome 01: Respecting and involving people who use services. We have judged that this has a minor impact on people who use the service.

Our findings

What people who use the service experienced and told usDuring our inspection of Strathmore House on 8 August 2012 we heard staff speaking with people in a respectful and kind way, and using people's preferred names. We noted that staff knocked on bedroom doors prior to entering in order to preserve people's dignity. However, we observed occasions when people's dignity was not promoted. For example, we saw staff moving someone in their wheelchair without talking to the person or explaining what they were going to do. We also saw people's dignity compromised during the mealtime. One person was not assisted to eat their pudding and consequently spilled food on themselves and their clothes. Another persontried to eat their dinner with a knife after staff had not noticed that they had dropped their fork.

People told us that there was not much to do during the day. One person said, "No one asks me what I like to do, I am bored." Other people told us that there was a limited range of activities which included board games, scrabble and radio or television. We didnot see staff supporting people with meaningful activities during our inspection other than a game of scrabble taking place in the afternoon. Two staff were supporting two people, neither of whom seemed very interested, to play scrabble. Other people had nothing to do.

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One person was in bed and calling out loudly all the time. Staff told us they always did this. We spent time with this person, who did not use words to communicate, looking at photographs and books. They clearly benefitted from the attention and did not call out at all.

Other evidenceAre people's privacy and dignity respected?

During our inspection we noted that there were times when people's privacy and dignitywere respected. For example, we saw someone being assisted appropriately with regard to their personal care. However, we also saw several examples of people's dignity not being respected. We saw one person being assisted to move from a wheelchair. Staff used an inappropriate method of assisting them. The wheelchair brakes were not on and so it was difficult for the person to stand safely as the chair wasmoving.

We spent time observing people in the area of the home where people with dementia lived and noted that there were long periods of time when staff were engaged with tasks but did not interact or communicate with people at all. We also noted at mealtimesthat there were times when staff assisted people but did not speak with them. For example, we saw one member of staff assist someone to move to enable someone elseto get to the table. The member of staff continued a conversation with someone else without talking to the person they were moving.

There were aspects of the environment which did not promote people's dignity and privacy. There were no bathroom facilities in one area of the home and so people had to go to another area of the home to have a bath. People living with dementia had to gofrom the area of the home they lived in to the other part of the home for their meals. This was not as a result of people choosing to do this but to enable staff able to supporteveryone in one dining room. There were no objects placed around the home for people living with dementia to pick up and look at.

We spoke with the manager and she told us that all staff received training with regard torespecting people's privacy and dignity. This training was provided during their induction. We spoke with two members of staff and they both confirmed that they had received this training. One of these members of staff was able to tell us about the training and how this was put into practice.

We spoke with a visiting health professional who told us that the staff respected people's privacy and dignity and gave us examples of how this was done.

Are people involved in making decisions about their care?

Information recorded in the care records that we looked at indicated that people, and their families where appropriate, had been involved in decisions about their care. For example, we saw evidence that people had been involved in decisions about end of life care, including 'do not attempt resuscitation' (DNAR) decisions. There was evidence within the care plans of people's likes and dislikes with regard to meals, and also about their preferred name. We also saw one care plan which clearly recorded that the personwas unable to communicate verbally but was able to make some of their wishes known through their body language.

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There were very few activities available for people to choose to be engaged in.

The manager gave us a copy of the results of the most recent quality assurance questionnaire that had been sent to relatives (May 2012). Four out of the six people who responded said that they had been involved in discussions about their relatives care plan within the previous six months.

Our judgementThe provider was not meeting this standard. We judged that this had a moderate impacton people. People's privacy, dignity and independence were not always respected.

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Outcome 05:Meeting nutritional needs


People who use services: * Are supported to have adequate nutrition and hydration.

What we found

Our judgement

The provider is compliant with Outcome 05: Meeting nutritional needs

Our findings

What people who use the service experienced and told usWe spoke with people who lived at Strathmore House and they told us that they enjoyed their meals. Not everyone knew that there was a menu which offered a choice at mealtimes. One person told us that there were always choices at mealtimes whereasanother person said that they were not aware that there was a menu, or that they were able to make a choice about the meals.

The inspection team carried out some observations at breakfast time and lunch time. Some of the team joined people at their tables for lunch so that we could experience a mealtime. The tables were attractively set with serviettes, condiments and sauces. We noted that people were offered drinks at both mealtimes although they were not offered a refill once they had finished. The menu was written in small lettering and situated nearthe serving hatch and so the menu was not easily available for people living in the home.

We saw that there was a choice, including hot and cold options, at breakfast time. People were eating a range of different things for breakfast, including porridge, poached egg on toast or bacon sandwiches. The main meal of the day was provided at lunchtime and there was a choice of beef stew or omelette with salad. A relative told us that they felt that the options during the evening meal were very limited with sandwiches being provided most days.

It took a long time for people to come to the dining room and this meant that some people had been sitting at the table for at least half an hour before their food came. Oneperson waited 55 minutes. Staff were busy assisting people to the table. Staff did speak

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with some people during this time but the majority of people spent their time waiting with no interactions with staff. Once people's meals had arrived staff assisted those people who needed assistance. People who chose to eat their meal in their bedroom were given their main course and their hot dessert at the same time, so the dessert would have been cold by the time they ate it.

