Inspection on 14/08/09 for Airedale Nursing Home

This inspection was carried out on 14th August 2009.

CQC found this care home to be providing an Adequate service.

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

Airedale Nursing Home 01/09/08

Airedale Nursing Home 31/08/06

Airedale Nursing Home 05/12/05

Airedale Nursing Home 08/06/05

Airedale Nursing Home 11/01/05

Airedale Nursing Home 10/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Airedale Nursing Home 44 Park Avenue Bedford Bedfordshire MK40 2NF Lead Inspector Nicky Hone Key Unannounced Inspection 14 August and 03 September 2009 09:00 DS0000017660.V377108.R02.S.do c Version 5.2 Page 1 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. 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. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Airedale Nursing Home Address 44 Park Avenue Bedford Bedfordshire MK40 2NF 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) 01234 218571 01234 215097 airedalenursing@btconnect.com The Airedale Nursing Home Mrs Jean Nichol Dr T Kamyar Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (35), Terminally ill (5), of places Terminally ill over 65 years of age (5) Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To limit the number of persons to be admitted under the category of terminal illness within the home. To limit the number of persons to be admitted in the age range between 45 and 65 years within the home in the category of PD. 1st September 2008 Date of last inspection Brief Description of the Service: Airedale is a care home offering nursing care situated in the centre of Bedford overlooking Bedford Park. The home has been slowly extended over a number of years and is currently registered for 35 people with nursing needs. Accommodation is provided in single and double rooms, all of which have ensuite facilities. Care is provided at ground floor and first floor levels, and there are offices on the second floor; stairs and a lift give access to the different levels. There are three separate communal rooms plus small reception areas, developed in the hall spaces throughout the home. The garden has been designed as a sensory garden and has full wheelchair access. The home is within walking distance of any bus that stops in Bedford town centre and is on the route of some local bus services. There is unrestricted parking on the road outside the home. The fees for this home vary from £700.00 per week, to £750.00 per week, depending on the funding source and assessed needs of the resident. This covers everything, including all the equipment they might need related to their disability, and furniture in their bedroom, including a television and a fan. People only pay to have their hair done by the visiting hairdresser, for a telephone in their bedroom if they want one, and for a personal newspaper. CSCI inspection reports are available in the hallway of the home, with the visitors’ book and service user guide. At the time of this inspection the home was being extended. The new extension will provide some additional bedrooms, lounges, dining areas, a large kitchen and a large laundry, as well as a sensory room, a larger garden and staff facilities. The main entrance to the home will move to St Alban Road where there will be an impressive reception area. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. For this inspection we (the Care Quality Commission) looked at all the information that we have received, or asked for, since the last inspection of The Airedale Nursing Home. This included: - The AQAA (Annual Quality Assurance Assessment) that the manager completed and sent to us in June 2009. The AQAA is a self-assessment that focuses on how well outcomes are being met for people who live at The Airedale. It gives the provider the opportunity to say what the home is doing to meet the standards and regulations, and how it can improve to make life even better for the people who live here. The AQAA also gives us some numerical information about the service; - Surveys which we sent to some of the people who live here. We received 4 replies. We included surveys for people to give to their relatives if they wanted to. We received 6 replies from relatives; - Surveys which we sent to the home to give to the staff. We received 6 replies; - What the service has told us about things that have happened. These are called notifications and are a legal requirement; - Any safeguarding issues that have arisen; and - Information we asked the home to send us following our visit. This inspection of The Airedale Nursing Home included a visit to the home on 14 August 2009. We had a tour of the premises and spent some time in the communal areas of the home, talking to the residents and observing the care practices and interventions that were carried out. We spoke with residents, the manager and some of the staff team. We also looked at some of the paperwork the home has to keep including assessments, care plans, risk assessments, and records such as staff personnel files, staff training records, and records relating to health and safety. The home manager Mrs Jean Nichol was present throughout the visit and assisted us with any required information. We gave verbal feedback throughout the inspection and at the end of the second visit. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 6 During the first day of this inspection the care of two people, was ‘case tracked’. Case tracking is part of CQC’s methodology which looks at the records kept about the care of an individual, and compares what is written to what is actually given. This is done in a number of ways, for example by observing what happens, speaking with the person, speaking with the person’s relatives (if possible), and speaking with staff. We looked at the way the home manages medication. We found a number of issues so we decided to complete the inspection on a second day (03 September 2009), when we were accompanied by a pharmacist inspector. We told the manager about the issues we had found and gave the home an extra two and a half weeks to get things right. On the second day we looked at care notes and medication for 10 people. What the service does well: People with spoke with, and the responses to our survey, indicated that people are very happy with the care they receive. One person told us “I’m happy – I’m glad I’m here. The girls are so good, they keep on making sure we’re alright”. Another said “You couldn’t better it”. And a third person told us “They’re looking after me very well indeed – no complaints”. We saw a letter from the relatives of someone who had died recently. They were raising a concern, but had also written “I could not fault the care……her last few days were made as comfortable as possible. The nursing care was excellent and everyone was so kind, thoughtful and considerate. They could not do enough for her” Comments from the surveys included “Nothing is really bad. I’m well cared for, the place is clean, the food is good, I like the activities”; “I’m happy, very contented and I have no complaints”; “Looks after me well and keeps me comfortable, clean and calm as possible”; “Staff always kind, helpful, happy, always give enough time, very thoughtful, especially management”; “The staff are always helpful and smiling, care is always available and helpfully given”; and “Staff are very nice”. When asked what the home does well, all six staff wrote that the care is very good/excellent, and 4 of them wrote that staff training is good. They also said “This home runs very well….we have a good reputation for being able to care for people with extremely high needs”; “Good relationships between management, staff and service users and family”; “Palliative/terminal care – carrying out Liverpool Care Pathway”; “The manager coming to see staff and patients every day”; and “Provides good facilities and provides daily activities for service users”. Thorough assessments of people’s needs are carried out and generally care plans contain detailed guidance for staff on the way each person wants their Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 7 needs to be met. Privacy and dignity are respected and people are encouraged to make choices. A wide range of activities is provided by a member of staff who is very enthusiastic about her role and works hard to find new and interesting activities for people. Food is very good, and mealtimes are enjoyed by most people. People know their complaints, if they have any, will be listened to. The home is comfortably furnished, well decorated and maintained, homely and exceptionally clean, providing a very pleasant home for the people who live here. Staff are recruited well, given a wide range of training, and receive regular supervision. The atmosphere in the home is relaxed, friendly and caring. Health and safety is given a high priority. The building work for the new extension is being carried out unobtrusively, with little or no disruption to the people living here. What has improved since the last inspection? What they could do better: The medicine management is poor and must improve to safeguard the people who live in the home. We have made 10 requirements relating to the management of medicines. One of these requirements is repeated from the last inspection. All staff must receive training in Safeguarding Vulnerable Adults. Instances when a service user is physically restrained must be recorded correctly. Records such as food and fluid charts must be completed properly when the need for the record has been identified in the care plan. This requirement has been repeated from the last inspection as it has not been met. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 8 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 enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 9 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 Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 6 People using the service experience good quality outcomes in this area. Good information about the home is available for people who are thinking about moving here, and people know their care will be based on a thorough assessment of their needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection, The Airedale has produced a new welcome pack. This is given to people who are thinking of moving into the home, and a copy has been given to each person currently living here. During our tour of the building we saw that copies of this pack were in people’s bedrooms. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 11 The pack includes a copy of the Service User Guide and Statement of Purpose, as well as examples of menus and information about activities. Copies of these documents are also kept in the hallway near to the visitors’ book, along with a copy of the latest CQC inspection report, the home’s newsletter, and other useful information. On the first day of this inspection we picked two residents at random to ‘case track’. This means we looked at their personal files in detail, spoke with each person, and observed the care that was given to them. Both of the files we looked at contained an appropriately completed preadmission assessment, which identified all the person’s needs and the level of support required to meet those needs. The assessment is used to develop a plan of care for the person. ‘Intermediate care’ is a service offered by some homes, which gives shortterm, intensive rehabilitation for people leaving hospital before returning to their own homes. This service is not offered at The Airedale, therefore standard 6 is not applicable. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People using the service experience adequate quality outcomes in this area. People are treated with dignity and respect and generally care planning has improved. However, the medicine management is poor. Inadequate systems had been installed to ensure that the medicines were administered as prescribed and records reflected practice. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Throughout this inspection we observed there to be a very comfortable atmosphere in the home. We watched staff integrating with residents in a familiar but respectful way, and we heard regular banter passing in Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 13 conversations. One person we spoke with made positive comments about the manager. Observations of care practices during our visit were generally very positive. We saw that moving and handling equipment was being used safely, and staff were communicating well with the residents while they were helping them to move. We also noticed that everyone who was transferred in a wheelchair had the safety lap belt correctly in place while the chair was being moved. There were care plans in place for all the residents that we case tracked. These were generally well written and most gave sufficient information to ensure that care could be delivered with continuity. The first file that we looked at gave a clear medical history for this particular resident. There were numerous needs identified and clear instructions were given to advise staff how best to meet these needs in a way that the individual prefers. For example, the plan clearly identified that this person likes to get up in the morning between 07:00 - 07:30 hours, and that he requires two staff to hoist him for all transfers. It identified that he prefers to be washed and dressed before breakfast is served. This resident had a pressure area identified on admission which was being monitored, and reviews indicated that the wound had gone from a grade 3 sore (a fairly serious wound) to a ‘very superficial wound, smaller in size’. Turn charts were in place for this person as was the pressure relieving equipment as described in the care plan. Other areas of care for this person, identified by risk assessments, included mobility, risk of falls, continence and catheter care. However we did note that fluid charts were not always being completed correctly. For example, the ‘fluid output’ column included ‘100mls of tea’, showing that staff were putting entries in the wrong column. Blood sugar levels were being recorded on a regular basis due to a diabetic condition, and details of food likes and dislikes were listed. We were however a little concerned that although a nutrition assessment had been completed and reviewed, no one had picked up on what appeared to be a serious issue on the weight record chart. The weight recorded for this resident on admission on the 17/07/09 was 95kg. The weight then recorded a month later on the 21/08/09 was 85.9 kg. This indicated a weight loss of over 9 kg (nearly 10 of body weight) in one month. Despite this apparently huge loss, staff had written, “To be weighed monthly – slight decrease in weight, but still within reasonable weight”. We asked for this person to be weighed during our visit and it read 87.2kg. We discussed this with the manager and agreed that this was probably a recording error on admission, or that the scales were not working properly. We are reassured that there is no evidence that this resident is losing weight, however we are concerned that this error was not identified and rectified Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 14 through the home’s own care plan audit/reviewing process. The manager agreed to address this immediately with the staff concerned. In a second person’s file we saw that the pre-admission assessment had been fully completed, was written in a person-centred way, and included details about what this person can do for herself. All sections of the assessment were completed in detail including information about the person’s sight and hearing. Any issues identified were cross-referenced to a care plan relating to that area of care, for example, skin integrity, falls, eating and mobility. However, when we looked at the care plan relating to skin integrity, we noted that the last entry had been made on 14/07/09. The manager had already told us that there had been a very recent (within the 2 weeks before our visit) change to the dressings that were being used on this person’s leg ulcer. This had not been recorded on the care plan. We also noted that this person had been seen by a physiotherapist in June 2009 who had given her some exercises to do 2/3 times a day. Due to some problems with her memory, it had been agreed that staff would help this person with the exercises. There was no mention on the daily records since that date, that staff had helped with the exercises, so there was no evidence to show that the physiotherapist’s instructions had been carried out. The manager told us that she meets weekly with the staff to go through the care plans. She said this focuses on each individual resident and gives all the staff the chance to be involved in developing the care plan and making sure it is meeting the person’s needs. This makes it even more disappointing that we found issues on each of the 2 plans we looked at, which should have been picked up during this process. During the inspection on the 14/08/2009 we briefly checked the medication. We found a number of errors so we decided a pharmacist inspection was warranted. We discussed the errors with the owner and the manager and explained that we would return to complete the inspection with a CQC pharmacist. The pharmacist inspection took place on 03/09/2009 and lasted 8 hours. The pharmacist reported: Ten people’s medication, Medicine Administration Record (MAR) charts, care plans and daily records were looked at. Two medication rounds were observed and two nurses were spoken with. All feedback was given to the owners during and at the end of the inspection. The manager had installed a lengthy auditing system whereby nursing staff counted all the medication at the end of each round to identify when errors Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 15 had been made and by whom. Despite this system errors were still found at this inspection. The majority of medicines were kept in a medicine trolley. This was not locked when the nurse went into the office so everybody in the home had full access to the medicines within. There was no set order in the trolley and medicines were scattered throughout. It was difficult to find some medicines as they were not always stored together in resident order. This may lead to errors as the nurse may not easily be able to find the person’s medicine. As the trolley was too small to hold all the