Inspection on 20/01/09 for Alexandra House

This inspection was carried out on 20th January 2009.

CSCI found this care home to be providing an Poor service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alexandra House 07/04/09

Alexandra House 11/02/08

Extracts from inspection reports are licensed from CQC, this page was updated on 18/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Alexandra House 143 High Street Pensnett Brierley Hill West Midlands DY5 4EA     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jean Edwards     Date: 2 1 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 57 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 57 Information about the care home Name of care home: Address: Alexandra House 143 High Street Pensnett Brierley Hill West Midlands DY5 4EA 01214343996 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): suebastable@alexhouse1.fslife.co.uk Mr Jayantilal James Bhikhabhai Patel Name of registered manager (if applicable) Susan Bastable Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users to be accommodated is 50. The registered person may provide personal care with nursing, and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: - Old age not falling within any other category (OP 30) - Dementia over the age of 65 (DE (E) 20) - Physical Disability over the age of 50 (PD 10) Date of last inspection Brief description of the care home Alexandra House is an extended and converted house, which is registered to provide nursing care for 30 older people of which up to 10 beds may accommodate people Care Homes for Older People Page 4 of 57 care home 50 Over 65 20 30 0 0 0 10 Brief description of the care home requiring terminal illness care and 20 older people with dementia. The home is divided into two units: Rose accommodates persons requiring nursing care, including palliative care and Briony which provides dementia care. The home also provides Accident and Emergency Diversion beds, Intermediate care and GP Respite beds when required. The home is situated on an easily accessible public transport route, is close to Merry Hill and Dudley shopping centres and other local shops and amenities. There is a car-parking facility to the side of the building and a garden, which is mainly laid with grass and secluded areas. The home also has a memory garden. Care Homes for Older People Page 5 of 57 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection took place on 11 and 21 February 2008. We, the Commission for Social Care Inspection (CSCI), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. Two inspectors visited the home over two days. We monitored the compliance with all Key National Minimum Standards at this visit. The range of inspection methods to obtain evidence and make judgements included: discussions with the registered manager, operational managers and staff on duty during the visit. We also had discussions with people living at the home, and made observations of other people without verbal communications. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted Care Homes for Older People Page 6 of 57 to the CSCI. A number of records and documents were examined. The registered persons submitted the homes Annual Quality Assurance Assessment (AQAA) as requested. We sent resident surveys, relatives surveys, health care professional and staff surveys to the home to be distributed and requested they be returned to the CSCI office in Birmingham. The collated results form part of this report. We toured the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. The home had not published the range of fees for the service and people are advised to contact the home for up to date information about the fees charged. What the care home does well: What has improved since the last inspection? We noted that some areas of the home had been redecorated and there were some areas being redecorated during our inspection visits. Some bedrooms had been redecorated and we noted that many bedrooms contained lots of personal effects including ornaments and photographs placed around the rooms. A relative commented to us some of the decor has improved. The home had continued with the replacement of some worn out furniture and we were told there were plans to replace more. Another survey included the comments, I have always found the manager and care staff at the home helpful, committed to the needs of the service users. I have worked closely with the staff at the home to improve positive outcomes for service users. A survey completed by someone who had used the service included the comments, I spent some time at Alexandra house, I was quite ill and also could not walk. I can only sing praise for the way I was looked after, food was very good and the medical care was first class, and very impressed by all the girls, nurses etc kept running up and Care Homes for Older People Page 8 of 57 down to care for me. There were 18 of the 27 care staff with an NVQ level 2 care award, which was a very positive achievement, and we told that there were other candidates registered and undertaking training to reach this award. Their knowledge, training and skills will benefit people living at the home. What they could do better: It was identified at the last key inspection almost a year ago that care records did not always support the good care practices and provide the required evidence that each person needs were being met. We identified that staff needed to complete each persons care records to confirm that required care had been provided. We also identified there was a need to make sure that care planning reflected all of each persons individual needs, choices and capabilities. At this inspection we found that these improvements had not been put in place and that people with complex and end of life care needs did not have assessments for all areas of risk and plans to meet their needs at this very important time in their lives. Furthermore at the key inspection in February 2008 we had issued a requirement for the management of the safe use of bedrails to protect people from injury. We found evidence that a safe system for the use of bedrails had not been thought through and put in place and this had also been highlighted to the home at an inspection by the Health and Safety Executive in December 2008 when Improvement Notices were served. We have told the registered persons that the CSCI regarded breaches of Regulations as serious matters, which placed people using the service at potential risk of harm, and further enforcement action will be considered to safeguard people using the services this home provides. The registered persons must make sure that care records are monitored more closely, especially for people with complex needs. This is to make sure that all staff are aware and meeting their needs such as fluid intake, feeding, turning, and observations to prevent falls. The registered persons must also make sure that any weight loss is accurately recorded, monitored with support and advice sought and acted upon from GPs and dieticians. We also made the home aware of a considerable number of areas of medication administration and recording, which must be improved so that there is assurance that everyone living at the home received their medicines as prescribed. Although there was some information relating to activities, we were told there were no outings. Community access must be improved and an individual activities planner put in place for all residents, relating to their preferred individual activities. Social contact must be improved for people being cared for in bed or in their bedroom. The records must be kept up to date and show refusals and any alternatives offered. Following this inspection visit we were made aware of an incident, and unexpected death, which was reported to other agencies and an investigation had taken place with Care Homes for Older People Page 9 of 57 the home. These matters were not reported to the CSCI. The registered persons must take immediate action to refer any incident adversely affecting residents welfare and safety to the lead agency, Dudley Safeguarding Manager and to the CSCI without delay. This is so that vulnerable people living at the home are protected from all risks of harm. The registered persons must also make a record of all complaints and concerns, together with full details of investigations and outcomes and proactively use opportunities presented to improve the quality for people living in the home. A comment from the CSCI surveys in relation to complaints stated, these are not always acted upon We were told that there was a planned refurbishment due to take place over the next financial year, which was positive news. However a repairs, renewal and maintenance plan needed to be put in place and the registered persons must continue with the improvements already identified, in a timely manner. Examples were the need for improvements to bathing facilities, security of wardrobes in bedrooms and improved infection control measures. The registered persons also need to consider carefully the impact of the transient nature of the short stay services upon the lives of the small number of people living permanently on Rose unit, formally consult with them and their supporters and take action to respond to their views. A healthcare professional survey included a comment in relation to privacy, choice and independence, I feel that this is difficult to achieve given the size of the establishment which in turn may put pressure on staff. Although Im sure staff wish to support individuals to live the life they choose they may find this difficult and therefore they may need to adopt more regimented procedures in order to get tasks done in time. The home was providing care, nursing and accommodation for a large number of people in two separate units. All persons accommodated had individual and often complex needs and aspirations, which required appropriate levels of clinical and staff support and supervision. The organisation must seriously review and consider the number of care staff on duty in each unit for the health well being and safety of everyone living at the home. We have issued a requirement for staffing levels to be increased on Rose unit to be able to respond to the high level of activity generated by the frequent admissions and discharges to short stay beds. Comments from relatives, people at the home, staff and some healthcare professionals have highlighted that the home has staffing shortages, which means that people may not have all their needs and preferences met. Comments from the CSCI healthcare professional surveys included, to be more geared to rehabilitation, especially if it is to be used as a step down and accident and emergency diversion facility. The home is very vast and it can be quite daunting to someone coming to stay there, and in my experience of Alexandra house my clients have gone there for a period of rehabilitation. Therefore when looking at the service from a rehabilitation perspective I would have to say that some staff may not have this experience especially when promoting empowerment and clients self determination. Staff appeared to be of a caring frame of mind, which is not a negative comment, however when it comes to rehabilitation a balance between caring and encouragement, empowerment and self determination needs to be made. Another example is that they may use a wheelchair to transport the client rather than allowing them to walk. Care Homes for Older People Page 10 of 57 There had been no analysis for accidents involving people living at the home from June to December 2008. A regular written accident analysis relating to residents must be put in place to highlight any trends or increased risks, which need to be controlled and minimised. There were other significant areas of health and safety and fire safety at the home, which required prompt attention and improvement. These included assurances that all 3 of the Health and Safety Executive Improvement Notices have been met in full and that priority action is to make sure all staff receive mandatory training and are supported with a formal system of staff supervision. We made the management of the home aware that we would be sharing information about our concerns to other agencies such as the Local Authority commissioning manager, PCT commissioning manager and the Health and Safety Executive. 