Inspection on 24/11/05 for Amberley Court Nursing Home

This inspection was carried out on 24th November 2005.

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

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

Other inspections for this house

Amberley Court Nursing Home 29/04/09

Amberley Court Nursing Home 06/05/08

Amberley Court Nursing Home 26/09/07

Amberley Court Nursing Home 17/10/06

Amberley Court Nursing Home 10/05/06

Amberley Court Nursing Home 05/07/05

Amberley Court Nursing Home 08/12/04

Amberley Court Nursing Home 30/06/04

Amberley Court Nursing Home 23/02/04

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Amberley Court Nursing Home 82-92 Edgbaston Road Edgbaston Birmingham West Midlands B12 9QA Lead Inspector Donna Ahern Unannounced Inspection 24th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Amberley Court Nursing Home Address 82-92 Edgbaston Road Edgbaston Birmingham West Midlands B12 9QA 0121 440 4450 0121 446 4670 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Limited Mrs Karen Hook Care Home 70 Category(ies) of Dementia - over 65 years of age (70), Old age, registration, with number not falling within any other category (70), of places Physical disability (70), Physical disability over 65 years of age (70), Terminally ill (70) Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. General nursing, males and females over 65 years and younger adults with physical disabilities or requiring terminal care. Up to 10 persons may receive day care additional to those in residence; subject to ability to meet all needs. 5th July 2005 Date of last inspection Brief Description of the Service: Amberley Court is a large purpose built nursing home; it is situated within the Moseley/Edgbaston area of Birmingham. The home provides care for a diverse range of residents both in terms of age, ethnicity and care requirements. There are plans to restrict further admissions of older persons with a gradual conversion to focussing upon care for younger adults. The current occupancy of younger adults far outweighs the ratio of older persons. The premises include three stories with the top floor housing the laundry facilities, staff rooms and offices. The first floor consists of two areas, one for high depency care and the remainder for rehabilitation. The first floor also provides a dedicated computer room for use by residents and a grillroom where meals can be ordered throughout the day. Further rooms include a harmony suite and a lounge that has been adapted for wide screen television use and discos. The ground floor has a large dining room, which is accessible by wheelchair users; meals are served over two sittings with timings being fairly flexible. Two more lounges are available on this floor situated at each end of the home. All communal rooms, bedrooms and bathing facilities are located on the ground and first floors. All bedrooms have en-suite facilities consisting of toilet and wash hand basin. A fenced garden area surrounds the home; a further garden is accessible from the dining room. There is a large off road car park, which accommodates many cars and larger vehicles. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct an unannounced inspection, which was carried out by two inspectors over a period of two days. The first inspection was a night visit and the second part of the inspection took place across a long day. The outcomes were determined by various means. In depth discussions were held with the regional manager and the inspectors held discussions with residents. Seven staff members were interviewed; three trained nurses and four carers. Relevant documentation was examined including three care plans and the complaints received by the home since the last inspection. The staffing levels, knowledge base and training provided for them were also reviewed. A partial tour of the premises was conducted and aspects of health and safety were scrutinised. What the service does well: What has improved since the last inspection? What they could do better: Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 6 The registered manager resigned from her position in mid November 2005. Temporary management arrangements were in place, which included the operations manager basing herself, fulltime in the home and a service manager from another area was supporting her with the day-to-day management of the home. The previous report identified a number of areas that required urgent attention. The areas of concern included, the management structure, care plan development, staff supervision, staff training and aspects of Health and Safety. The action plan received from the provider on the 23 August 2005 in response to the announced inspection July 2005 indicated that progress had commenced on all areas of concern. The findings of the unannounced inspection was that the inspectors could not evidence that progress had been made in the majority of assessed areas and in many of the assessed areas there was evidence of further decline and this is a significant concern. A letter of serious concern regarding health and safety, medication, recruitment practice, security of information, manual handling and risk assessment was served on the 2nd December and a Statutory Requirement notice regarding care planning and Fire safety was served on the provider towards the end of December 2005. A Response was received on the 6th December 2005 from the provider regarding the letter of Serious Concern detailing the action that had been taken on all matters raised. All outstanding requirements from previous inspections must be addressed, as these have been outstanding for