medicines, some were taken out of the cabinet in the office and put on the drinks trolley ready for administration before each medication round. These then were not kept in a locked facility and again everybody in the home had full access to them, putting the people who live in the home at risk. All the cupboards used to store medicines were locked, but one bag of medicines that apparently was delivered in error, was found in a plastic bag under the desk in the open office. Again everybody had access to these medicines. The home had a controlled drugs cabinet that complied with current regulations. This was too small to store all the controlled drugs on the premise, so one controlled drug was not stored correctly. Medicines requiring refrigeration were stored in a dedicated locked medicine refrigerator. The temperature was read daily. It was too high to safely store medicines in compliance with their product licences, so their stability may have been affected and not work as intended. The nurses had failed to act appropriately despite documenting that the temperature was too hot on a daily basis. Two nurses undertook the medicine round on both the morning and lunchtime rounds observed. One nurse prepared the medicines from the trolley and put them in an open medi-pot, signed the MAR chart and then gave the medi-pot to the other nurse. She then walked through the home to the person to administer them. This is poor practice because the first nurse prepared the medicine and signed the MAR chart before they had actually been administered and also had not actually administered them. The risk of error is increased as it was verbally communicated who the medicines were for. The second nurse could easily give them to the incorrect resident and there was no record that she had actually administered them. We, the commission, advised the nurses that the practice was poor, but they both still continued the poor practice. We were assured by the manager, Mrs Nichol, during lunch that this was not a regular occurrence, however the same practice was seen by two nurses in the afternoon. One nurse was apparently being supervised but he was preparing the medicines and signing the MAR chart and then giving them to a second nurse to administer. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 16 Currently the home does not have a system to check the prescriptions before they are dispensed to ensure that all the medicines required have been prescribed. The MAR charts and dispensed medicines are not adequately checked upon receipt into the home. One error was seen where the label on the box stated the medicine should be administered eight times a day but the MAR chart recorded that it should be administered daily. It was not possible to confirm which dose was correct. Nursing staff routinely gave the medicine daily as that was what they always gave. Had the checking in procedures been more robust this would have been identified and the discrepancy addressed before any administration. One medicine had been recorded twice on the MAR chart. This had not been recognised by the nursing staff and they recorded that they had administered it twice, even though they could not have done. This indicates that the nurses are not accurately recording what they have administered, are not reading the MAR chart adequately and are not checking the MAR chart for accuracy upon receipt. The home had some photographs for some but not all of the residents. These were not named so it was not possible to use them to identify the resident. There was no facing page identifying all the residents with supporting information, for example, any allergies, how they preferred to take their medication, doctors name. The quantities of all the medicines had been recorded on the MAR chart enabling audits to take place. Any balances of medicines from previous cycles had not been carried over so in these instances it was difficult to demonstrate exactly what had occurred. The majority of medicines had been dispensed in a monitored dosage system (MDS), where one dose per day per medicine was dispensed in a blister pack. Two people’s medicines had been kept together with no divider so it was possible for a nurse to inadvertently give the incorrect medicine. Audits indicated that the medicine dispensed in the MDS had been administered as prescribed and records reflected practice. It was found that medicines dispensed in traditional bottles and boxes had not always been administered as prescribed. Nurses had recorded they had administered some doses when they had not. Others were missing with no explanation. Reasons for nonadministration were not always recorded so it was unclear why a medicine had not been administered. One medicine had not been ordered in time resulting in the person not having any pain relieving medication for two days while a new supply was sought. This medicine had been given routinely as prescribed for moderate pain relief, up until the time it was not available, indicating the person did require regular pain relief. Nurses had failed to identify when they would run out and order a new supply in time to ensure there was enough medicine to administer at all times. This was a requirement from the last inspection and had not been met. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 17 One medicine that had been discontinued was still available to administer in the medicine trolley. It had not been removed. Any medicine that is no longer required should be removed so it cannot be inadvertently administered. One medicine was found in the fridge that was unlabelled so it was not clear who it belonged to. It was also out of date and had not been removed or replaced. The nurses had endeavoured to record the variable doses of medicines but due to the small space on the MAR chart this did not always occur. Mrs Nichol was keen to install an easier system to ensure nurses record exactly what dose they had given. Entries had been recorded in the CD register but not on the MAR chart, again indicating incomplete recording by the nurses on duty. In addition three entries had not been dated in the CD register again indicating incomplete recording and failure to follow safe procedures for medicine administration. On the box of one medicine it stated that it should not be crushed. This was a slow release preparation of oxycodone tablets for moderate to severe pain designed to release a set amount of medicine throughout a 12 hour period to alleviate the pain. We, the Commission, told the nurse on duty who said she would omit the dose. This would have meant that the person would not have the strong pain relieving medication as the doctor intended. In addition, the nurse on duty should have been aware of the potential adverse side effects of crushing a slow release formulation. “The administration of broken, chewed or crushed oxycodone tablets may lead to the rapid release and absorption of a potentially fatal dose of oxycodone”. (Summary of Product Characteristics, Napp Pharmaceuticals Ltd, 4/12/08). Whilst it is acknowledged that an additional pain relieving medicine had been prescribed, this would not be a suitable substitute to control the pain. The nurse’s decision to immediately stop the strong pain relieving medicine, in addition to not contacting the doctor for a more suitable formulation was cause for concern and potentially unsafe practice. Some medicines were administered via a PEG tube. There was no supporting medical information in the home to ensure that the most suitable formulation is administered via this route. The care plans gave detailed information of how to administer nutritional supplements via this route but no information regarding the correct administration of the medicines. The care plans recorded detailed information about the clinical condition of the people. The majority had been updated on a regular basis but reference to some medication was found that was not available and no longer prescribed. Nurses had routinely recorded all the external healthcare professional visits, for example, when and why the doctor had visited together with the outcome. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. People are encouraged and enabled to make choices about most aspects of their lives, a wide range of activities is offered, and menus and meals reflect people’s choices. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we spent an hour and a half sitting in the communal lounge area, observing activities and staff interactions with the residents. This period of observation started at 10:00 hours and there were just three residents present. As the morning progressed more residents joined us in the lounge. Some immediately joined in the group activities which included a game of ‘Down Memory Lane’ which generated discussions of various subjects such as Field Marshall Montgomery, and others just sat and chatted and watched what was going on around them. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 19 We saw that everyone in the room was engaging with someone or something. Mid morning refreshments were served either on individual trays or from a trolley, and a choice of hot and cold drinks was available. We also visited some of the residents who had spent much of the morning in their rooms. Some were waiting to be assisted to come and join the groups, and others preferred to spend time in their rooms. One person said “Diana [the activity coordinator] keeps us going. She does no end of things with us. She gets us all going and we’ve had some lovely games. Musical bingo is the latest thing – it’s jolly nice”. The activity coordinator showed us the resident’s activity profiles. These included information relating to what individuals enjoyed doing, and photographs and examples of work they have done over recent months. Most recent were photographs taken during the visit of ‘Canine Partners’. The pictures indicated that all the residents, including those on bed rest had enjoyed this activity. The activity coordinator was planning to use these photographs to generate another discussion group. One resident had won a small ‘canine partner puppy’ in a raffle that was held during this session. She was keen to show us her prize which took pride of place on her bedside table. One person who responded to our survey suggested that there should be activities organised at the weekends. The activity coordinator told us she had asked residents and families about this, and the majority had said that weekends were better without activities. They said weekends should be a quiet time, to ‘recover’ from all the activity during the week, and to spend quality time with families. Work on menus and individuals’ choices is also addressed through activities. Each month residents participate in completing personal menus, indicating what their favourite meals are. These are then discussed and used to review the menus for the home. We also saw some very impressive memory work that had been done in the activity groups. One resident had designed the ‘London Skylon’ in 1951. He was asked to draw it as he remembered it. The activity coordinator then researched this and printed off a picture of this structure. The likeness of the two pictures was incredible. A similar exercise had been done with another resident relating to something form their past. On the day of this inspection the weather was fine and some residents were participating in groups outside, whilst others just enjoyed the sunshine while it lasted. Some residents remained in the garden to have their midday meal. We spoke to the chef who has been working in this home for about a year. He is very passionate about providing a varied and nutritious menu for these Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 20 residents, which is well presented. The kitchen was spotless and the fridge and freezers well stocked. The menu for the day we visited was fish and chips. The fish was cooked in a sauce, and seasonable vegetables accompanied it. There is an alternative menu available at all times, which includes salads, jacket potatoes and other lighter options. It was therefore a little disappointing, when a resident who we were sitting with in the garden, was served a jacket potato with cheese and onion as he had requested, and was looking forward to. However instead of the salad he’d asked for, staff had put two scoops of mashed potato and chips on the plate as well. This resident understandably lost his appetite when presented with this. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience adequate quality outcomes in this area. People know that their concerns will be listened to, but safeguarding is not dealt with in a completely satisfactory way. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Airedale has a complaints procedure which is given to everyone in the Service User Guide and welcome pack. It includes information on how to contact other agencies such as Social Services and CQC. One person told us if things weren’t right she would be happy to speak to the senior nurse, or any of the staff, or the manager. Another said he’d never had any complaints. The home keeps a record of any complaints that have been made. There was only one recorded in the past 12 months. The family of a deceased resident had raised concerns about their relative’s property which was not handed over when the person died. The manager had resolved this quickly. In their letter, they also wrote how grateful they were for the care given to their relative during her brief stay at The Airedale. Staff training records showed that 15 of the 23 care staff had received training in Safeguarding of Vulnerable Adults (SOVA), in March and June 2009. There Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 22 was nothing on the records for 8 care staff to show they had received any SOVA training, nor for any of the domestic/kitchen/maintenance staff. Following the inspection the provider wrote to us stating that the care staff had undergone induction training which includes safeguarding. When we looked at the care plan files on both days we noted that a ‘Mental Capacity Act (MCA) Assessment’ had been completed for each person. However, this was a ‘blanket’ assessment, saying the person has no capacity to make decisions. MCA assessments have to be ‘decision-specific’: for example it might be assessed that a person does not have the capacity to decide to administer their own medication, but that they do have capacity to decide what they want to eat, what clothes they want to wear and so on. We also saw that there was an ‘Advance Plan’ on some people’s files. This is a document giving instructions about what the person wants to happen to them at the end of their life. We noted that for some people, their families had signed to say that the person had decided they did not want to be resuscitated. However, the MCA assessment completed about these people noted that they do not have capacity to make decisions. On reading one persons file we found daily records that showed that this person had, on a few occasions, been strapped into her wheelchair. Notes also showed that on more than one occasion this person had been given when needed sedative medication close to being given her regular sedative medication. This person had been admitted to the home from hospital. While she was in hospital a Deprivation of Liberty Safeguarding (DOLS) authorisation was granted. A DOLS authorisation is a decision made by a number of people on behalf of someone who has been assessed to lack capacity to make a specific decision. The people making the decision are a best interests assessor (appointed by the local authority) and can include the persons family, doctors and other professionals. If granted, the authorization allows the persons liberty to be restricted if it is considered to be in their best interests. The authorisation allowed the staff to restrain the person when she was particularly agitated, by strapping her into a wheelchair. The authorisation had been reviewed on admission to The Airedale: the best interests assessor had authorised the home’s staff to strap the person into her wheelchair for short periods if she was at risk of injuring herself. There were some conditions attached to the authorisation, including that the staff should record the frequency, length of time and use of the lap strap. A form had been introduced but we saw that some occasions when the person had been strapped into her chair had been recorded in the daily notes, and not on the form specifically introduced for the purpose. Following the inspection we discussed this authorisation with the Safeguarding Lead at Bedford Borough Council who asked the Mental Capacity Act (MCA) Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 23 Coordinator to visit The Airedale. This person is responsible for DOLS issues. The MCA Coordinator agreed to visit The Airedale and review the authorisation to ensure that the care being given to the person is in their best interests. The person’s family was included and they wrote to tell us that they are very happy with the care being given to their mother. The authorisation will remain in place for another year. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 People using the service experience excellent quality outcomes in this area. The Airedale gives the people who live here a very homely, comfortable, wellmaintained and exceptionally clean home. It is safe, well equipped, and meets the need of the people who live here. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we carried out a complete tour of the premises. The building was clean, bright and fresh throughout with no evidence of any offensive odours anywhere in the building. Hand cleaning facilities were strategically placed in the corridors promoting universal infection control measures. The home was welcoming and the corridors displayed photograph Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 25 collages of various leisure events held at the home, such as barbeques and parties. The bedrooms are all decorated to a very high standard and furnished individually, and each room had either an individual or a shared en suite shower / wet room facility. These were very impressive. Bedrooms could be identified by names and numbers on the doors. They also had a ‘do not disturb’ facility in situ, which staff used when they were assisting with personal care. New profiling beds have been purchased for all rooms, including