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 11 of 57 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 12 of 57 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information about the services the home provides is not entirely up to date and does not include information about the fees charged. People who wish to live at the home permanently have an assessment of their needs giving assurance that staff are aware of their and can meet them. Intermediate care is not always provided effectively, though people do generally benefit from the working relationships between Alexandra House and other Health care professionals. Evidence: The information contained in the homes AQAA about what it did well stated, Admit new clients on basis of full assessment. Have appropriate equipment for clients. Relatives to view without appointment. Intermediate clients next of kin may view without appointment. Welcome, friendly, clean. The evidenced claimed by the home was, preadmission assessment, welcome pack, letters of invitation. Dedicated accommodation provided with specialist equipment. Training of equipment. Thank you Care Homes for Older People Page 13 of 57 Evidence: cards, verbal feedback, refurbished to enhance, no smell. We looked at a copy of the homes statement of purpose and service user guide, which had been revised when the home was purchased by the new registered proprietor in August 2007. However the information had not been updated since that time. We were told that each person was given their own copy and there were copies in a welcome pack in each bedroom. Unfortunately we were not able to verify this information on our tour of the premises. The registered persons had not included information about the range of fees in the service user guide. We discussed this omission with the registered manager and operations manager and recommended that information about fees should be included in the service user guide to give people comprehensive information about the service to help them make decisions about the choice of home. We were not able to establish the accurate status of all of the people admitted to the home or their funding arrangements from the information provided in the homes AQAA or from information at the home. During the two day inspection visit there was frenetic and often chaotic activity, which made it difficult to obtain and evaluate the information about people at the home, especially those who were admitted for short stays. We were told that senior member staff undertook an assessment of the needs for all people admitted for long term care before they come to live at the home. We were also told that people admitted for a range of other care such as emergency care from the hospital accident and emergency department, respite care funded by their GP, intermediate care or palliative care had an assessment of their needs undertaken by a health care professional or member of the hospital staff. Information was then faxed to the home. We were told that the procedure was for the home to undertake a full assessment of their needs after they have arrived at the home. We were concerned that the staff did not appear to have the capacity to undertake good quality assessments or put in place care plans and risk assessments to ensure their health, well being and safety needs were known and met. From the information made available to us at the home and from the AQAA containing only very basic information it was not possible to establish how many people were funded through Local Authorities and how many and what status through the PCT. It was also not possible to establish how many persons were self funding, though the majority appeared to be funded through continuous health, Primary Care Trust or Local Authority care budgets. The homes AQAA indicated there were 5 people privately funded, all with contracts. As indicated the homes AQAA contained only very basic information and did not identify how many new residents had admitted to the home or discharged since the last key inspection. The homes AQAA stated there had been 72 deaths in 12 months, though these were not collated in any way, for example Care Homes for Older People Page 14 of 57 Evidence: on which unit, or whether persons were admitted for palliative care, whether the deaths occurred at the home or in hospital. We had held a telephone discussion with the registered manager recommending that this would demonstrate a positive approach to management information. For the majority of people admitted to the home there was no evidence that they had an opportunity to visit the home before they were admitted, especially to the recently increased number of Accident and Emergency diversion and intermediate care beds. The intermediate care unit continues to be incorporated into Rose unit, with no separate communal rooms such as lounges, dining rooms, bathing or toilet facilities. We expressed our concern that the 5 people living permanently in this unit, which was their home, were in the midst of continual upheaval as people were admitted and discharged, often at short notice. As at the previous inspection the registered manager told us that, residents preferred to be altogether. However we did not see any evidence of consultations to confirm this statement. We were told that staff received ongoing training in the care of people who required intermediate care. We saw evidence that Physiotherapists and Occupational Therapists visited the home most days and it appeared that they had a good relationship with the home. We received a range of comments about peoples experiences of their short stays. We looked at the care records for a number of people with admitted to Briony unit, which was the more stable unit with only 11 people. We saw that though each person had a contract and terms and conditions, these refered to the previous providers and had not been updated, nor did they include information about individual fees or Registered Nurse Care Contribution (RNCC) reimbursements. Briony unit was a twenty bedded dementia care unit at the home. As noted at the previous inspection in February 2008 the majority of staff had received training in dementia care but we noted more recently appointed staff did not have accredited dementia training. Also as at the previous inspection visit we observed that some staff were more motivated and knowledgeable than others demonstrating a better understanding of people with dementia. This needed to be taken into consideration when allocating staff to work with the differing groups of people accommodated. At the previous inspection in February 2008 we strongly recommended that staff were employed to work either on the Dementia Care unit or the Elder Frail unit to provide continuity and consistent care for people accommodated. During the inspection , especially the first day the home was chaotic with staff being called from Briony unit to Rose unit to help out and after lunch and care staff on long 13 hour shifts swapped from Rose unit to go and work on Briony unit. No action had been taken to change the staffing arrangements in consideration of the good practice recommendation and the registered manager told us that this was the way staff preferred to work. We discussed Care Homes for Older People Page 15 of 57 Evidence: the need for continuity for the people living in the home with her. We reiterated the needs of the people accommodated were paramount, she responded that she would consider changes and put it to a vote at a staff meeting. We discussed her management style and the need for clear and strong leadership for this complex service. Care Homes for Older People Page 16 of 57 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are care plans and risk assessments, which are not always adequate to identify peoples needs and provide staff with guidance. There are not always assurances that all individual needs will be met for each person. The arrangements for administration of medication do not always ensure people receive their medicines as prescribed by their doctor, which may pose risks to their health and well being at times. People are generally treated with respect and their privacy and dignity is maintained. Evidence: We looked at a sample of peoples case files on Briony and Rose units containing care plans, risk assessments and held discussions with staff about how people were supported and given assistance to meet their daily needs. We noted from the sample of records no residents or their relatives and representatives, had signed the plans to indicate their agreement. Care Homes for Older People Page 17 of 57 Evidence: At the previous inspection we reported that all care plans we looked at were the same presuming that everyone had all the same needs, with no differences in choice, capability or need. This had not changed at this inspection visit. The registered manager explained that four experienced nurses had left the home, for valid reasons, and the recruitment of recently qualified and therefore less experienced nurses had an impact on the development and implementation of improvements to care planning. At the previous key inspection in February 2008 we issued requirements relating to care planning and meeting each persons needs and preferences for their personal hygiene. One requirement stated that care plans must identify all the persons needs and when updated must show when changes are made to their plan of care. The evidence we gathered demonstrated that this had not been met. We also required that the arrangements for bathing residents must be reviewed to ensure that people are bathed regularly and to promote their health and wellbeing. There was insufficient evidence to demonstrate this had been met. There had been no action to improve bathing facilities. There was no key worker or named nurse system for continuity of care or system to demonstrate each persons preferences for their personal care were known about and met. The sample of plans for the people with complex needs or towards the end of their lives, did not always consider all areas of the persons life including health, specialist treatments, personal and social care needs. There were a number of areas where there were shortfalls. From the sample of plans we looked at, we noted that there were residents identified with poor nutrition, however their nutritional assessment and care plan had not been reviewed and updated. One person living permanently at the home had weight records, which showed a weight loss of 9lbs from July to November 2008. The weight record showed that the BMI had decreased from 24 to 20 but also recorded 0 weight loss, which was either inaccurate or inconsistent. There was no record to show that these inaccurate recordings had been monitored, queried, or rectified. There were no other records to show that this person had been weighed since the last date recorded on 23 November 2008. There was no record to show that this persons weight loss had been specifically referred to the GP or community dietician for advice and support. There was no care plan to meet this persons dietary needs relating to weight loss. We discussed the concerns with the registered manager. She told us that this persons weight loss had been discussed with the GP who felt that the weight loss was associated with the persons condition. However she acknowledged that there was no documentary evidence to show that support and advice had been sought, or what the Care Homes for Older People Page 18 of 57 Evidence: plan for this person should be. We looked at the care of two people admitted for end of life, palliative care and one person admitted for short stay intermediate care with a view to going home. We were very concerned to note that the one page care plans were inadequate, the persons needs and preferences were not clearly identified and the information did not provide guidance for staff as to how each persons needs for assistance or support were to be met. One person admitted for palliative care 7 days prior to this inspection