some considerable time. Failure to comply with statutory requirements may lead to the commission being minded to take further enforcement action. Care plans have been inadequate for an extensive period of time; these must be adapted so that they meet the needs of the majority of the client group, who are younger adults. The medicine management was very poor and must be improved to ensure the residents receive all their medicines as prescribed. A separate letter of serious concern was sent on medication matters to the provider. The complaints procedure is readily available but lacks evidence that outcomes of complaints are being monitored. This must be addressed so that residents feel that their concerns are listened to and followed up on. The home must address the long standing concerns regarding lack of formal staff supervision and provision of mandatory and appropriate training to enable staff to meet the needs of residents. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 7 The organisation must formally review the arrangements for staff handover at the point of shift change, where information should be shared regarding residents care so that there is a consistent approach to meeting residents needs across all shifts. The organisations staffing proposals required further discussion with CSCI so that appropriate staffing levels are provided to meet the complex, diversity and range of needs that people living at the home have. All aspects of Health and Safety in respect of fire safety and maintenance of lifting equipment was of concern. Significant improvements are required so that the health, safety and welfare of residents is protected. Birmingham Social Care and Health have been informed of the concerns at Amberley Court Nursing Home. Who will be arranging a meeting in January 2006 to talk to the organisation about what they need to do to make people safe. CSCI are monitoring the home and further unannounced and monitoring inspections will be conducted to monitor progress against requirements made. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Prospective residents are not provided with sufficient written details about the services provided to assist them in making an informed decision about the home. EVIDENCE: The Statement of Purpose was deemed as requiring significant development at the inspection July 2005. A copy of the revised Statement of Purpose was requested to be forward to CSCI so that it could be assessed. At the time of compiling this report the revised document had not been received and therefore the outstanding requirements are carried forward to this inspection report. The operations manager stated that a letter detailing the room to be occupied had been appended to the “ The contract of terms of residency” the inspectors did not assess this at the time of the visit. The admission policy was dated September 2003 and required review as raised in the previous inspection report. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 There is no clear and consistent care planning system in place to provide adequate information for staff to deliver acceptable levels of care. Resident’s are at risk as health care needs are not being fully met or relevant risk assessments being carried out. Staff practices regarding the administration of medications were found to place residents at risk. EVIDENCE: The care plans examined in July 2005 identified that although some improvements have been made many gaps and inconsistencies were found. The home had introduced an interim basic assessment form that should be completed within 24 hours of admission; in some cases these were only partially completed or in one case not completed at all. There were no shortterm care plans for occasions when residents developed complications such as chest infections. The records indicated that the monthly weight and observation charts and prescribed daily passive exercises had significant gaps. Where it could not be evidenced that they had taken place. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 11 The manual handling assessment of one resident failed to include equipment used to provide means of mobilising and to carry out the prescribed daily exercises. Care planning and progress notes failed to address psychological assessments, needs and guidance on action to be taken by staff in the event of inappropriate behaviour. At the time of the unannounced inspection sampled care plans indicated that limited progress had been made on developing the care plans. There was no pre admission assessment form on the care plan for resident (A.T). Short-term care plans implemented for residents when Doctors input was required did not include any follow up or evidence that the health issue had been resolved. One resident (B.M) had an ulcer to the lower leg the doctor was informed and swabs taken. There was no further documentation regarding monitoring treatment or outcome. A manual handling assessment had been completed however there was no information on which limbs were affected. Another resident (E.B) required 400mls of fluids a day fluid charts over a number of days indicated that the resident did not receive the required level of fluid. The record chart for the last four days were examined and showed intake levels of 100mls for two days 500mls for one day and 200mls for one day. Resident (M.H) who requires their fluids to be monitored had only ticks on the chart and no entries of amounts given were recorded. This is not adequate to safeguard or promote residents health. The care plan proforma had not been developed to reflect the needs of younger adults. This is an outstanding