three ‘ultra low’ beds. These can be lowered to approximately eight inches from the floor and therefore enable people to sleep safely without the use of bed rails and without the risk of falling from the bed. Rooms are personalised by people’s own ornaments and photographs, which reflect each person’s life history and give the rooms a homely feel. Many rooms have wall mounted televisions and fans (provided by The Airedale), so that residents have all the home comforts they need without cluttering up the floor space. Communal areas are spacious and comfortable; however work is ongoing to improve this further with a large extension. It is hoped this will be completed in early 2010. There are also plans to introduce a sensory room in the near future. We look forward to seeing this. This home has beautiful gardens to the rear, and on the day of the inspection many of the residents were making the most of the sunshine. Some were even having their meals served ‘Al Fresco’. Whilst the refurbishment of this home is ongoing, a ‘mobile’ kitchen is in use. This has been attached to the home and just looks like part of the building. The kitchen is a good size, provides more than adequate cooking and food storage facilities and is kept spotless by the chef. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. Staff are recruited and trained well, and employed in adequate numbers to meet people’s needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During our visits we noted that there were a lot of staff on duty. Each day there were 2 trained nurses, a number of care staff, domestic staff, chefs, a maintenance man, and an activity coordinator as well as the manager/owner and the co-owner. Generally staff were very competent in their roles, although we had some concerns about some of the practice of the trained nurses when they administered medication (see Health and Personal Care section of this report). People we spoke with, and those who responded to our survey, were very positive about the staff. The comments we received included “Staff always kind, helpful, happy, always give enough time, very thoughtful, especially management”; “The staff are always helpful and smiling, care is always available and helpfully given”; “The girls are so good, they keep on making Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 27 sure we’re alright”; and “Staff are very nice”. Two people we spoke with said that when they call, staff come as quickly as they can. One said “Staff are worked off their feet but come as quickly as they can”. He also said how lovely it is that they “have a joke and a laugh with you”. One person said that sometimes there are misunderstandings with the language. The Airedale has made a huge effort to ensure that all the overseas staff they employ are able to speak good English, enrolling them on college courses if they need to improve their speaking and/or written skills. Records of staff training show that all staff have undertaken a number of training courses in the past 12 months, including mandatory courses such as infection control; safe food handling; first aid; and fire safety. They have also done courses in dementia care, mental capacity act/deprivation of liberty; nutrition; wound care; Parkinson’s disease; and so on. The manager told us that all care staff have either completed, or are undertaking, a National Vocational Qualification (NVQ) in care. She was very proud of some of the staff who started working at The Airedale last year and have already completed NVQ level 2. We looked at the personnel files for 3 staff who had started work at The Airedale during the past 12 months. Most of the information that the home has to have in place before the person starts work, was in the files. This includes a Criminal Record Bureau (CRB) disclosure; POVA list check; 2 written references; details of any criminal offences; a full employment history; and a statement by the person about their mental and physical health. The Airedale uses a recruitment agency to provide the home with some staff from overseas. The administrator said the agency is very reliable and provides very good staff. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 28 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 People using the service experience adequate quality outcomes in this area. The management of this home is still not good enough to ensure that people have the best possible care and are kept safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager/owner of The Airedale, Jean Nichol, is a qualified nurse and has undertaken the Registered Manager Award (NVQ level 4), so has the Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 29 appropriate knowledge and skills for this role. The co-owner, Dr Kamyar is a doctor. They have owned and managed the home for 22 years. Discussions with residents throughout this inspection indicated that Mrs Nichol is very well respected by the clientele in this home. One resident referred to her and the other staff as “wonderful people, the unsung heroes”. One of the relatives who completed our survey wrote “Staff……..very thoughtful, especially management who continually try to find solutions to MND [Motor Neurone Disease] problems – will spend extra money on equipment”. Other quotes showing how much people appreciate the service offered at The Airedale can be found in the Summary of this report. Our inspection showed that the manager and staff have worked hard during the past year to improve a number of aspects of the service which we made requirements about following our last inspection. Generally there was much improvement in the way care plans are written, and in the detail and guidance for staff they now contain; a wide range of activities is now offered to all residents; mealtimes have improved for people who depend on assistance; correcting fluid is no longer used on records; and doors have all been fitted with a Dorgard so that they can be held open safely if people want them open. However, the medication administration was disappointing, and even more so as we gave the home an additional two and a half weeks to put things right, between our two