visit did not have a care plan and some health screening tools and risk assessment were incomplete or completely omitted. For example there was no moving and handling assessment even though the person was nursed entirely in bed and staff told us was moved and had position changes using a slide sheet and lifting belt. We looked at a sample of fluid balance records and there were instances showing insufficient fluid intake and often no record of output. For example on 10/1/08 total 860 mls fluid intake, and no evidence of Fortisip offered or refused. We also looked at this persons MEDIFORM Individual Prescription Sheets and Medication Administration Record. There was insufficient evidence that Fortisips were given or offered as prescribed on a regular basis, there were gaps with no code or signature at 1200 on 16/12/08 and 1800 on 13, 14, 15, 17, 19, 20, January 2009 and during the majority of 6 weeks records codes were recorded as R or A indicating no Fortisips were taken. The medication Calogen had also not been administered consistently. There were no recorded reasons for gaps, codes A or R. The samples of fluid charts were inadequate to demonstrate adequate nutrition and hydration. There were also examples of bowel records, which were not completed with any entries. We looked in detail at the care being provided for another person admitted for palliative care. Alexandra House Nursing Homes basic admission record, noted past medical history and medication on admission but no other sections were completed including end of life discussions. The homes personal details form was partly completed, indicated a nasogastric tube was insitu, and Oxygen was being administered via nasal specs. We noted this person was not receiving oxygen and asked if this was still prescribed. We were not assured of the answer even after asking this question of the trained RGNs on duty on the first day and the registered manager the following day. Daily progress record dated 13/1/09 indicated the person arrived at Alexander house, in an ambulance on a stretcher at 1900 hours, and a pressure relieving mattress to put on bed was needed. It was also noted that the Nutrison feed not sent from hospital. It was recorded that the person was receiving oxygen and on enquiry the ward was unable to clarify whether the oxygen was to be continued. There was an entry to show at 22:30 the night nurse contacted the hospital ward as very messy admission. Notes go on to highlight confusion over medication and whether it Care Homes for Older People Page 19 of 57 Evidence: could be given by the nasogastric tube. We discussed this situation with the homes representatives because this highlighted the difficulties and problems, which can occur when the home does not take control of admissions of people with complex needs. There were no care plans in place to meet this poorly persons immediate needs and no end of life care planning in preparation to implement The Liverpool End of Life Care Pathway, which the registered manager and nurses told us was followed for people receiving end of life, palliative care. We discussed the omissions with the registered manager, and the operations manager, requesting that they reviewed the records as we looked at them. They acknowledged that there were no satisfactory risk and health care assessments or care plans in place for this person. We saw an entry in this persons daily records that they were visited by their own GP who was not happy that his patient had been transferred to the care of the GP contracted to the home for short stay beds. We noted that the nurse at the home had contacted the PCT who requested that GP be contacted to see if he would cover out of hours. The GP confirmed he would be happy to do out of hours call. The persons GP also prescribed stronger pain relieving patches. The change of medication was not recorded elsewhere, and there was no care plan for the pain management regime. We looked at the records for the feeding regime dated 12/1/09, as prescribed by the Department of Nutrition and Dietetics. A nasogastric tube was to be used for 1500 ml Nutrison Standard at 75 ml in 1 hour over 20 hours and 500 ml water at 125 ml in 1 hour over 4 hours. In addition a 50ml water flush pre feed and 50ml water flush was to be given post feed. The nutritional content of final regime was 1500 calories and 2000 mls fluid. We noted that Alexandra House Fluid Intake record dated 13/1/09 recorded, Nutrison 1000, and no times were entered for start and end time or speed of feed and 18:30 Meds H2O 100, running total 1100. This was a typical record and on 17/1/09 at 0600 it was recorded Meds H2O 100 H20 500, no start or end time entered, 18:00 Meds H2O 100, Nutrison 1000, no times entered for start and end time or speed of feed. Running Total 1700. We checked the feed regime actually in place and the Nutrison the prescribed feed in a 1500 ml container was in place. This had not been accurately recorded and no flushes pre and post feed were recorded, though we were told they were given. The night sister and registered manager acknowledged the recording omissions. This record did not demonstrate that the prescribed feeding regime was being accurately followed and there was insufficient evidence that crushed medication was being given at prescribed times via the nasogastric tube, especially as there were 9 separate medicines being given in the morning, 3 separate medicines being crushed and given three times each day, and 1 medicine being given 4 times each day. Care Homes for Older People Page 20 of 57 Evidence: This meant that this person who had been admitted with a prognosis of less than 4 weeks, for end of life care, had records, which did not demonstrate that staff had a proactive approach to end of life care. We visited this person in their bedroom, and we noted that there was a single bedrail in place on left side of bed, which was a Kings Fund bed, the other side was against the wall but with an excessive gap. The bedrail had no bumper or wedge in place. There was no risk assessment on file. We noted that the pressure relieving mattress was a fully inflated at a pressure reading for a weight of 200kg, the adjustable bed was raised at the head and the persons feet were wedged flat against the footboard. We raised our concerns with the nurse in charge who told us that the original pressure relieving mattress was not working and this new mattress had been put in place but she was unfamiliar with the make and model. She told us she did not know how to adjust the setting. There was no written guidance for staff as to the correct setting for this person and as previously noted there was no record or approximation of weight, MUST assessment or BMI on admission. The nursing staff on duty acknowledged that there were no manufacturers instructions for the use of pressure relieving mattresses. We spoke to this person who indicated that they were uncomfortable. We noted that there was a tray for oral care but as previously indicated no care plan in place. We revisited this person with the registered manager the next morning. The registered manager told us she did not know why the bedrail had been put in place and said that it was not needed and had been removed, which we noted. She told us that the bed head should not have been elevated in conjunction with the use of the new type of pressure relieving mattress because it impeded the airflow. She told us that she felt staff should have been aware of how the mattress and bed should have been used but could not produce any written instructions or evidence that staff had been trained or shown how to use the equipment. Although she told us that the air mattress was at the correct setting at 200 kg she could not produce any documentary evidence to support this assertion. We saw evidence of some access to other healthcare professions, for example people admitted from hospital were seen regularly by occupational therapists and physiotherapists, although there were no treatment plans for staff to follow to support people with rehabilitation regimes. We also saw that some people had access to dental and chiropody services. We noted that the care documentation included end of life care plans and relatives expectations but these were generally not completed on the sample of residents care records examined. The nurses told us that this was a sensitive area, which was often difficult to discuss, especially with relatives of very poorly residents. Whilst we acknowledged the sensitivity of the subject, the lack of information may result in the Care Homes for Older People Page 21 of 57 Evidence: persons final wishes not being met and this may have important significance, especially for people with strong spiritual or cultural beliefs. We recommended that staff receive training to give them the skills and confidence to discuss and record final wishes for residents end of life plans. From the sample of care records looked at across the two units, there were no short term care plans for additional care needs associated with time limited conditions such as urinary tract infections or chest infections. Recent short term plans to be useful, should be included as part of the persons care file for reference. The registered manager told us that the home did not undertake the full range of risk assessments and healthcare assessments and did not develop care plans for people admitted for short respite stays, intermediate care, or hospital A/E diversions. We stressed to her the need for care records which were sufficient to identify all risks and care needs and give staff adequate guidance as to how those needs should be met for everyone admitted to the home, including those admitted on an emergency or short stay basis. We stressed that where the home chooses to provide any type of intermediate, short term care that appropriate records must be kept, and suitable facilities and staffing arrangements must also be provided. This is to ensure that the health, well being and safety of all persons admitted to the home are safeguarded. We looked at a sample of care records relating to people with late stage dementia living on Briony unit. Although there was little development since the last key inspection records were generally more detailed. During discussions with the nurse in charge and later with the registered manager there seemed to be a lack of understanding of the actions required in compliance with the Mental Capacity Act and the involvement of independent advocates and multi-disciplinary decisions for the persons best interests. The nurse acknowledged that she had not received training relating to The Mental Capacity Act. When we discussed this with the registered manager she told us that she had booked the nurses on training but had not informed them, as her practice was to tell them near to the date of the training. The home did not have a key worker system, which should enable staff to establish special relationships and work on a one to one basis. We heard from a number of staff who told us they really liked working at the home but found the work very pressured and they felt they often did not have sufficient time to spend with each person. From observations we noted that the routines were very task orientated. There were considerable variances in how well the healthcare screening tools, risk assessments and care planning were implemented, monitored and maintained. The care records for people admitted for short term care were poor and not reviewed as Care Homes for Older People Page 22 of 57 Evidence: changed occurred. This meant that not all persons living at the home could feel assured that all their care needs were known about, understood and would be met. We were told that people living permanently at the home had care plans for social activities. However there were only 5 people permanently accommodated on Rose unit, the remaining 25 beds were occupied by people admitted for short periods of time for a wide variety of reasons and often at short notice. There were 11 people living on Briony Unit, and we were told they all had late stage dementia. There had been no improvements to care planning to meet needs for socialisation or for people with