Inspection on 22/06/06 for Acocks Green Nursing Home

This inspection was carried out on 22nd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Acocks Green Nursing Home 05/06/07

Acocks Green Nursing Home 29/11/05

Acocks Green Nursing Home 21/09/05

Acocks Green Nursing Home 09/03/05

Acocks Green Nursing Home 26/11/04

Acocks Green Nursing Home 16/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Acocks Green Nursing Home 1079-1081 Warwick Road Acocks Green Birmingham West Midlands B27 6QT Lead Inspector Unannounced Inspection 08:30 22nd June 2006 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Acocks Green Nursing Home Address 1079-1081 Warwick Road Acocks Green Birmingham West Midlands B27 6QT 0121 707 2611 0121 707 6549 acocksgreen@schealthcare.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Care Management Limited Mrs Petra Thompson Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56), Physical disability (56), Physical disability of places over 65 years of age (56) Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Older people requiring nursing care Service users in category PD over 55 years of age and the older persons receiving residential care are over the age of 65. 29th November 2005 Date of last inspection Brief Description of the Service: Acocks Green Nursing Home provides 24-hour care for older adults aged 55 and over. It is a purpose built home and is situated in a residential area of Birmingham, close to a local shopping centre with all amenities including public transport. The home has two floors and accommodation consists of single rooms with some en suite facilities. There are two double rooms available and communal space consists of two large lounges on the first floor and one large and one smaller on the ground floor. Corridors are wide and the building has basic adaptations for residents with limited mobility, including a passenger lift. The home has hoists and pressure reducing equipment available and there are assisted bathroom and toilet facilities. There is an attractive garden situated to the side and rear of the home with a patio area and garden furniture for residents to access weather permitting and this is accessible to residents in wheelchairs and those who have limited mobility. Car parking is available at the front of the home. Inside the home, the reception area has notice boards, which display information about forthcoming events and other articles that may be of interest. The current scale of charges for the home is £443 - £650 per week. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork was undertaken by two inspectors over thirteen and a half hours and was assisted throughout by the Manager. There were 49 residents living at the home on the day of the fieldwork. Information was gathered from speaking with residents and relatives, from interviewing staff and observing staff perform their duties. Care and health and safety records were reviewed along with medication management. Staff personnel files were reviewed and a partial tour of the building and garden was undertaken. The manager had completed and returned a pre inspection questionnaire prior to the fieldwork being carried out. Three immediate requirements were made on the day of the fieldwork and an improvement plan was received from the organisation, with details of how the requirements would be met. What the service does well: The home completes comprehensive pre admission assessments and sends out letters of confirmation; this ensures that the home and the prospective resident know that identified needs can be met prior to admission. Residents and relatives meetings are held and this enables them to voice any concerns and express opinions as to how the home is run and how it could be improved. The management of medication is good and this ensures that residents are safeguarded from harm. There are a wide variety of activities available and day trips for residents to participate should they choose and this encourages interests and choice. A relative stated, “If I was asked to recommend this place I would say yes” Comments from residents included: “I have lived here for two years and I’m very happy” “I go out with my daughter on Saturdays shopping” “I’ve been to Stratford and we are going to Western Super Mare” “Food is nice, I have no complaints” “I would talk to the manager if I was unhappy, she comes around to talk to us” “Staff are mostly good, some night staff can be rough” “Everyone is ok” “The manager is very approachable” Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: There have been some improvements to the care planning system since the last fieldwork visit to the home and now staff need to ensure consistency in recording is maintained on all files. Staff must determine when risk assessments should be incorporated into the care plans to ensure that information is easily retrievable for staff to follow. Documentation of complaints requires improving in order to demonstrate at what stage the complaint is at, actions taken and outcomes and future actions to improve the service in order to achieve better outcomes for residents and their representatives. The home must continue to work towards the recommended 50 of staff who hold the NVQ Level 2 qualification to ensure a well trained and competent workforce provides care. Night staff attitudes and approach to residents must be addressed, to ensure that residents are comfortable and feel safe in their environment. Recruitment procedures must be improved to ensure that all relevant checks are in place prior to staff commencing employment at the home in order to safeguard the residents from potential harm. Staff must receive formal supervision sessions as a minimum of six times per year or more often if indicated to ensure that performance and developmental needs are addressed. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 & 4 The quality outcome in this area is good. This judgement has been made using evidence available including a visit to the service. Residents are issued with terms and conditions of stay at the home. The home completes assessments and gathers pre admission information and this enables the home to ensure that they can meet the needs of the residents. EVIDENCE: On the four resident files reviewed a contract of terms and conditions of stay at the home was available, and included detail of the room number and fees to be paid and this ensures that residents are informed about conditions of stay at the home and the room they are to occupy. Residents come to live at the home on a trial period of four weeks and this gives them the opportunity to decide if they would like to live there on a permanent basis. Comprehensive pre admission assessments had been completed which had generated a pre admission care plan. Details of any equipment the resident would require upon admission were recorded and this ensures that the home can meet the individual requirements of the resident prior to admission. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 10 Following pre admission assessment the manager sends a letter of confirmation to the resident or their representative to ensure that the resident knows that the home can meet their needs. The home does not offer intermediate care. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 The quality outcome in this area is adequate. This judgement has been made using evidence available including a visit to the service. Residents’ health and personal care needs are generally well met. Some care practices and documentation in respect of this was inadequate, failing to ensure that residents’ needs will be met. There are robust procedures in place for the management of medication and this ensures that residents receive their medication safely. EVIDENCE: Each resident has a written care plan. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the resident to maintain their needs. The care plans for the residents at the home had all recently been reviewed and re written, to ensure that they were up to date and gave staff enough details to follow to ensure the residents individual needs were met. Care plans provided some good details for staff to follow, for example ‘can wash hands and face herself’ and this promotes and encourages residents to maintain their independence as much as possible. The recording of good Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 12 details is not consistent across files and an example of this is a plan which stated ‘need hoist for transfers’ but did not say which hoist or what sling to use, another plan stated regular toileting but did not state how often regular was, on another plan it was stated two hourly. Lack of consistency does not ensure that staff have the information required to meet the assessed needs of the residents. It was noticed on all hygiene care plans that all residents were to have ‘ a weekly bath’ but there was no documentation whether the residents wanted a bath or may prefer a shower, how often they wanted a bath or particular preference to time of day. This suggests that residents are only offered a bath once a week and the manager must review the recording of preferences to enable the residents to make the choice. Risk assessments for development of skin sores, dependency levels, nutrition and manual handling were completed each month and this ensures that potential and actual changes in residents care are identified in order for actions to be taken to ensure that residents needs are met. Continence assessments were detailed with the type of the continence aid to be used and this ensures that staff know what aids the resident requires to keep them clean and free from infection or development of skin sores. A care plan for nutrition stated that a resident was to be weighed weekly, but there were only monthly recordings available. Following discussion with the staff a separate book with weekly weights was shown to the inspectors which showed that weekly weights were being recorded, however the recording of this needs to be kept consistently to ensure that the evidence is available to ensure that residents weights are being appropriately monitored. The care plan had inappropriate details of the outcome of a poor nutritional intake and this was brought to the attention of the manager as required discussing with the staff member who had written it. Each month the manager has to submit an audit of all the residents weights for review by the Operations Manager and this is an extra monitoring system in place by the organisation. There was evidence of care reviews taking place with the resident and their families and there was evidence that relatives signed care plans and reviews after discussion. One relative said, “I see the care plans and sign them”. This enables them to make and express any choices or concerns about their care or living at the home. Many of the risk assessments were repeated in the care plans, and some of the risks identified could be incorporated into plans of care to prevent repetition as some files became confusing and had excessive information repeated in different areas. This does not allow for ease of retrieval of information. Staff require further training to determine what should be in a care plan and how risk assessments can be incorporated into the plan. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 13 There were good daily reports written about how the resident had spent their day and changes in condition reported. It was noted that one resident had been tearful and wanted to go home and was wheeling the wheelchair to the door but no risk assessment was in place for the potential of the resident leaving the building and staff must act upon the information recorded to ensure the safety of the residents. There is evidence of visits from external healthcare professionals such as GP, Chiropodist, Speech and Language Therapist, Optician, Social workers and Tissue Viability Nurses and this ensures that residents have access to external healthcare professionals. Although information was available within the evaluations and wound assessments were ongoing, wound care plans did not always identify the wound dressing of choice and the wound care regime as identified within the care plan was not always followed. For example one care plan stated that a dressing was to be changed every two or three days but documentation was completed after seven days, then a further nine days. There was also documented evidence that different dressings had been applied to those on the care plan and this does not ensure that the residents are receiving the appropriate treatment and care to enable wounds to heal. The manager completes a monthly pressure sore audit and this was detailed with type of equipment used, size and location of wound, Waterlow score (which is a skin assessment tool) and details of conversations or visits from the Tissue Viability Specialist Nurses. This is good practice as shows that staff are monitoring progress or decline of skin and the actions taken in response to this to ensure that residents receive the appropriate treatment. Residents were well presented and were appropriately dressed for the time of year. One relative commented, “shaving can be a bit hit and miss, but I only have to say and it’s done” “Teeth and glasses are always cleaned” During the tour one resident who was nursed in bed had not had any fluid or diet intake recorded on the chart for that day (this was at 11.25 am). The personal hygiene record chart had not been completed for two days and there was no evidence of position changes or oral care being delivered. An immediate requirement was made that turn charts and oral care must be implemented for the resident to evidence that pressure relieving actions were in place and that oral care was being delivered to keep the resident comfortable and free from infection. The management of medication was reviewed and the arrangements for the receiving, administration and disposal of medicines was good, with the exception of drugs on the ground floor which were due for return as these were not in a locked cupboard and this is required to ensure that medication is Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 14 stored securely to prevent vulnerable residents from accidently swallowing them. The manager completes a monthly audit of medications and audits of medications by the inspector were correct. Copies of prescriptions are kept and this is considered to be good practice. There were no gaps on the Medication Administration Records (MAR) and two nurses signed any handwritten MAR charts. Fridge and room temperatures were recorded and Controlled Drugs were checked each shift, these were also found to be correct. Good management of medication safeguards the residents from potential harm. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 The quality outcome in this area is good. This judgement has been made using evidence available including a visit to the service. The home provides well-organised, varied social and recreational activities that meet the expectations of the residents and provide interest and pleasure. Residents are able to exercise their choice over their daily lives and the activities that they choose to participate in which promotes their individuality and independence. Residents receive a wholesome and varied diet, which meets any special dietary needs. EVIDENCE: On the day of the fieldwork the activities coordinator was taking a resident out shopping, and this is commendable as enables residents to maintain some independence and to make their own choices. There are a variety of activities on offer including arts and crafts, reminiscence, gardening, beauty care, bingo, armchair games, library exchange, cinema shows, flower arranging, music to movement, domino club, sing-alongs plus many other activities. There were photographs on display in reception of a trip to the Black Country Museum and there were plans for a trip to Weston Super Mare. There had been Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 16 a commemorative day in January and there was a summer fete planned. Professional entertainers come into the home and there had been a St Georges day entertainer. There are church services organised for those who wish to attend and a church choir had also been into the home. One resident was observed to be reading a large print book, which she stated the staff get for her when requested. The home has an open visiting policy, which means that residents can receive their visitors at anytime. Residents can go out of the home as they choose with their family and friends; the only requirement is that staff are aware the resident is out of the home for safety reasons. One relative said” I can have tea anytime with my husband, friends have just visited and we had a tray of tea” Comments from residents included: “I go out with my daughter on Saturdays shopping” “I join in the activities when they are available” “I’ve been to Stratford and we are going to Western Super Mare” “I’m going out with them in two weeks” The activity coordinator keeps daily records of the activities participated in and these were very detailed and included actions to be taken, for example one residents record who was enjoying watching the world cup stated “ensure TV magazine is available to see when matches are on and ensure nibbles are available to watch the match with” The activity coordinator holds residents and relatives meetings and minutes of these were available for review. Such meetings give the opportunity for residents and their representatives to raise concerns and suggestions for future events and improvements to the home. A monthly newsletter is produced and contains details of resident’s birthdays, new staff, poems, dates of trips planned and other activities or articles of interest. An employee of the month competition has been implemented and the residents choose who receives this, which enables them to make choices, and boosts staff morale. Dining tables were laid appropriately with tableclothes, serviettes, plastic flowers, glasses, menus and condiments. Sauces were available for residents who required these. Notes were on display in the dining area regarding information about residents who required thickened fluids, special diets or soft options and this was brought to the attention of the manager as should not be on display for everyone to read as is not confidential. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 17 Menus were reviewed and were found to be nutritious and offered choices. A tea menu was available and this included sandwiches or a hot meal. Cooked breakfasts and fruit juices were available for residents who choose this option. Tea and snacks are also served at 8pm. The home can cater for special diets and religious wishes and provides soft and pureed meals for residents with swallowing difficulties. Fresh fruit and refreshments are available at anytime. Menus were a little confusing as there were a number of different menus around the home and the manager stated that they were in the process of agreeing which menu style they would be using, so that all the menus were in the same format to reduce any confusion. Comments around food from residents were complimentary and included: “Food is ok” “Food is nice, I have no complaints” Each floor had a catering comments book which had a comment made by a resident that it was a “beautiful lunch yesterday”. It had been recorded on the residents meeting minutes that there were some concerns about the quality of food served on Sundays, and some residents had stated that the Sunday lunch was burnt and the meat was overcooked. The manager had addressed this with the weekend kitchen staff and there was no further evidence to suggest that there were any further problems with the food served on Sundays. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 The quality outcome in this area is poor. This judgement has been made using evidence available including a visit to the service. The complaints procedure is comprehensive and is accessible to residents and their representatives should they wish to make a complaint. A clear response of outcome and future action to improve the service will achieve better outcomes for the residents and their representatives. The home has systems in place to protect residents from abuse. EVIDENCE: There is a comprehensive complaints procedure, which is accessible to residents and their representatives, should they wish to make a complaint. The complaints book identified that the home had received a number of complaints since the last fieldwork visit. However there were inconsistencies in respect of the content of the written documentation about these and it was not always possible to ascertain at what stage of the complaint process each complaint was at in order to action improvements in the standard of service provided at the home. Informal complaints were not recorded as it was stated that these were generally resolved at the time they were raised and it is recommended that a ‘grumbles’ book be implemented to record any concerns raised and evidence any action taken to address these. Pre inspection information did not include detail of any complaints received. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 19 CSCI had been informed of a complaint since the last fieldwork visit and the Registered Provider using their own complaints procedure had investigated this. No other complaints had been received pertaining to the home. There were a number of Thank you cards and letters on display in the reception area of the home. Comments from residents included: “I would talk to the manager if I was unhappy, she comes around to talk to us” “I’ve never needed to complain but I would see the nurse” “If I have any problems they are sorted” Residents meeting minutes were reviewed and there were comments made that the laundry was missing and not put away properly and clothes were piled in the bottom of wardrobes. The manager must review the laundry system and ensure that clothing is returned and put away appropriately. In the reception area there were leaflets for an advocacy service and this is commendable as such services assist residents and their families to exercise personal autonomy and choice over their lives. The home had a good adult protection policy in place and had the local multi agency guidelines to follow; this ensures that staff have guidelines to follow in the event of any situation occurring. All staff had watched a video regarding adult abuse recently and staff interviewed were able to give appropriate responses as to what they would do if they suspected abuse and this ensures the safety of the residents. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25 & 26 The quality outcome in this area is adequate. This judgement has been made using evidence available including a visit to the service. Residents are provided with a homely, comfortable and generally clean environment to live in, where residents appeared to feel relaxed and secure. EVIDENCE: There are four lounges and two dining rooms, which are decorated to a high standard with the exception of the small lounge on the ground floor, which requires redecoration to ensure it is homely for the residents to live in. The corridors around the home are wide and have handrails available to assist residents who have decreased mobility. The home has four assisted bathing facilities and two shower facilities, which were in full working order and meet the needs of residents living at the home. Communal toilets have raised toilet seats and handrails to assist residents. One raised toilet seat was not secure and this was brought to the attention of the manager as could pose a risk of Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 21 falls or slips. The handyman, to prevent any injury occuring, immediately secured this. On the day of the fieldwork the home was found to be clean and fresh, with no offensive odours. The exception