requirement from the previous three inspections. One resident said that they would like their hair washed every week however it had not been washed for two weeks. Another resident said they would like a shower two or three times a week but they are actually showered less than once a week. The resident also stated that the replenishment of jugs of water in their room can be hit or miss and sometimes they have to ring to have it refilled. There was no evidence that a comprehensive review system of care plans was in place. Concerns were raised again about response to the nurse call system. One resident said that they can wait from between half to one hour before the buzzer is responded to. Another resident stated that they could wait for an hour to be supported to go to bed. Specific concerns were raised about not being turned in the night and not being checked during a particular night. On this specific point the resident said they complained to staff, there was no record of the complaint being logged. The operations manger stated that the printer to the call system has been activated again so that staff response times can be monitored and agreed to follow up on these matters of concern. Not all medicines had been administered as prescribed in all instances. Records did not accurately support actual administration. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 12 Medicines had been administered at the wrong time of day and incorrect doses of medicines had been administered in some instances. Medicines had been recorded for administration on the Medicine Administration Record (MAR) chart but were not available for administration. Conversely medicines were available but not recorded on the MAR chart. Medicines prescribed for one resident had been used as a homely remedy. This was the property of the resident only and also a Prescription Only Medicine and should not have been used as a homely remedy. There was inadequate checking of medicines received into the home. Not all quantities of medicines received had been recorded or balances carried over so audits were difficult to undertake in some instances to demonstrate that medicines were administered as prescribed. Nursing staff did not routinely refer to the MAR chart before the administration of medicines and sign or record the reason for non-administration directly afterwards. Hand written MAR charts were poor and did not record all the relevant information in all instances. Managerial staff did not undertake routine staff drug audits to confirm nursing staff competence in medicine management. Residents are encouraged to self-administer their own medicines but inadequate risk assessments were documented and no compliance checks were undertaken. The medication rooms were very hot at the time of the inspection and the stability of the medicines stored within could not be guaranteed. The Controlled Drug cabinet was not reserved solely for the safe storage of Controlled Drugs, indicating that other staff may have access to it. Recordings for Controlled Drug transactions were not accurate in all instances. The home had not removed all unwanted medication and the nursing staff was unaware who was contracted to remove these. These medicines had not been stored in a lockable facility. The medication refrigerator contained an old sample of urine and had not been reserved solely for the storage of medicines requiring refrigeration. The provider has received a letter of serious concern in respect of the management of medication. Further visits will be made to assess compliance with requirements made. If there is insufficient progress the commission will be minded to consider enforcement action. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Some further development is required to ensure residents have access to a range of activities that affords them a meaningful lifestyle and that matches their age and expectations. EVIDENCE: The home employs two activity coordinators who are responsible for the development of an in-house and external activities programme. Residents spoken to indicated their general satisfaction with the range of internal and external activities. One resident said he enjoys the bingo and crossword activities. Another resident said she “loves the bingo, crossword and the hairdressing facilities”. Staff spoken with indicated that due to staffing difficulties opportunities for residents to go out were very limited. One of the sampled care plans indicated that the resident had enjoyed trips out to Birdland and Hatton Park in August 2005, shopping trip in September 2005 and a trip to Severn Trent Railway in October 2005. The previous report commented due to the diverse needs and age groups of the people currently residing at the home there was insufficient staff and transport facilities to cater for all requests made. The inspectors did not fully assess progress in this area. The operations manager stated that the organisation recognises that there is more work to be done regarding the development of appropriate daytime activities and occupation. This will be fully explored at future inspections. No progress had been made on risk assessments for activities or residents accessing the community. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Arrangements for protecting residents from harm are not satisfactory, placing them at possible risk of harm or abuse. The complaints procedure does not give residents confidence that their concerns are listened to. EVIDENCE: Examination of the complaints log identified that some complaints had not been logged. The complaint return sheet stated that no complaints were received in September 2005 however there were details regarding the attitude of a staff member on the complaints file. In October 2005 the log indicated that four complaints were received. One of the complaints did not have all the complaint details on file and the paperwork for another complaint was not available. The previous inspection required the provider to develop a system of monitoring the outcomes of complaints to ensure that action taken remains constant, this remained outstanding. The file contained two complaint policies, which were dated March 2003 and July 2004. Out of date policies must be removed to avoid any confusion. Since the inspection in July 2005 CSCI had received a complaint from another professional in October 2005. The complaint was forwarded to the provider to investigate and the concerns raised were as follows; Lack of respect for personal privacy Unacceptable waiting times for assistance from staff No support from staff for therapy Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 15 Essential equipment continually broken Inadequate equipment for personal hygiene Poor follow through of actions by staff The outcome of the investigation remained outstanding at the time of producing this report. A further complaint was investigated by CSCI, the allegations and outcomes are as follows: • Failure to utilise the purpose made wheelchair, this was upheld, it was determined that the footplates were missing and staff were using an alternative wheelchair • Lack of appropriate recreational stimulus, this was upheld, staff were not offering or supplying an adequate level of activities • Failure of the home to make available personal monies for external activities, this was not upheld. A critical incident occurred in the home during October 2005. The provider informed the appropriate authorities and a police investigation was instigated and remained ongoing when this report was being completed. CSCI made a referral to Social Care and Health for a serious incident meeting to take place; adult protection procedures were instigated and remained ongoing when completing this report. The written policy regarding adult protection was in the process of being reviewed by CSCI personnel. Amendments to the missing persons and physical intervention remain outstanding. The training matrix indicated no progress had been made in respect of provision of appropriate training for all staff of adult protection matters. Lack of compliance with this standard has been raised on numerous occasions; the home has provided little evidence of its intention to address this issue. Due to the significant concerns raised during the inspection a letter of Serious Concern regarding health and safety, medication, recruitment practice, security of information, manual handling and risk assessment was served on the 2nd December and a Statutory Requirement notice regarding care planning and Fire safety was served on the provider late December 2005. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22 and 26 Improvements are needed within the home to provide residents with homely, safe, accessible and comfortable surroundings. EVIDENCE: As raised on previous inspection reports the home continues to give a general appearance of tiredness with many areas being in need of re-decoration. The diverse and complex needs of residents have not been specifically provided for. The provider forwarded a maintenance and redecoration schedule to CSCI in November 2005.This included replacement of flooring to seven single bedrooms, the dining room and residents smoke room. Replacement of furniture in some resident’s bedrooms and the dining room. Redecoration of the smoke room and dining room. This work was in progress at the time of the inspection. There is a good selection of lounges for residents to choose from, meals are taken by two sittings in the dining room or the grillroom and residents may eat in their own rooms. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 17 There has been no progress in respect of adaptation of communal bathing facilities in respect of the plans, which were discussed at the announced inspection July 2004. Bathrooms are a good size and in the main provided ease of access. CSCI were informed of plans to paint the bathrooms, work on these had just commenced. The provider must ensure bathrooms are appropriate for the individual assessed needs of the people accommodated. At the time of the previous inspection an assessment of the premises has been carried out; both inspectors reviewed the report and found that it failed to cover all aspects of the home: • No reference that some residents are unable to open their bedroom and communal doors • Staff inability to hear the call system when attending to residents in their bedrooms • Non access of wheelchair users to the garden from the dining room • Lack of individual risk assessments for communal areas maintained within the individuals care plan An update of the above issues was discussed. The provider stated that enquires had been made and quotes sought from different contractors regarding alterations to doors in the home to make them automatic opening. They are not able to make the doors automatic opening due to the design of the door’s but will have alterations done to make the automatic release doors. Priority is to be given to the dining room and front door, the provider will then consider other doors that require altering such as the doors leading to the computer suite and activity areas on the first floor so that residents can freely access these areas. The operations manager stated that they have identified the residents who are unable