dementia or sensory impairments. At the previous key inspection we issued a requirement for the registered persons to ensure that when people need bedrails they have a suitable risk assessment in place. This also meant that the home must have a safe system in place for the use of bedrails to safeguard people from risks of harm. From the evidence we assessed this requirement had not been met. We found evidence that the Health and Safety Executive had issued the registered proprietor with 3 Improvement Notices on 10 December 2008. One of the Notices related to the safe use of bedrails and gave the registered proprietor until 30 January 2009 to implement a range of actions. Although there were some risk assessments in place they were not well completed or adequate. The registered manager acknowledged that no staff training had been provided relating to the safe use of bedrails and there were no documented maintenance or regular checks in place. We looked at two sets of third party bedrails, which had excessive gaps. Furthermore an accident had occurred to a person admitted to the home for short term care, when the nurses acceded to a relatives demand to use integral bedrails, even though there was evidence that the person would attempt to climb over or through the bedrails. There was no evidence of a comprehensive assessment of risks and consideration of all other options. Additionally there was evidence that the homes own written procedure for the safe use had not been followed. We looked at the homes systems for the administration of medication for people living at the home. On Briony unit as identified at the previous key inspection there were consent forms to give medicines covertly in all care files that we looked at. Covert medication means giving medicines without the person being aware that that are taking the medicine, for example disguising it in a sandwich or in their porridge or soup. The consent forms had not been changed in accordance to advice given at the previous inspection, which at the time the registered manger had agreed to action. We had recommended that the consent records must state what medicine should be given covertly, how it should be Care Homes for Older People Page 23 of 57 Evidence: administered covertly and why there was a need to give it covertly. The records did not specify which foods, forms seen were not signed by relatives, other professionals or GP, and the only signature was that of the nurse in charge of Briony Unit. We were told that only one person needed medication to be crushed and given covertly. We discussed the use of the covert medication assessments and issues of consent with the registered manager on the second day of the inspection. She stated that not all nurses, unlike the nurse in charge, could persuade people take their medication and a number of people needed covert medication in food. We asked to see a written protocol demonstrating compliance with the NMC guidelines and Royal Pharmaceutical Society of Great Britain guidance for covert administration of medication. The registered manager admitted that there was no written protocol at the home. Additionally no action had been taken to undertake assessments for mental capacity in compliance with The Mental Capacity Act, and there had been no involvement of independent advocates for decisions to be made in each persons best interests. There was also no guidance sought for suitable foods for crushed medicines. The storage and administration medication was generally well organised for the 11 people on Briony unit, though some improvements were needed. We looked at arrangements for the administration of medication on Rose unit. There were 2 medication trolleys containing each persons medication in original containers in individual named boxes. We were told trolley 1 contained medicines for permanent and palliative care and trolley 2 medicines for people admitted for intermediate step-down, rehabilitation, GP respite care or from accident and emergency department to a diversion bed. There was a Folder with instructions and good practice guidance such as the need for 2 signatures for hand written entries on Mediform Individual Prescription sheets (MAR) sheets, there must be no gaps, there must be care plans, and records of administration of creams and lotions. We noted that the MIPS, (Mediform Individual Prescription sheets) and MAR (Medication Administration Records) Sheets were for 12 weeks. These were not used to record receipt of prescriptions, receipts of medicines, disposals, and destructions. All medicines were recorded as handwritten entries, many did not contain full details, and were not routinely signed and witnessed by two staff, increasing risk of errors. The majority of the medication records did not include a photograph of the person. This carried an increased risk of errors, especially in as there was a high turnover of admissions and discharges often at short notice with nurses under pressure. On the first day of the inspection visit our observations showed the morning medication started at 0800 was not completed by 11:35, the lunchtime medication round started at 14:00 and was not finished until after 15:30. We acknowledged that Care Homes for Older People Page 24 of 57 Evidence: the nurses had large amounts of medication to administer, often to unfamiliar people, some with complex needs. We considered the situation was posing the risks that people may not be given their prescribed medication at evenly spaced intervals. There may be excessive periods overnight or there may be insufficient time between antibiotics and pain relieving medicines. The medication was stored in the treatment room, and daily temperatures were recorded, generally as 25 C but there were a few occasions were temperatures of 26 C and 28 C had been recorded. The medication fridge temperatures were recorded daily and were generally in an acceptable range between 2c and 8 c. However there were occasions in October 2008 when excessive temperatures were recorded. For example 8 October 2008 a temperature of 13c was recorded. After the medication fridge was defrosted it was recorded as 2c. Medicines stored at excessive temperatures may deteriorate and be ineffective or become contaminated. We told the registered manager that there must be closer monitoring of temperatures of the treatment room and medication fridge to ensure that medication is stored within temperature ranges to maintain its integrity and effectiveness. To avoid further disrupting the medication administration we looked at a random sample of MARS. There were an unacceptable number of gaps with on signature or code for non-administration. Audits were very difficult because receipt of medicines were not recorded on the MAR sheets. We were told all medicines were recorded in 2 separate books, one Rose and one for Briony Unit. We were not shown copies of these books. We noted that a person admitted 10 days previously for intermediate care had Anticoagulant Therapy appointment due on the first day of this inspection visit, 20/1/09 at 1:15, we drew to the attention of the nurse in charge on Rose unit, that this person had not had a blood test to measure their INR level for the next dose of Warfarin on the evening of 20/1/09. The nurse informed us that he had contacted the covering GP, who had verbally told him to continue with 1 tablet each day. This meant that this person was being prescribed verbally 1 x 3 mg tablet daily, instead of the previously prescribed dose based on INR results recorded on the anticoagulant therapy record. The following day, on 21/1/09 the registered manager told us that the RGN had contacted the family who had said the hospital stated that Alexandra House was to continue with the existing regime. This was recorded as Warfarin 3mg and 4.5 mgs on alternate days. We requested that the registered manager clarify this persons anticoagulant medication regime with an appropriate medical practitioner. We were particularly concerned that someone admitted to the home for end of life palliative care who required 2 Fentanyl Patches 12mcg x 1 and 50mcg x 1 every 72 Care Homes for Older People Page 25 of 57 Evidence: hours had not received their Fentanyl Patch 50mcg at 0900 on 10/1/09. The nurse told us it was not given because there was no supply available. The persons last patches were administered at 11:30 on 7/1/09, the Controlled Drugs Register showed a zero balance on this date. We noted that a new supply dated was dispensed on 13/1/09 and it was recorded that 5 x 50mcg Fentanyl Patches were received on 14/1/09. We spoke to the Nurse in Charge on 20/1/09 and she stated that she did not know why the 50mcg Fentanyl patches were not available, and sometimes nurses phone the GP for prescription, and sometimes ask for a fax to be sent to the pharmacist, and sometimes nurses fax a request. She acknowledged there was no recorded audit of what had been done or by whom to obtain supplies. This meant that a person admitted for end of life palliative care was without essential and significant medication to manage their pain for more than 4 days. We discussed omission with the registered manager and asked if there was any other explanation. She went away and came back and told us that she could not find any explanation as to why the prescription for the Fentanyl Patches 50mcg had not been re-ordered but she gave us a copy of a diary page dated Monday 5 January 2009. This had an entry, XX, please fax prescription to pharmacy, and in brackets not needed yet some in cupboard. This entire message was crossed through. The registered manager indicated that she thought this referred to the lack of Fentanyl Patches 50mcg. We saw entries in the persons daily progress records that they had experienced episodes of break through pain requiring oral pain relief and had appeared unsettled and unwell during the period of reduced pain relief. Subsequently their daily records had shown they were more settled and were not requesting additional oral pain relief. The registered manger acknowledged that she had not undertaken formal supervision with staff, particularly the nurses, for their professional development. There was no evidence that the registered manager was undertaking rigorous quality monitoring audits of the medication system or competency assessments of nurses managing and administering medication. These are essential measures to ensure people receive their medicines as prescribed for their health and well being. We saw that staff treated residents with respect and protecting their privacy for the majority of time during the inspection. During discussions staff demonstrated a good understanding of how to protect residents privacy and dignity. We discussed the poor standard of record keeping with the registered manager and indicated that the nurses were not demonstrating compliance with the NMC guidelines for maintaining records and required as a matter of some urgency, that additional monitoring and competency assessments be implemented with training and support given as necessary. We have made the registered manager and the organisations representative aware that we will be discussing these and other failures with people Care Homes for Older People Page 26 of 57 Evidence: commissioning the service and holding an internal CSCI management review with a view to making a referral to the CSCI Regional Enforcement Team for consideration of formal enforcement action. Care Homes for Older People Page 27 of 57 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at this home have only limited opportunities to take part in activities. People are encouraged to maintain contact with their friends and families and visitors are welcomed. Most meals are appetising, although there may not always be sufficient staff to give people who need assistance the support they require to maintain good levels of nutrition and hydration, which may pose risks to maintenance of their health and well being. Evidence: At the previous inspection we noted that progress had started to find out about each persons preferred daily routine such as the time they get up or go to bed, whether they wished to have a bath or shower and at a time of their choice. However