to this was a build up of soap residue under the bath hoist seats and this was brought to the attention of the manager. One bathroom was found to have tiles broken around the door and toilet and these required replacing for health and safety and to prevent any infection occurring. Zimmer frames were being stored in the bathroom and these required removing, as the residents were not able to access the bathroom or toilet freely. Kitchenette areas on each floor were reviewed and these were found to be clean, a bowl of fruit salad was in one fridge with an expired use by date and staff should ensure that food is within its storage time to prevent residents from any infection. Fridge temperatures were checked and recorded and cleaning schedules were in place, except at the weekends. The manager must address this with weekend staff to ensure that procedures are followed and food areas are clean at all times and that food is stored appropriately to ensure the residents are protected from contamination. Two electrical sockets were out of order in the kitchen and an immediate requirement was made for these to be replaced and be in full working order. All bedrooms seen were personalised and door guards were fitted on all bedroom doors to ensure that residents could safely have doors held open. The domestic’s room was open, however no COSHH products were stored in there. A bucket of dirty water was in there with a mop inside and it was recommended that clips are put on the walls to store mops inverted in order to dry effectively and prevent the spread of infection. Liquid soap and paper towels were available in all communal areas and this ensures that hygienic hand washing facilities are available to all to reduce the potential risk of cross infection. The laundry room was clean and the staff use dissolvable bags for soiled laundry to prevent any cross infection risk. A storage room was stored high with equipment that was no longer required and it was unsafe. This posed a health and safety risk as staff could not easily access equipment that they did require. Equipment no longer required must be returned and other equipment should be safely stored. The home had started to use a room as a smoking room but the manager was undecided whether it would continue to be used. If the room remains then this Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 22 will need to be reflected in the statement of purpose and also on the fire risk assessment, to ensure that residents are informed of the room and that prevention of fire is maintained to ensure safety of the residents and staff. The home has large gardens, including a seaside themed area and these were easily accessible to residents for their enjoyment. However the gardens required a general tidy up in order for residents to access all areas of the garden safely, including the path which had become overgrown in places with tree branches and bushes. It was recommended on the day of the fieldwork that the Infection Control Nurses should be invited into the home to complete an audit and advise on any areas of concern. The manager responded well to this and invited the nurses in. The home achieved an overall score of 89 and the home must now work towards the recommendations made to ensure infection control within the home is maintained and to provide residents with a safe environment to live in. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 The quality outcome in this area is poor. This judgement has been made using evidence available including a visit to the service. Adequate staffing levels are maintained at the home to meet the identified needs of the residents. The recruitment practice was poor and does not ensure that residents are protected. Staff undertake some relevant training to ensure that they are competent to do their jobs. EVIDENCE: In addition to the care staff, the home also employs domestic, maintenance; kitchen and laundry staff to ensure all the needs of the residents are maintained. Staffing rotas were reviewed and these identified that the home was working within approved staffing levels and this means that there are adequate numbers of staff available to meet the identified needs of the residents. Staff are allocated residents and individual jobs for the shift by the team leader on a daily basis, and this ensures that a named member of staff is responsible for supporting individual residents to meet their needs. There home currently has 20 of care staff who hold NVQ Level 2 or above in care and a number of staff are enrolled to complete this training. The home Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 24 must continue to train staff in order to meet the recommended 50 of staff who hold this qualification to ensure that residents receive care from a well trained and competent workforce. Comments from residents included: “Staff are mostly good, some night staff can be rough” “Carers are very good, including night staff” “Everyone is ok” “Two cares are a bit rough, don’t waste much time and do things quick” A relative stated, “Its fine here, I speak to everybody and they are friendly staff” Resident’s comments were discussed with the manager at the time of the inspection and these areas must be addressed, to ensure that residents are receiving good standards of care throughout the night as well as during the day. Four staff files were reviewed and these did not have all the required information. References are received but these were not always from the last employer and the capacity of the person writing the reference was not always known. One reference received for a member of staff did not marry to the work history on the application form and there was no evidence that this had been explored. One PoVA first check had not been received until a week after the staff member had started and this does not ensure that residents are protected from harm. Health declarations were completed and this ensures that staff are fit for the role they are employed to undertake. One