visits. Also, some of the charts used to record particular issues, such as food/fluid intake, occasions when restraint is used, and so on, were still not being completed correctly. This means that 2 requirements from last year have been repeated. The home’s quality assurance system includes asking residents, relatives and other stakeholders to complete a questionnaire. This is done each year and the results are collated (anonymously) into a report: a copy of the report is in the Service User Guide. During our feedback of the findings from the inspection, we discussed with the manager where some of the reviews/audits that are in place are not fulfilling their role. These need to be improved to ensure that all aspects of the service are quality checked, and any issues are identified and dealt with. The home completes notifications as required by regulation 37, to let CQC know when significant events have occurred. The Airedale does not get involved in the financial affairs of any of the residents, and does not hold any money for anyone. There was evidence on the staff files we looked at that staff receive regular supervision, which is recorded and signed by the supervisor and the staff being supervised. The manager said she supervises the trained nurses and the new staff; the trained nurses supervise the senior carers; and they in turn supervise the care staff. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 30 Fire records show that the fire alarm and emergency lighting systems have been tested as required, and regular fire drills are held. The building work is not only being done in a way that does not intrude on the lives of people living at The Airedale, it is also being done with due regard to health and safety. The garden has been securely fenced off, and doors into the building area have either been blocked off, or are kept locked. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 31 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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 3 3 4 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 2 3 Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 32 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 OP9 Regulation 13(2) Requirement There must always be a sufficient supply of people’s medication in stock, so that people get the medicines they have been prescribed. This requirement was not met. Timescale 15/09/08 The medicine administration record (MAR) chart must record the current drug regime as prescribed by the clinician. It must be referred to before the preparation of the service users medicines and be signed directly after the transaction and accurately record what has occurred. This is to ensure that the right medicine is administered to the right service user at the right time and dose and records reflect practice. The practice of one nurse preparing and signing they have administered medicines and giving to a second nurse to administer must cease. DS0000017660.V377108.R02.S.doc Timescale for action 03/09/09 2 OP9 13(2) 03/10/09 3 OP9 13(2) 03/09/09 Airedale Nursing Home Version 5.2 Page 33 This is to ensure that the records reflect actual practice. 4 OP9 13(2) Staff must transport medicines throughout the home in a safe manner and all medicines must be able to be securely held in a locked facility in the event of an emergency. This is to ensure the service users health and well being is safeguarded at all times. 5 OP9 13(2) All controlled drugs must be held 03/10/09 in a controlled drug cabinet that complies with current regulations and the controlled drugs register is completed accurately in addition to the MAR chart. This is to ensure there is no mishandling. 6 OP9 13(2) A system must be installed to check the prescription prior to dispensing and to check the dispensed medication and the medicine charts against the prescription for accuracy. All discrepancies must be addressed with the healthcare professional. This is to ensure that the service users are administered medicines as prescribed at all times. 7 OP9 13(2) The quantity of all medicines received and any balances carried over from previous cycles must be recorded. This is to enable audits to take place to demonstrate the medicines are administered as prescribed. Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 34 03/10/09 03/10/09 03/10/09 8 OP9 13(2) All dose regimes recorded on the MAR chart must be checked by a second member of staff for accuracy. This is to ensure that the staff have clear directions to follow and the service users are administered medicines as prescribed at all times. 03/10/09 9 OP9 13(2) A quality assurance system must be installed to assess individual nursing staff competence in their handling of medicines. Appropriate action must be taken when these indicate that medicines are not administered as prescribe and records do not reflect practice. This is to ensure that all medicines are administered as prescribed and this can be demonstrated. 03/10/09 10 OP9 13(2) All medicines must be stored in compliance with their product licences. Any medicine that has passed its expiry date must be removed from the premise. This is to ensure the medicines’ stability. 03/10/09 11 OP18 13(6) Evidence must be available to show that all staff have received training in safeguarding vulnerable adults so that people are kept safe from abuse. Any occasions when a service user is physically restrained must be recorded correctly, so that the restraint can be monitored to ensure it is in the person’s best interests. DS0000017660.V377108.R02.S.doc 31/12/09 12 OP18 13(8) 30/09/09 Airedale Nursing Home Version 5.2 Page 35 13 OP37 17 and schedule 3 If the care plan requires records, for example bowel charts, food and fluid intake records and so on, to be kept, these must be accurate, so that there is a true picture of the way the person’s health is being monitored. This requirement was not met. Timescale 15/09/08 30/09/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Airedale Nursing Home DS0000017660.V377108.R02.S.doc Version 5.2 Page 36 Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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