there was no evidence that this process had been continued or was reflected as personal choices and flexible routines. There were some preferences recorded on Briony unit, though it was not clear as to whether one person had been bathed or showered, as just a tick had been entered on the personal care record. It had been identified that electric showers triggered this persons agitated behaviour. We did not see preferences recorded as part of the sample of care records on Rose unit, which was operating like a mini hospital and was described to us by people staying there and their visitors as Care Homes for Older People Page 28 of 57 Evidence: often chaotic and frenetic. We stressed the need for peoples wishes and preferences to be recorded and respected. We spoke to one person admitted to Rose Unit for intermediate care and his relative who was visiting, they told us the home was always short staffed. The person told us he had to wait for a long time for help. He stated he could walk with a frame and wanted to go home. He had been assessed by the occupational therapists and needed assistance of one member of staff to walk. His relative stated he had waited half an hour from 12 midday to 12:30 to go to the toilet. He told us he had accidents in his trousers, whilst waiting, which he said was very upsetting. His care records, which indicated a goal to go home, showed there was some deterioration in his condition since admission and confirmed he was becoming incontinent at times. There was a record that he had been offered a urinal for night use, which if it was to save staff time, might create dependence for someone wishing to regain life skills to go home. The nurse in charge on Briony unit told us the home did not have an activities coordinator and that staff provided some activities. She told us there were some activities provided by external providers, such as music and some people join in activities on Rose Unit. However there were no structured activity programmes and there were no records of each persons preferred activities, hobbies or preferences for socialisation. There were no activity records to show any activities, planned or spontaneous or participation or refusals. We were told that there were no outings organised for people living on Briony unit, and it was stated that this was because of insufficient staffing. We were told there used to be outings but none now. We saw that some efforts had been made on the dementia care, Briony unit to identify peoples life history with the help of the person or their family. As we previously noted a record of a persons life history was a good way to provide activities and daily routines within the home, which meets peoples choices, needs and capabilities. Very little progress had been made to transfer the information into a their plan of care to make it person centred. Any activities provided at the home were mainly organised by care staff. We were told there was music to movement and a craft sessions each week of each, church services from a local church each month, and a singer engaged to come to the home to provide entertainment. People who live at the home were able to have visitors at any reasonable time in the day. We observed several visitors arriving and leaving during both days of this inspection. We circulated CSCI surveys to gain peoples views about the home and we also spoke to some people on the telephone. There was a range of views, some people Care Homes for Older People Page 29 of 57 Evidence: were positive about their experiences, others had some concerns and a few wished to raise complaints about unsatisfactory standards. We were told about one person with no relatives in contact and with Court of Protection, from Sandwell Social Services Department in place. We were told that this person might have a relative in Eastern Europe but no one to assist with decision making. We discussed issues of assessment for mental capacity, and strongly recommended organising a review to involve Sandwell Social Services and an independent advocate. We noted that the majority of the 11 people with late stage dementia on Briony unit needed feeding and had pureed meals and the first day of this inspection we saw that everyone had braised beef, vegetables and mashed potatoes. There were no menus in formats, which would be appropriate to their understanding. The menus for lunch were written in chalk on small board in reception outside communal lounge on Rose unit. The home did not have a dining room everyone ate their meals at small tables by their armchair or in their bedrooms. This meant that mealtimes are not made special or social occasions. The lunch time meal on Briony unit was relatively peaceful until staff were called away to help out on Rose unit, causing some disruption and delay. The mealtimes on Rose unit were chaotic, with staff appearing hurried. On the first day the cooked lunch on Rose unit was served at around 12:15, and the pudding was not served until around 1:35 p.m. The main meal was braised beef, vegetables, broccoli, potatoes, with the alternative chicken casserole. The pudding was cinnamon sponge and custard, or ice cream, or choc ice. The cook told us that she served pureed and diabetic diets. Some people really liked the meals, others told us they did not like some meals so much. We noted that there was a large amount of wastage on Rose unit at lunchtime. One person told us that they had not eaten their meal because they had asked for salt twice but none was provided. A member of care staff who overheard the conversation said that she would have brought the saltcellar if she had been asked but the person stated it was too late. Another person said that the meat was gristly. It was positive that one person did not want either choice and had egg on toast, which they said they enjoyed. We saw the cook offer a relative on Briony unit a cup of tea, whilst she was waiting for lunch to be finished. She told us she visited the unit frequently and said the staff were wonderful, lovely, and friendly. On a positive note we saw lots of banter between residents and staff. Care Homes for Older People Page 30 of 57 Care Homes for Older People Page 31 of 57 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot always have confidence their concerns or complaints will be listened to or investigated and the management practices do not always safeguard people living at the home from risks of harm to their health and well being. Evidence: The homes AQAA contained brief information about what was claimed the home did well, discuss with family and clients any queries at time of voicing. Informed families immediate and permanent of procedure to complain. Ensure clients are safeguarded from physical, financial, psychological, neglect or sexual abuse. The evidence cited to show how it was done well was, complaints log, few complaints. Policy and complaints procedure in easy view with telephone numbers. Displayed on foyer wall, statement of purpose in all rooms. Policy and procedure regarding whistle blowing, adult protection. Training, supervision, appraisals. The homes AQAA stated that there had been one complaint in the past 12 months, not upheld and resolved within 28 days. It stated that there had been no safeguarding referrals. We were not able to verify that all of the information provided was accurate. It was accurate that the complaints procedure was displayed in the hall of the home and also included within the service user guide. However we did not see copies of the service user guide as was claimed, available in each bedroom. We saw varied evidence from the CSCI surveys that indicated some people were not entirely satisfied and some Care Homes for Older People Page 32 of 57 Evidence: people have felt they did not receive an appropriate response. Some examples were, these are not always acted upon, Because of the staff shortage carers do not always listen. Important messages do not get passed on to the right department. I attend to my relatives laundry. I was on a short break over the Christmas period and requested that her laundry be attended to by the Alex. However on my return none of her laundry had been dealt with, which made me extremely angry. I raised the matter with the Sister, who said they would deal with the matter. Extremely bad breakdown of communication. lately washing for the elderly is being neglected as they are concentrating on bed clothing, so the clothing for the patient is suffering A professional healthcare workers stated in my experience of Alexandra house it can, at times, be difficult to liaise with staff when either giving information or trying to retrieve it as they appear to be so busy and not necessarily raised concerns, but trying to talk to a lead nurse can be difficult because they are so busy. Sometimes if they say they will look into something they do not act and get back to you. There was also a positive response, have always found that the manager in care staff are very Alex house respond immediately and deal effectively with any concern raised by myself or service providers about care issues We spoke to someone who told us that their relative had been at the home for several years but over past few months standards had deteriorated and though the older more mature staff were very caring the younger staff did not appear so caring, compassionate or interested. They said the home always appeared short staffed, with people rushing about. It was often chaotic and frenetic with lots of people coming and going. They said their relative had deteriorated and had been recently diagnosed with dementia. They described the issue of the soiled laundry left in their relatives room for 2 weeks whilst they were away on holiday, despite requesting it be done at the home for that period of time. They had had raised this with the registered manager who had told them she could not understand why it had not been done. The home subsequently lost several items of clothing, 3 were still missing, and there had been no appropriate response to the missing items, despite repeated requests. The person described an incident where they had taken their relative for a hospital appointment and discovered that the resident had faecal incontinence and had no incontinence pad or pants under their trousers. They said that often the persons nightwear was heavily soiled with faeces. We have strongly recommended that they request a formal response to the concerns and if not satisfied makes a formal complaint to the registered persons with a copy to the CSCI. Care Homes for Older People Page 33 of 57 Evidence: There were other complaints not recorded as such, examples were a person admitted for palliative care, whose daily progress records show they were unhappy with the noise and lights and level of activity during the night time hours. Another person unable to eat a meal, a person unhappy about having to wait excessive lengths of time for attention causing incontinence. As highlighted at the previous sections of this report no action had been taken to date to ensure staff were aware of their responsibilities under the Mental Capacity Act. As at the previous inspection visit we advised that information on Advocacy services should also be available. We have also received information immediately following the two day inspection visit about a safeguarding referral made by the ambulance service, which the PCT, and eventually police and Local Authority were made aware of. This concerned a death of a person admitted into a GP respite bed. This had not been notified to the CSCI either as a death notice or safeguarding mater and significantly was not mentioned to us at any time during the inspection process. This constitutes a breach of trust between the registered persons, the CSCI and other agencies. We expect all registered persons to operate in an open and co-operative manner. This matter is subject to further enquires. Care Homes for Older People Page 34 of 57 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The changes needed to the decor and furnishings would contribute to create a pleasant environment for people to live in. The grounds are maintained to provide an interesting outdoor environment for