staff file had a CRB form from a previous employer but there was no PoVA first check in place for this home. Original Criminal Records Bureau checks were not available to the inspectors and the home must make provision for this. A Personal Identification Number for a trained member of staff had expired and there was no evidence on the file to say how it had been checked to ensure that the nurse was still registered to practice. Evidence of these checks must be available to ensure that nurses are able to practice in order to safeguard residents living at the home. A staff training matrix has been devised and this showed evidence that staff had recently had training in PoVA and abuse, customer care, administration of medication, safe use of bed rails, moving and handling, fire and health and safety. This will ensure that staff have the appropriate knowledge and skills to meet the individual assessed needs of the residents and protect them from harm. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 25 A overseas staff induction programme was reviewed and was found to contain a vast amount of information to be covered over two days. The home must review the induction programme and ensure that it is in line with the skills for care guidance. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36, & 38 The quality outcome in this area is adequate. This judgement has been made using evidence available including a visit to the service. The manager has experience of managing care homes and is keen to continue to make the changes required and to sustain improvements already made. There are systems in place to monitor the quality of the service on offer and the systems for resident consultation are good. Staff are not afforded adequate support to have their performance monitored and developmental needs addressed. Maintenance checks of equipment used ensure that the safety of residents is protected. EVIDENCE: The Registered Manager is a Registered General Nurse and has had much experience in caring for older people and had a Diploma in Management Studies and a Masters Degree in Business Administration. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 27 One relative stated “the manager is very approachable” and this indicates that relatives are happy to approach the manager to discuss any concerns. The Operations Manager supports the Registered Manager by visiting the home and also completes Regulation 26 visit reports regarding the service provided by the home, this ensures that staff and residents views are listened to and acted upon, and that the home continues to make improvements. The manager has held monthly staff meetings and the minutes of these were available. Heads of departments meetings are held every three months and this ensures that all staff are aware of any concerns raised or any changes that are required to be made. Relatives meetings are held and a relative confirmed this by stating, “there are relatives meetings about every three months, I always come and they put tea, coffee and cakes on” This is good practice as enables them the opportunity to put suggestions for improvements forward. The home had recently completed the Bettal audit and had been recommended for the Quality Premium Award and stated it was “a well run home”. In addition to this Southern Cross Healthcare had also completed its own audit that had produced requirements and monthly validation had been completed. This ensures that views of residents and visitors are sought and plans put in place for future development of the home. Residents personal monies held by the home were not reviewed on this occasion as the home was in the process of moving from a paper system to a computer system and this will be reviewed at the next key fieldwork visit to the home. Some staff appraisals were seen on file and these identified future training needs and discussed general work competence of staff. Formal supervision sessions had been commenced; however further improvements are required to this, as some staff were still not receiving these sessions. Where problems had been identified with staff members, there had not always been enough supervision following this to ensure that improvements were being made. The Team Leader had originally been given responsibility for all the care staff supervision and this is not acceptable as is too much for one person to complete. The manager was re organising how the supervision was to be allocated, as supervision is required to ensure that staff are given the appropriate support they require to meet the residents needs. The home checks bedrails on a weekly basis to ensure that they are correctly fitted and are of the correct height and length and this minimises the risk of any injuries occurring through inappropriately fitted rails. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 28 Risk assessments were in place, but no risk assessments were written in respect of the garden area and this is required to ensure safety when residents are outside. Risk assessments for COSHH products were available along with data sheets but these were in separate folders and it is recommended that theses are kept together in one folder for ease of finding information when required. The accident book was reviewed and was compliant with the data protection act. The home informs CSCI of any accidents or injuries as per Regulation 37 reports. The manager audits all accidents each month and the audit reviews time and place of incident, if it was witnessed and what follow up action needs to be taken. In addition to this the manager has to complete a quarterly summary for the organisation. Maintenance records were reviewed and servicing had taken place for portable appliances, hoists, legionella, fire alarms, emergency lights, five yearly wiring, sluice machines and the passenger lift. The gas safety certificate indicated that work was required to have permanent ventilation behind the cooker and the manager received an immediate requirement for this work to be completed, to ensure that equipment was safe to use. Water temperature checks were completed and were within acceptable limits and this ensures that the risk of residents scalding themselves is reduced. The fire risk assessment was reviewed and the manager had reviewed this in April. The risk assessment needs to state that that activation of the fire alarms opens the doors so that staff are aware that residents could leave the building unattended or visitors could enter the home without the staffs knowledge, in order to safeguard residents at the home. Fire drills were undertaken and the names and signatures of staff attending had been recorded and this ensures that staff have training and are aware of the procedure to follow should the fire alarm be activated. Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 3 X 3 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 2 Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 30 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP4 Regulation 12(1) Requirement Mental health risk assessments must be undertaken as deemed necessary for current residents. (Previous timescale of 15/12/06 not assessed on this occasion) The care planning system must be further developed to include: The actual care to be afforded to residents and equipment required recorded consistently. (Previous timescale of 15/12/05 partly met) Risk assessments must be written if there is a potential of a resident leaving the building unaccompanied where they are at risk. Turn charts and records of oral care must be implemented for identified resident. (The manager received this as an immediate requirement) Staff require further care plan training to determine how to incorporate the risk assessments. Records of weights must be kept DS0000024814.V290887.R01.S.doc Timescale for action 08/09/06 2. OP7 13(4)(c) 15 30/09/06 3. OP7 12(1)13(4 )(c) 23/06/06 4. OP7 18(1)(c)(i ) 12(1) 20/10/06 5. OP8 31/07/06 Page 31 Acocks Green Nursing Home Version 5.1 6. OP8 7. OP8 8. OP9 9. 10. OP15 OP16 11. OP16 12. OP19 13. OP19 14. 15. OP19 OP19 16. OP19 consistent for ease of monitoring. 12(2) The manager must review the frequency of baths being offered and ensure that care plans reflect individual preferences. 12(1) Wound care afforded must reflect the wound care regime as identified in the care plan. (Previous timescale of 30/11/05 & 10/02/06 not met) 13(2) All cupboards storing medication must be lockable. (Previous timescale of 30/11/05 not met) 12(4)(a) Details of resident dietary needs must not be on display in the dining room. 22 The manager must ensure that complaints are fully documented as to the stage they are at, how investigated and outcomes for residents. 22 The manager must review the complaints regarding missing laundry and clothing not being put away properly. 23(2)(b)(c Electrical sockets in the kitchen ) must be in working order and once made good, the tiling must be replaced across the wall. (The manager received this as an immediate requirement) 13(4)(c) The kitchen requires permanent 23(2)(p) ventilation behind the cooker and fryer. (The manager received this as an immediate requirement) 23(2)(d) The ground floor small lounge requires re decoration. 23(2)(b)( One identified bathroom requires d)(l) tiles replacing around the door and toilet. Zimmer frames must be removed from the bathroom. 23(2)(o) The garden area requires a general tidy up and trees cutting DS0000024814.V290887.R01.S.doc 31/08/06 30/09/06 06/10/06 19/07/06 21/08/06 21/08/06 23/07/06 23/07/06 23/10/06 22/09/06 07/07/06 Acocks Green Nursing Home Version 5.1 Page 32 17. 18. OP19 OP26 23(2)(l) 16(2)(g)(j ) 16(2)(j) 12(5) 19 Sch 2 19. 20. 21. OP26 OP27 OP29 back. The storage room must have unused equipment returned and items must be stored safely. The manager must ensure that weekend kitchen staff complete fridge temperature recordings and cleaning schedules. The manager must ensure that there is no build up of soap residue on bath seats. The manager must address night staff attitudes and approach. References must be sought from the last employer. Work history must be explored. PoVA first checks must be in place prior to staff commencing work at the home. The home must make provision for CSCI to see the CRB records. Personal Identification Numbers for trained nurses must have evidence of checks for current practice. The home must ensure that the induction programmes are in line with the skills for care guidance. The Registered Manager must ensure that the programme for formal staff supervision and appraisal is fully implemented. (Previous timescale of 21/12/05 partly met) Risk assessments must be written in respect of the garden area. Fire risk assessment must state that activation of the fire alarm system opens all doors. 21/07/06 07/07/06 28/06/06 30/06/06 20/07/06 22. OP29 19(1) 20/07/06 23. 24. OP30 OP36 18(1)(c)(i ) 18(2) 31/08/06 28/09/06 25. OP38 13(4) 31/08/06 Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 33 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP15 OP16 OP26 OP28 OP30 Good Practice Recommendations One style of menu should be devised to reduce confusion over which menu is on offer. It is recommended that a ‘grumbles’ book is implemented to record any informal complaints. It is recommended that clips are installed to stand mops inverted. The home must continue to work towards 50 of staff who hold an NVQ Level 2 qualification. It is recommended that staff training records include the content and duration of each training session, together with an indication of when updated training will be necessary. (Not assessed on this occasion) It is recommended that risk assessments for COSHH products are filed alongside the data sheets. 6. OP38 Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 34 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Acocks Green Nursing Home DS0000024814.V290887.R01.S.doc Version 5.1 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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