to reach/use the nurse call and have documented on their care plan that regular checks should be undertaken. The nurse call system has had the volume control raised and a full maintenance of the system will take place. The printer has been put back on so that staff response times can be monitored by the organisation. Quotes have been sought to up grade the system. The service manager indicated that they are considering up grading the system so that it includes a pager system that will link into the present system. Only a few residents’ bedrooms were assessed at this inspection. Bedrooms continue to be very personalised; residents bring personal possessions and items of furniture into the home. All rooms have a lockable bedside cupboard, telephone socket, television with remote control, suited door locks and a nurse call system. Temporary extra sockets have been provided for those residents who have a large number of electrical devises. The home had carried out generic risk assessments until sufficient permanent electrical sockets are provided. The risk assessment did not consider risks to specific residents within their own room and the potential risk of trailing leads. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 18 These matters were discussed with the Providers health and safety advisor at the time of the inspection so that issues requiring attention could be clarified. The hygiene levels within the kitchen were not assessed at this inspection. Carpets in general were stained; an armchair in a bedroom was heavily soiled and required replacement. The nighttime inspection raised concern regarding the cleanliness levels throughout the home and the cleanliness of bathrooms were of particular concern. The homes established maintenance person left in June 2005 the position was vacant until August 2005. The new person required a period of induction and support to familiarise themselves with BUPA’s procedures. There was significant evidence to indicate that the period without someone in this role and the introduction period of the new person clearly had a negative impact on the physical standards and heath and safety monitoring at the home. Several areas of Health and Safety had declined and had the potential to place residents at risk. As further evidenced under standard 38 of this report. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 and 30 Recruitment practices fail to ensure the safety of vulnerable persons. Staff do not possess the skills and knowledge to provide satisfactory standards of care that meets residents needs. EVIDENCE: The home was required to carry out an audit of staffing levels at the announced inspection of July 2004. A detailed response was received on 18th November 2005. CSCI would like the opportunity to discuss these proposals in more detail and propose to meet formally with the provider in January 2006. Discussions with staff and examination of the rota raised concern regarding the systems in place for a comprehensive and effective handover at the point of shift changeover. This currently takes place in staffs own time, there is no time built in at the point of shift change 08.00hrs and 20.00hrs. It is imperative that a thorough handover takes place so that staff are fully briefed of the needs and changing needs of individual residents to ensure the continuity of care. Sampled staff files raised concern about recruitment practice. Staff file (E) the inspectors were not able to establish if the references were from the person’s last employment or manager as it was not possible to establish the relationship with the employee. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 20 The POVA check for the same employee was dated 1/11/05 their commencement date in the home was 3/10/05. Staff must not commence employment at the home until a POVA (Protection of Vulnerable Adults) check is in place. There was no evidence on sampled R.G.N, s files that they had received supervision from management. One record of supervision undated and unsigned was seen. The homes previous manager who left in January 2005 had undertaken the supervision session. The lack of staff supervision had been previously raised as an area of concern. It is essential that staff receive regular supervision so that the monitoring of individual residents needs takes place and that staff receive the support guidance and training they require. Confidential information, including an application form from a prospective employee, a CRB check, photographic identification and a number of personal records pertaining to residents were found in the communal lounge on the first floor. Previous inspections have highlighted the need for all staff to receive all mandatory, refresher and training to meet the needs of the current client group. A training matrix was forwarded to CSCI, which was received on the 10th November 2005. This identified that training in a number of mandatory areas was outstanding including First Aid, Health and Safety, Moving and Handling, Food Hygiene and Risk assessment. CSCI was advised that some interim training consisting of briefing sessions took place in November 2005 on Manual Handling, Risk Assessment, Health and Safety and Food Hygiene, these were not comprehensive training sessions but an interim measure to try to improve staffs ability to meet residents needs. The provider must fulfil its duty to ensure staff are adequately trained as a matter of urgency. No progress had been made on providing training to staff on the diverse needs of residents including training specific to the needs of younger adults. This is particularly important, as the home is moving towards accommodating more younger adults. The home did not have 50 of care staff that had completed NVQ level 2 training or above however a large number of staff are currently undergoing this training. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 Staff management and formal supervision is inadequate resulting in poor communications and standards of care. The home had not complied with health and safety legislation thus putting residents and staff at risk. EVIDENCE: The previous report stated that the manager had the clinical skills, knowledge and experience to manage the home and was developing her management skills. Concern was expressed about that the level of responsibilities placed upon the manager in such a large and complex home and it appeared to be an impossible task to achieve. During a meeting with the area manager (July 2005) assurance was given to the inspectors that a temporary deputy manager would be found until the home recruited to the vacant position. A deputy manager recruited through an agency commenced in August 2005. The registered manager resigned from her position at the end of November 2005. Temporary management arrangements are in place, which included the operations manager basing her self-fulltime in the home and a service Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 22 manager from another area supporting her with the day-to-day management of the service. The previous inspection report raised concerns about the homes failure to fully address health and safety issues. Risk assessments in respect of the premises, fire safety, staff, infection control, and food were in need of review. The weekly testing of the fire alarm system and monthly testing of the emergency lighting had not been carried out since the departure of the maintenance operative. Although portable electrical equipment had been tested there was no certificate to verify this. The certificate regarding testing of water for Leigonella was found to be out of date. The lifting aids had been serviced in May 2005 and the majority were determined to be in poor condition with no action having been taken to carry out the required repairs. CSCI received an action plan on 23/8/05 stating that all these matters had been dealt with. The findings of the unannounced inspection raised significant concern about the lack of evidence that these serious requirements had been actioned. The risk assessments in respect of the premises had not been reviewed. The records for fire alarm testing, emergency light testing and fire drills could not be produced prior to November 2005. The provider was not able to evidence that the manager had undertaken the tests as required and was not able to produce any of the homes records in relation to fire safety prior to November 2005, even the records previously maintained by the maintenance operative. It was of significant concern that there were no records prior to November 2005 and that the previous records seen by the inspectors in July 2005 and December 2004 were now not available. The provider must comply with The Fire Precautions Act (1971) and Fire Precautions (workplace) Regulations (1997) as amended. The provider must undertake weekly fire alarm panel checks, monthly emergency light checks, and fire drills at least every six months. Staff must receive fire training every six months. The provider must have documented evidence that these tests have been undertaken and of the action taken to remedy any defects and the records must be available in the home at all times. Failure to do so has the potential to put residents at risk. The legionella report available in the home was dated 14/7/05. Recommendations had been made following the tests. There was no evidence that the provider had actioned the recommendations. The report also stated that the logbook was not available in the home for the contractors to refer to. This information must be available. On the evening/night of 24/11/05 the inspectors were concerned to find the bathroom on the ground floor contained five hoists. Three of the hoists required repair and labels on two stated they were “waiting parts” and one was “out of order”. The hoist condemned as not operational and requiring attention blocked in the two hoists in working order. Staff reported Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 23 incidents of residents being manually lifted by staff. Staff also reported the need to move the one hoist in operation between the two floors via the homes lift. Staff spoken to on the 30/11/05 stated that some residents could not get out of bed because of the situation with the hoists. This was not fully evidenced. An urgent review of the homes manual handling equipment must take place. There was no documented evidence of what action the manager had taken following the immediate requirement raised on the 06/07/05. There must be adequate and appropriate lifting equipment in place to meet residents assessed needs. The provider must be able to evidence that the equipment is serviced as required and any identified problems must be dealt with promptly. At the Announced inspection in July 2005 two senior staff (R.G.N) were not able to demonstrate that they had adequate knowledge regarding the homes responsibility to record and report incidents under Regulation 37. At the unannounced inspection on 30/11/05 again two senior staff in the home were unable to demonstrate this knowledge. Examination of the homes accident records identified that there were incidents and accidents that should have been reported to CSCI under Regulation 37 that had not been. The manager had not undertaken an audit of