residents. Evidence: Alexandra House was an extended and converted house situated in a residential area on a main high street surrounded by some shops. The home was registered to provide nursing care for a total of 50 older people, 30 beds for frail older people requiring nursing care of which up to 6 beds may accommodate people requiring end of life, palliative care, and there were 20 beds for older people with dementia. The home was divided into two units: Rose accommodated persons requiring permanent nursing care, including palliative care, which was sited on the lower ground floor, and Briony which provides dementia care. The home also provided Accident and Emergency Diversion beds, Intermediate care and GP Respite beds on Rose unit when required. We found that the Dementia Care Unit lacking homeliness. We also found the toilets and bathrooms to be clinical and institutional and requiring refurbishment, which we had highlighted at the previous inspection in February 2008. The home had a variety of aids and adaptations throughout which were suitable for Care Homes for Older People Page 35 of 57 Evidence: dependent people and a staff call system throughout the home. Toilets were situated throughout the home, were accessible and had grab rails. We were told none of the people who live in the home hold keys to their own bedroom. We saw that a number of bedrooms had been personalised and were decorated in different colour schemes. However there were a large number of bedrooms, which needed minor repairs, the majority had wardrobes, which were not secured for safety and there were bedrails in use, which were not properly secured and with excessive gaps. The concerns regarding bedrails are highlighted at the Health and Personal Care Section of this Report. We were told all bedrooms on the lower ground floor had been redecorated and all had lockable facilities for individuals to store any valuables as required. We viewed a number of bathing and toilet facilities throughout the home. Many areas need attention, such as a toilet where the paper towel dispenser needed replacing and there was no evidence of liquid soap dispenser. Another toilet had a liquid soap dispenser but no paper towel dispenser. Others need minor repairs and improvements to make them less clinical. We saw a shower room, where the toilet lid was broken and not attached to the toilet. A chair was being stored in this room and it was acknowledged that this needed to be removed so there was room to manoeuvre. We were told that the walls in the lower ground floor assisted bathroom were to be redecorated. There was storage of continence pads, a dressing gown, slippers, which must be removed to adhere to infection control procedures. We were told that this would be done. There was a thermometer displayed on wall to ensure temperatures are monitored and water temperatures are tested. The cold water tap was dripping in the hand washbasin and this was pointed out to the handyman to be fixed. There was a single toilet on the lower ground floor but we were told that it has not been used for some time and was being used to store decorating materials. We toured the Palliative Care Unit. We were told there were up to six palliative care beds on the lower ground floor of the home. The hallways on the palliative care unit were being decorated at the time of inspection. Staff told us that it was decided to place palliative beds on this floor due to it being a quieter area of the home and there were pleasant outlooks from the bedrooms onto the garden area. We looked in three bedrooms on this floor, one bedroom had an en-suite and we were told that in the main individuals requiring palliative care would require assistance in using the toilet area. However, we found no infection control procedures in place, such as liquid soap and paper towel dispensers. Care Homes for Older People Page 36 of 57 Evidence: In all bedrooms there were window restrictors and there were televisions provided by the home. We found that the wardrobes in a large number of bedrooms were not secured to the wall and though there were hooks in place that could be used, it would mean that wardrobes would need repositioning for these to be secured appropriately. We looked at another room designated for palliative care, there was no name on door but bedroom was in use. The wardrobe was not secured to the wall though a hook was in place and the door to the en-suite was restricting access to the hook, which meant the wardrobe would need repositioning. Once again there were no infection control procedures in place when staff assisted people in their en-suites. Although we were told that three paper towel dispensers were on order, the member of staff could not confirm where these would be placed. We looked at a third lower ground floor bedroom with a hand washbasin but no infection control measures in place and again it was confirmed that individuals would need assistance in the palliative care unit. The wardrobe in this room was not secured to wall and there was a piece of wood fixed to the wall where the bed was positioned, which was hanging off. The member of staff could not exactly confirm why these pieces of wood needed to be on walls and it was agreed that these would be removed as there were health and safety risks due to the position beside the bed. We looked at the laundry room, which was managed by dedicated staff from 09:00 15:00, seven days per week. There were pigeon holes with names of individuals who lived at the home, where laundered clothes were stored and this ensured organisation of clothes was maintained. We noted that the iron press needed a new cover. There were two commercial washing machines and dryers. There were infection control measures in place and evidence of colour coded mops in use. We toured Briony Unit, which had a combined lounge and dining area. This had been decorated and new carpets provided. The lounge area had comfortable seating, a television and there were painted murals on the walls. One wall had an image painted to resemble a pub that people in the home would be able to recognise. The opposite wall had been painted to resemble a shop with jars of sweets and other items. Rose unit also had a large lounge but no separate dinning area, and as previously mentioned people ate their meals from small tables placed near their armchairs. There were no separate facilities for the five people living permanently at the home. We raised the issues of the very busy, hectic environment with numbers of people coming and going at short notice, with the registered manager. We highlighted that the National Minimum Standards for older people stated that separate and dedicated facilities should be provided for people receiving intermediate, short stay care. This is Care Homes for Older People Page 37 of 57 Evidence: so that there is little or no intrusion for people who live at the home as their permanent place of residence. The registered manager assured us that the 5 people enjoyed the activity. However we were not shown evidence to support this view and we received comments from a relative giving a totally opposite view, stating that they were aware that at least one person could not stand the noise at times. The home had a small room, which was currently used for meetings. We were told that was going to be refurbished to provide a room that would be used for rehabilitation purposes with a small kitchen facility. This would enable people who were admitted into the home for the purpose of intermediate care to be able to practice their independent life skills in the readiness for leaving the home and returning to live in the community. The home had domestic staff to clean the home every day, between 09:00 - 15:00, seven days a week. The home also employed bed makers ensuring beds were made. The standards of cleanliness were good and there were no discernable malodours during this inspection. The homes AQAA cited the following evidence as improvements made in the last 12 months, update equipment, soap dispensers etc. New sluice machine fitted. Maintenance program audit in place. Replaced valves in all sinks. Maintain and update policy and procedure. Care Homes for Older People Page 38 of 57 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skill mix of staff do not always consistently meet the needs of people living at the home. Recruitment and selection procedures are robust and safeguard vulnerable people. Evidence: The homes AQAA cited the following as evidence of what they do well, encourage and listen to staff. Maintain skill mix and appropriate to the assessed service users needs. Encourage and train staff. Maintain few vacancies. Use few agencies. Home operates a thorough recruitment procedure for all new staff. Continue to train. The homes AQAA cited the following as evidence, maintain staff rota. Residents satisfaction survey. Few complaints. NVQ training quite high percentage. Small portion of agency staff. Personal files, and equal opportunities, a completed application forms, 10 year employment history, to references, photographs, CRB enhanced and health questionnaire. First-day induction and foundation within three months. Training matrix and certificates. Appraisals and supervision. We were unable to verify the accuracy of all of the positive practices claimed in the homes AQAA. The staffing levels in place to meet all of the needs of people accommodated at this home were questionable as highlighted though the previous sections of this report. There were 11 people with late stage dementia accommodated Care Homes for Older People Page 39 of 57 Evidence: on Briony unit and 30 people accommodated on Rose unit, with a variety of dependency levels, complex and diverse needs over the two day inspection. The homes AQAA did not contain the required level of detail about the dependencies of everyone accommodated at the point it was completed. There were no details of people receiving palliative care or intermediate care. We saw and heard about people waiting for attention, especially medication, assistance with feeding and assistace to the toilet. We witnessed staff being called from Briony unit during the lunchtime meal to give assistance on Rose Unit, leaving people who were being fed. We were told that there was no key worker or named nurse system or staff specifically allocated to meet individual persons needs on a daily basis. This meant there was little in the way of continuity or consistency especially for people with very complex needs on either unit. We were particularly concerned about staffing arrangements for Rose unit, accommodating 30 people, only 5 permanent residents. It can have up to 6 people admitted for palliative care, and other people admitted into a mix of beds designated GP respite, Accident and Emergency Department diversion and intermediate step down, all which could be admitted at very short notice. We were told that there were usually 2 RGNs during the early shift, 1 RGN on the late shift, and 1 RGN on night shift. There were 4 carers on early and late shifts and 4 carers in total for the home at nights. Many staff worked long day shifts but swapped from one unit to another part way through the day. For example three staff who had worked the early shift on Rose unit, worked the late shift on Briony unit. This issue was raised at the previous key inspection. The registered manager told us that this was how staff preferred to work, so that they had variety and did not spend long periods with either very heavy or very stressful workloads. We expressed our concern that this did not provide adequate continuity for the people being cared for and serious consideration must be given to allocating staff to work with people on a consistent basis so that they know, understand and can meet their individual needs and preferences. We also pointed out that consideration needed to be given to the issue, that where staff rotas allocate long 13 to 14 hour working days, staff must have a reasonable break, during which time, the home may not be maintaining adequate staffing numbers on duty and available to respond to peoples needs. We were not shown dependency tools, which linked to staffing levels to allow the home Care Homes