We noted that the skills of staff were variable when assisting people. Some staff were patient and took time to explain to people what they were eating as well as checking that they were enjoying their meal. However, we also noted that other staff were not so skilled at this. For example, one member of staff assisted someone with their meal without speaking with them at all. They then left the person alone and no-one assisted them with their pudding. As a consequence of this the person spilled food on themselves and onto their clothes. Another person dropped their fork and tried eating their dinner with their knife until a member of staff noticed and replaced their fork.

Other evidenceAre people given a choice of suitable food and drink to meet their nutritional needs?

The manager said that people living in the home were asked about their likes and dislikes with regard to meals. She said that people were always offered a choice of at least two options at mealtimes. The manager said that fresh produce, including meat, vegetables and fruit were used. This included vegetables from the home's garden. The chef liaised with the dietician with regard to people's individual dietary needs.

We looked at a selection of care records and these showed that nutritional assessments had been carried out for people when they moved to the home. These had been reviewed and updated as required. Food and fluid charts had been implemented for those people who needed them. The records included information about people's likes and dislikes. There was also information about the pureed diet that was required by one person and the care plans included advice that had been given by the dietician and speech and language therapist with regard to this.

The care staff and kitchen staff who spoke with us were aware of the signs to look out for that would indicate that someone was not receiving sufficient amounts of food or fluids. The care records included records of people's weights and there was evidence that action had been taken if it was identified that someone was at risk of poor nutrition or hydration. The kitchen staff were aware of people's likes and dislikes as well as any specific dietary needs, such as people with diabetes, or those that required a pureed diet.

Are people's religious or cultural backgrounds respected?

Staff we spoke with said that there was currently no-one living in the home for whom specific food was needed for cultural or religious reasons. However, the kitchen staff said that they would be told about anyone's specific dietary needs by the manager and that there would be no problem in providing alternative meals.

Are people supported to eat and drink sufficient amounts to meet their needs?

The care records that we looked at described the support that people required to eat

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and drink sufficient amounts. One person's care plan gave good details about the ways in which the person indicated that they did not want a meal through the use of body language and gestures. The records included clear guidance from the dietician and speech and language therapist about the ways in which people needed to be supported. For example, one care record stated the position that the person should be in when they had their meals and we observed that the person was positioned correctly for their meal.

We observed that most people were seated comfortably at the dining table but that one person was unable to fit their wheelchair under the table. This meant that they had to twist to eat their meal whilst sitting sideways on to the table. Staff did not offer this person a more comfortable way to eat, such as an over-chair table in front of them.

The breakfast time experience was calm as there were fewer people present at any onetime. However, the provider may find it useful to note that the lunchtime meal was quite chaotic. The time taken for staff to assist everyone into the dining room was unacceptably long. Also, the number of staff and people present in one dining room was not conducive to people being supported and encouraged to eat their meal in a calm, relaxed atmosphere. In addition to this, the support that people received from individual staff was not consistent. Some staff supported people well whilst other peopledid not have the same experience. For example, some staff did not speak with people while they were assisting them.

We noted that people were offered drinks throughout the day and the majority of peoplewere assisted with these. However, we also noted that for one person who spent the day in their room their water jug was out of their reach and remained there all day without anyone noticing and taking it nearer to them.

Our judgementThe provider was meeting this standard. People were protected from the risks of inadequate nutrition and dehydration.

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Outcome 07:Safeguarding people who use services from abuse


People who use services: * Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld.

What we found

Our judgement

The provider is compliant with Outcome 07: Safeguarding people who use services from abuse

Our findings

What people who use the service experienced and told usWe spoke with people living in the home and a relative. Not everyone was confident that their concerns would be dealt with appropriately or were aware of the complaints procedure. We spoke with a visiting health professional and they told us that they had no concerns about the home and that it was, "A good home, with very caring staff".

Other evidenceAre steps taken to prevent abuse?

Staff told us that they had received training about safeguarding vulnerable adults. They knew how to recognise signs of abuse and were aware of the procedure to follow if theyhad any concerns about abuse. Staff were also aware of the whistleblowing policy. The provider may find it useful to note that not all staff were aware that they could raise concerns about abuse directly with external agencies.

The manager told us that staff had all attended an update of safeguarding training on an annual basis. We saw the training record and this showed that all staff except one were up to date with this training. New members of staff received awareness of safeguarding training within their induction.

The care records that we saw included assessments of risks that had been identified foreach person. The risk assessments included guidance for staff about steps to take to reduce the risks for the person, or those around them.

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Do people know how to raise concerns?

The provider had a complaints procedure in place. We saw evidence of action that had been taken following concerns that were raised with the manager.

Are Deprivation of Liberty Safeguards used appropriately?

We spoke with the manager who had attended training about the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). She said that the staff would be provided with this training as not all staff had undertaken this. One of the senior carestaff who spoke with us had a good understanding of this issue. The manager said that there was currently no-one living in the home for whom a DoLS application was appropriate.