for Older People Page 40 of 57 Evidence: to respond in times of increased need. The staffing rotas both in terms of numbers and stability did not demonstrate that managers regularly monitored residents dependencies and occupancy levels and reviewed and revised staffing levels, making appropriate adjustments. This was particularly important during the period when we inspected the home because the registered proprietor had agreed a contract with the PCT to increase the number of beds to be available for short term, often short notice admissions, for a temporary period. However no additional staffing resources had been planned for. The result was that on a day of extreme pressure there were insufficient staff to cope adequately with 5 short notice discharges to community resources and the urgent admission of an influx of up to 5 people late in the afternoon, with only one recently qualified RGN to take control and responsibility. The staff had to rely on support from the organisations operations managers, who happened to be at the home, to help pack peoples belongs ready for discharge. We also spoke to the night sister the following morning who described a chaotic night with buzzers sounding and people in unfamiliar surroundings anxious for reassurance, in addition to the needs of heavily dependant people already at the home. The homes AQAA recorded that 19 care shifts were covered by temporary or agency staff in the previous 3 months. These were potentially people who would not know the residents and their needs well. We noted that the homes AQAA showed that 7 staff had left the homes employ during the past 12 months and we were told that this included 4 very experienced, well qualified nurses, who had left for valid reasons. We looked at a sample of staff personnel files at this visit and the manager had continued to demonstrate generally satisfactory recruitment practice, well ordered staff files and documentation. However application forms must show a full employment history, rather than the 10 year employment history referred to the homes AQAA. It was positive that 18 out of 27 care staff have obtained an NVQ 2 qualification. We were told that there were additional care staff who were working towards this Award at present. The registered manager told us she had taken action to improve the systems for mandatory training at the home, though we noted from the training matrix there were still a number of significant gaps. We were told that all staff were now attending regular training sessions ensuring that their knowledge and skills were being kept up to date. We spoke to the nurses about clinical practice and updates available for conditions such as diabetes, tissue viability, Parkinsons, infection control and whether there were any link nurses with specialist areas provided or supported by the PCT. We were told Care Homes for Older People Page 41 of 57 Evidence: that that there was good access to all mandatory training but they did not seem aware of opportunities for keeping up to date with clinical practices. As highlighted earlier in this report when we discussed training for nurses with the registered manager she told us that she booked them on training courses and informed them near the time. Despite the claims made in the AQAA completed by the registered manager she acknowledged that she had not provided regular structured supervision or appraisals for staff. This was confirmed by responses from CSCI Staff surveys, such as, in the three years I have worked here I have had one appraisal with the matron, I have never had an appraisal or supervision meeting whilst working at Alexandra house. You can always discuss any concerns you have but it is not an official meeting and a positive response, yes I think it is good to know how you are doing at work and to make sure I am up to date with everything. Regular supervision and support for professional development is especially important for recently employed, recently qualified nurses, responsible for running shifts. During discussions staff demonstrated that they were generally aware of the aims, policies and procedures of the home. We saw evidence that staff had a warm rapport with residents and families and had some, if not always detailed knowledge of their needs and preferences. Comments from staff indicated that they felt they were short staffed and worked under presure. Comments from the staff surveys, included, sometimes there is enough, but when we are nearly full with AE and GP respite, palliative, palliative respite and stepdowns, I feel there is not enough. At the moment we have 5 very poorly clients on complete bed care and need 2 carers for personal care etc. so leaves 1 carer to do everything else., when we are full on our nursing, AE side we are normally short staffed, therefore if we have morning activities, a majority of patients miss out as they are still in bed and care is first-class, but would be better with more carers and when full we need more staff to be able to give each patient quality time. Also when full, bedbound palliative patients do tend to be left and last priority. There were a mixture of views from people at the home as recorded throughout this report, others included, There appears always to be a staff shortage and agency workers do not know how to deal with some of the residents, and a great deal could be improved at the Alex with permanent properly trained staff although the older staff are very caring but unfortunately have to carry some members of staff who do not take their duties seriously. We noted that there was a commitment to some staff training and development and to provide staff with appropriate training to raise awareness and skills to respond to peoples changing needs. We saw evidence that 18 of 27 care staff had achieved an NVQ level 2 care award with new candidates registered for training. Care Homes for Older People Page 42 of 57 Care Homes for Older People Page 43 of 57 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at this home cannot be assured that the management arrangements always provide effective leadership to ensure that their health, well being and safety of will be safeguarded. Evidence: The registered manager, Susan Bastable had been in the post since 2007. We noted that she had achieved the Registered Managers Award, RMA and she had RGN qualifications and many years of clinical experience. She used to be a night sister at Alexandra House Nursing Home for many years before becoming deputy manager for the previous registered proprietors. Her managerial hours were generally supernumerary but she told us she had recent being working a number of clinical nursing shifts at the home. We were told the registered manager had the support of an Operations Manager but we were unclear as to whether there was a designated, experienced deputy manager within the home. Care Homes for Older People Page 44 of 57 Evidence: We noted that a number of areas of quality auditing had ceased since June 2008. The records showed that bedroom audits were last recorded on 06/06/08, the kitchen audits were last recorded on 06/06/08, and monthly audits were last recorded on 06/06/08. As already mentioned in earlier sections of this report we received the homes Annual Quality Assurance Assessment report when requested. However the information was not sufficiently detailed to demonstrate the service was based on robust and continual self assessment and improvement and some information was found to be inaccurate and misleading. The registered persons must ensure that the AQAA is thoroughly and accurately completed and be aware that the information will be sampled and verified as accurate or not at future inspections. We noted that the homes AQAA recorded that there had been 73 deaths in the last 12 months. We were told the death notifications had been audited and collated against differing categories as we had strongly recommended during a phone conversation in October 2008 about the level of notified deaths occurring at the home at that time. We had acknowledged that the home provided up to 6 palliative care beds for end of life care and stressed the importance of collating meaningful data, to corroborate information or to identify trends. We looked at the homes quality assurance system and noted that the operations manager made regular unannounced visits and provided the home with Regulation 26 reports about the conduct of the home. There were reports dated 06/06/08 and 30/05/08, which included medication audits, action needed to update photographs but everything else satisfactory. Unfortunately the management and administration of medication was not satisfactory at the time of this visit and the evidence found was shared with the operations manager and registered manager. The regulation 26 report dated 12/09/08 recorded that the refurbishment programme was to be continued, staff shortages were mentioned, and comments such as Food is wonderful Well looked after were reported. The report dated 20/12/08 indicated there were no concerns and verbal complaints record is kept, New carpets fitted downstairs and staffing was better. We discussed our serious concerns with the registered manager, highlighting that she did not appear to be coping and was overstretched, with the home appearing disorganised and chaotic. We highlighted that the organisation needed to develop supportive and effective management strategies to resolve the quality failures highlighted in this report and implement quality improvements, which would benefit people accommodated at this home. Care Homes for Older People Page 45 of 57 Evidence: The registered manager told us that there were no relatives meetings as she considered the home had an open door policy. We noted at the earlier section of this report that the registered manager had not undertaken competency assessments of the trained nurses, especially relation to their medication administration practice. We noted that none of the staff had received an annual appraisal and there was no formal structured supervision system, which meant that care and particularly recently qualified nursing staff were not being appropriately supported and supervised with their professional development. We looked at a sample of mandatory staff training records, fire safety and maintenance service records, which were not entirely satisfactory. Examples were that the Health and Safety Executive on 10 December 2008 had issued the registered proprietor with three Improvement Notices, one relating to bed rails not fitted appropriately, with a compliance date of 30 January 2009. This identified that a previous requirement issued by the CSCI relating to bedrails was also breached. This was highlighted at the Health and Personal Care section of this report. The second and third Notices related to Hoists/slings with no report of thorough examination with a compliance date of 30 January 2009, and a lack of suitable water management system in place to control risk of Legionella bacteria with a compliance date of 30 January 2009. On a positive note the home had been inspected for food safety on 31/10/08 and achieved a good rating, and 3 stars. We noted that there were some considerable gaps in mandatory training, such as food hygiene, first aid and moving and handling. Prioritised action must be taken to ensure essential mandatory up to date training is provided for all staff commensurate with their role. We looked at the accident records for the past 12 months. There were 168 recorded accidents relating to residents in the last 12 months. Accident audits, which were completed from January to June 2008 showed times, location, and whether sent to hospital, which was good practice. However there were no accident audits undertaken after June 2008 until the unannounced key inspection visit on 20 and 21 January 2009. The organisations operation manager had already identified the lack of analysis of accidents and review of risk assessments as part of her quality audits and had given the registered manager the task of bringing them up to date. The registered manager was not present on the first day of this inspection and on the second day she acknowledged she was not up to date with quality audits