Our judgementThe provider was meeting this standard. People were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse andprevent abuse from happening.

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Outcome 13:Staffing


People who use services: * Are safe and their health and welfare needs are met by sufficient numbers of appropriate staff.

What we found

Our judgement

The provider is non-compliant with Outcome 13: Staffing. We have judged that this has a minor impact on people who use the service.

Our findings

What people who use the service experienced and told usWe spoke with a family member who told us that they could not speak highly enough about the staff who they said had been wonderful with their relative. They said, "There are some lovely staff here." Another family member told us that they felt the dementia and personal care was getting better. A visiting professional said that the staff were very caring and that they contacted health professionals for advice appropriately.

We observed staff providing care to people. In most instances staff provided care in an appropriate way but we did observe an example of poor moving and handling practice. We also observed some examples of staff not recognising the support that people needed, which resulted in their dignity being compromised.

Other evidenceAre there sufficient numbers of staff?

During our inspection on 08 August 2012 there were 22 people living in the home, including eight people with nursing needs. There was one nurse and four care staff on duty during the day. In addition to this there were catering and domestic staff on duty aswell as an activity co-ordinator. The manager was also on duty during the week. This meant that there were sufficient staff numbers. However, staff were very busy carrying out tasks and did not meet everyone's needs. They did not spend time with people and were very disorganised at lunchtime. There was a lack of any activity for people to engage in. At lunchtime some people waited a very long time for their meal, people in their rooms were given their main course and hot dessert at the same time and some

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people were not given the assistance they needed.

Do staff have the appropriate skills, knowledge and experience?

Staff told us that they had received training with regard to nutritional assessments, dignity and safeguarding vulnerable adults. In discussions with staff they had a good understanding of the issues associated with nutrition and the importance of monitoring people's food and fluid intake. However, staff worked in a way which was task orientated rather than person centred. There was little evidence that staff had received training with regard to providing care to people living with dementia. Some staff did not communicate with people when they were assisting them, and we saw an incident of poor moving and handling practice.

Our judgementThe provider was not meeting this standard. We judged that this had a minor impact on people using the service. There were not enough qualified, skilled and experienced staff to meet people's needs.

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Outcome 21:Records


People who use services can be confident that: * Their personal records including medical records are accurate, fit for purpose, held securely and remain confidential. * Other records required to be kept to protect their safety and well being are maintained and held securely where required.

What we found

Our judgement

The provider is compliant with Outcome 21: Records

Our findings

What people who use the service experienced and told usWe spoke with people during our inspection at Strathmore House on 08 August 2012 but their feedback did not relate to this standard.

Other evidenceAre accurate records of appropriate information kept?

The care records that we looked at showed that appropriate nutritional assessments were carried out and that care plans were in place. Records relating to monitoring people's weight and their food and fluid intake, where appropriate, were maintained. The records included information about people's individual choices and preferences.

We looked at the records relating to one person who received their nutrition via a peg feed. The records showed that the correct rate of fluid had been given and there was evidence that the dietician was regularly contacted with regard to the nutritional needs of the person. However, the provider may find it useful to note that the fluid balance charts for this person had not accurately reflected the correct balance as the peg feed was not included within this.

Are records stored securely?

People's confidential records were stored securely but could be located promptly when

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required.

Our judgementThe provider was meeting this standard. People were protected from the risks of unsafeor inappropriate care and treatment because records were completed well. People's right to have their confidentiality respected and maintained was protected because records were stored securely.

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Compliance actions

The table below shows the essential standards of quality and safety that are not being met. Action must be taken to achieve compliance.

Regulated activity Regulation Outcome

Accommodation for persons who require nursing or personal care

Regulation 17 HSCA 2008 (Regulated Activities) Regulations 2010

Outcome 01: Respecting and involving people who use services

How the regulation is not being met:People's privacy, dignity and independencewere not always respected.

Accommodation for persons who require nursing or personal care

Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010

Outcome 13: Staffing

How the regulation is not being met:There were not enough qualified, skilled and experienced staff to meet people's needs.

The provider must send CQC a report that says what action they are going to take to achieve compliance with these essential standards.

This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

The provider's report should be sent to us within 14 days of the date that the final review of compliance report is sent to them.

Where a provider has already sent us a report about any of the above compliance actions, they do not need to include them in any new report sent to us after this review of compliance.

CQC should be informed in writing when these compliance actions are complete.

Actionwe have asked the provider to take

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What is a review of compliance?

By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care.

The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety.

CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care.

Where we judge that providers are not meeting essential standards, we may set compliance actions or take enforcement action:

Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. We ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met.

Enforcement action: These are actions we take using the criminal and/or civil proceduresin the Health and Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people.

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Information for the reader

Document purpose Review of compliance report

Author Care Quality Commission

Audience The general public

Further copies from 03000 616161 / www.cqc.org.uk

Copyright Copyright © (2010) 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.

Care Quality Commission

Website www.cqc.org.uk

Telephone 03000 616161

Email address [email protected]

Postal address Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

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