of records. She gave us a Care Homes for Older People Page 46 of 57 Evidence: documented audit for the accidents, which had occurred in December 2008, though these had not been reflected in revised risk assessments, especially important for people experiencing repeated accidents such as falls. We saw there were several examples where people had experienced several frequent accidents. We noted that copies of accident records were not kept on each persons care file and two nurses spoken to told us they were unaware of the frequent accidents to the people mentioned. On the sample of residents care records looked at none of the falls risk assessments highlighted accidents sustained or remedial actions, which meant that dealing with accidents in isolation posed risks that staff would not be aware of previous incidents and the risk of further harm to residents would not be managed or minimised. We have made the registered provider and registered manager aware that were have taken copies of evidence of previous requirements, which were not met and are breaches of The Care Regulations 2001 and in view of the serious concerns the Commission for Social Care will carefully consider further enforcement actions which may be taken to safeguard the people living at this home. We have also made the registered persons aware that additional monitoring inspections will be undertaken at Alexandra Nursing Home and that information will be shared with other agencies to safeguard people accommodated at the home. Care Homes for Older People Page 47 of 57 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 Care plans must identify all 30/04/2008 the persons needs and when updated must show when changes are made to their plan of care. The arrangements for bathing residents must be reviewed to ensure that people are bathed regularly and to promote their health and wellbeing. When people need bedrails they have a suitable risk assessment in place. 30/04/2008 2 8 12(1)(a) 3 8 13(4) 30/04/2008 Care Homes for Older People Page 48 of 57 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 12 The registered persons must 02/03/2009 ensure that special care records such as food, fluid balance charts and turn charts are in place, with care provided appropriately recorded and monitored. This is to ensure residents health and well being is maintained 2 8 12 The registered persons must 02/03/2009 take action to ensure that residents with poor nutritional intake and / or weight loss are weighed or monitored using the MUST as frequently as required by their risk assessment and care plan. This will ensure that staff take required actions to promote residents health and well being. 3 8 12 The registered persons must 02/03/2009 take action to ensure that Page 49 of 57 Care Homes for Older People the all aspects of health care assessments and risk assessments identify and provide guidance for all areas of risk and reflect all changes to each persons health and needs, including short term care needs. This is to ensure that people living at the home are safeguarded from risks to their health and well being and safety at all times. 4 9 13 The registered persons must 02/03/2009 ensure that medication is stored within the temperature range recommended by the manufacturer at all times to ensure that medication does not lose potency or become contaminated. This is to safeguard the health and well being of people living at the home. 5 9 13 The registered persons must 02/03/2009 take action to ensure that Staff who administer medication are assessed as competent and their practice must ensure that people living at the home receive their medication safely and correctly. This is to safeguard the health and well being of people living at the home. 6 9 12 The registered persons must 02/03/2009 ensure that appropriate information relating to Care Homes for Older People Page 50 of 57 medication is kept, for example, in risk assessments and care plans to ensure that staff know how to use and monitor all medication including when required and as directed medication to ensure that all medication is administered safely, correctly and as intended by the prescriber to meet individual health needs. This is to safeguard the health and well being of people living at the home. 7 9 13 The registered persons must 02/03/2009 ensure that the records of the receipt, administration and disposal of all medicines for the people who use the service are robust and accurate to demonstrate that all medication is administered as prescribed. This is to safeguard the health and well being of people living at the home. 8 9 13 The registered persons must 02/03/2009 provide a written protocol for the administration of covert medication, which incorporates NMC and Royal Pharmaceutical GB guidance and maintains records reflecting the reasons why covert administration is required, how the medicine is given, the persons agreement, or evidence of an assessment in Care Homes for Older People Page 51 of 57 accordance with the Mental Capacity Act, with an Independent Advocate as necessary to indicate decisions are made and reviewed in the persons best interests. Documented Pharmaceutical must also be obtained to demonstrate which medicines can be given covertly and in which food preparations. This is to safeguard the health and well being of people living at the home. This is to safeguard the health and well being of people living at the home. 9 16 22 The registered persons must 02/03/2009 demonstrate that all complaints are fully investigated, with records of outcomes, actions and responses to complainants where they are known. This is to ensure that the health and welfare of people living in the service are safeguarded. 10 18 13 The registered persons must 02/03/2009 ensure that ALL allegations or suspicions of abuse are referred to the designated person in accordance at the Lead Agency in accordance with the multi-agency Safeguarding Procedure without delay. Care Homes for Older People Page 52 of 57 This is to ensure that the health and welfare of people living in the service are safeguarded. 11 27 12 The registered persons must 27/02/2009 take action to ensure staffing levels are reviewed in conjunction with occupancy and dependency levels to ensure that each persons needs are consistently being met throughout the day and night. This is to safeguard the health, well being and safety of people living at the home. 12 27 12 The registered persons must 27/02/2009 increase the numbers of staff on duty on Rose unit to a minimum of 2 qualified nurses and an extra care assistant for the day shifts, throughout the waking day, with additional contingency arrangements at times of high activity. This is to safeguard the health, well being and safety of people living at the home. 13 33 24 The registered persons must 31/03/2009 implement effective quality monitoring systems, which demonstrate that positive quality outcomes are consistently achieved for all persons living at the home. Care Homes for Older People Page 53 of 57 This is to safeguard the health, well being and safety of people living at the home. 14 36 12 The registered persons must 27/02/2009 implement a robust formal staff supervision system for staff support and development to ensure that they have the knowledge, skills and training to met each persons individual needs. This is to safeguard the health, well being and safety of people living at the home. 15 37 37 The registered persons must 27/02/2009 ensure notifications are submitted to the Commission of Social care and Inspection of any incident that has affected the health, safety or wellbeing of the people at the care home, without delay. Some examples are incidents requiring safeguarding referrals and all significant pressure ulcers. This is to safeguard the health, well being and safety of people living at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 It is recommended that information about fees should be Page 54 of 57 Care Homes for Older People included in the service user guide to give people comprehensive information about the service to help them make decisions about the choice of home. 2 2 That each person living at the home is given an up to date, accurate contract of residence with details of their individual fees and RNCC reimbursement where applicable, signed date and witnessed. It is strongly recommended that staff are consistently deployed to work either on Briony the Dementia Care unit or Rose the Elder Frail unit with people permanently living in the home or allocated to provide for the needs of people admitted for emergency or intermediate short stays at the home. That manufacturers guidelines for use and maintenance of pressure relieving mattresses should be available on each persons risk assessment and care plan to ensure that they are maintained that the correct pressure for the persons individual care. That each persons last wishes in respect of death and dying should be explored and be recorded within their end of life care plan. It is strongly recommended that staff record the date and time medication is commenced on the original container for ease of auditing. That all handwritten entries on MAR sheets are signed and witnessed by two trained competent staff to minimise the risks of errors. That photographs of people accommodated at the home are available on the medication system as an aid to identification to minimise risks of errors. That there should be daily menus produced in appropriate formats, such as large print or pictorial, suitable for people with dementia or sensory impairments to assist their understanding and help them make realistic choices. There should always be an equitable choice of meal available. This was a previous good practice recommendation, not met. That the organisation continues the maintenance, renewal and redecoration programme throughout the home, with clearly identified priorities and timescales to provide a pleasant and comfortable environment for people living there. That serious consideration be given to providing separate facilities for people admitted for short stays or intermediate care, so that they do not intrude on people who live Page 55 of 57 3 6 4 8 5 9 6 9 7 9 8 9 9 15 10 15 11 19 12 20 Care Homes for Older People permanently at the home, unless this is with their clear documented agreement and consent and is regularly reviewed. 13 20 That serious consideration be given to the internal environments of each unit to provide more orientation and stimulation, especially for people with dementia and sensory disabilities. That all assisted bathrooms and shower rooms being used as inappropriate storage for items of equipment are cleared of all extraneous items, which limit space for people needing any physical assisting and pose risks to staff assisting people in taking baths or showers. That the action is taken to undertake minor repairs to bathrooms and WCs , and bedrooms including securing wardrobes, which could pose health and safety risks to people living in the home. To provide sufficient and appropriate bath and showers at the home to give assurance that facilities are suitable for peoples needs. That there are working liquid soap in dispensers in all areas to ensure that all staff working at the home can maintain good infection control practices. That serious consideration be given to implementing a key worker and named nurse system and introducing allocated workers for each person with complex or immediate needs on a daily basis to ensure all their needs are effectively met. That regular documented accident analysis be resumed to ensure that accident records are fully completed, with the unit clearly identified and risk assessments are reviewed and revised in accordance with any changed needs. Prioritised action must be taken to ensure essential mandatory up to date training is provided for all staff commensurate with their role. 14 21 15 21 16 21 17 26 18 27 19 38 20 38 Care Homes for Older People Page 56 of 57 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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) Commission for Social Care Inspection (CSCI). 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. 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