accidents since June 2005. The provider must ensure that any incidents or accidents that occur in the home are reported as required and that staff in the home are fully aware of their responsibilities to record and report such incidents. The laundry on the second floor was unlocked at the time of the night inspection 24/11/05. COSHH items were unsecured in this area and a store cupboard containing further COSHH items was unlocked with the key in the door. An immediate requirement to secure this area was made. CSCI were informed that immediate action was taken on 25/11/05 to secure this area when not staffed by laundry staff. The previous inspection required that strategies were established for enabling staff and residents to affect the way in which the service is delivered. It required that a regime of regular staff meetings must be introduced. The action plan received 23rd August 2005 indicated that staff meetings had been reinstated as of 30th August 2005. Examination of these (three sets of minutes available two for R.G.N’s and one for senior carers) identified that such meetings were infrequent and the minutes were inadequate in content and detail. The operations manager stated that she had instigated meetings through November 2005 and dates had been scheduled for forthcoming meetings for the next year. Residents meetings had also been re-established and must be used to provide opportunity for residents to voice their views and affect the way in which the service is delivered. The operations manager stated that policies and procedures had been reviewed however the homes systems for evidencing this required attention so that the most up to date copies are available in the home. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 2 X X 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X 1 1 1 Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1)c1 Requirement The statement of purpose requires numerous amendments and additions. A review of the registration of the home must be carried out and the statement of purpose amended to reflect this. The service user guide requires significant development to include those items listed under Standard 1.2. N.B. Not assessed but carried forward. The homes written admission policy must include a threemonth trial period followed by a review. The pre-admission assessments carried out must be comprehensive and include mental health state and cognition. The registered manager must undertake an urgent review of all care plans and ensure that the files provide comprehensive documentation in respect of residents long and short term needs and include regular and DS0000024817.V269157.R01.S.doc Timescale for action 31/01/06 2. OP1 5(1)a-f 31/01/06 4. OP3 12(2)(3) 14 12(2)(3)1 4 (1) (2) 31/01/06 5. OP3 31/12/05 6. OP7 15(1)(2)b c3 31/12/05 Amberley Court Nursing Home Version 5.0 Page 26 7. OP7 13(4)abc 8. OP8 12(1)ab 9 10 OP9 OP9 13(2) 12(2) sch 3(3)(i) 13(2) 11 OP9 13(2) Sch 3(3)(i) 12 OP9 13(2) 13 OP9 13(2) formal reviews. GP visits must be clearly documented. All relevant risk assessments for 31/01/06 resident’s activities both internally and externally must be carried out and regularly reviewed. The registered person must 31/12/05 ensure that proper provisions of the health care needs are fully met. The administration of prescribed amounts of water, oral hygiene and passive exercises must be carried out. Monthly observations and weight must be monitored. Observations of abnormal physical episodes must be accurately monitored and recorded. All staff must adhere to the 12/12/05 policies and procedures in the safe handling of medicines All service users wishing to self 12/12/05 administer their own medication must be risk assessed as able and compliance checks undertaken to ensure the safety of the service users The quantities of all medicines 12/12/05 received or balances carried over from previous cycles must be recorded to enable audits to take place to demonstrate that the medicines are administered as prescribed. All nursing staff must refer to the 12/12/05 Medicines Administration Record (MAR) chart before the administration of medicines and directly sign following the transaction or record the reasons for non-administration. The MAR chart must accurately reflect what has been administered within the home. All service users must be 12/12/05 administered the right DS0000024817.V269157.R01.S.doc Version 5.0 Page 27 Amberley Court Nursing Home 14 OP9 13(2) 15 OP9 13(2) sch 3(3)(i) 16 OP9 13(2) sch 3(3)(i) 17 OP9 13(2) 18 OP9 13(2) 18(1)abc 19(1)a 13(2) 19 OP9 20 OP9 13(2) 21 OP9 13(2) medication at the right time and the right dose. All prescriptions must be seen prior to dispensing, checked and a system implemented to check the dispensed medication and the MAR chart for accuracy. All discrepancies must be rectified to ensure the service user receives the correct medication at all times All hand written MAR charts must accurately record all the medication the service user has been prescribed, the strength of the medicines and the correct dose The MAR chart must accurately record all the medication the service user has been prescribed and these medicines must be available for administration The registered manager must undertake staff drug audits for all nursing staff on a regular basis to confirm staff competence in medicine management The nursing staff must be adequately trained to understand the therapeutic indication and common adverse effects of all medicines they administer All medicines must be stored in a lockable facility within the medication room. This includes medicines awaiting collection by a clinical waste company for destruction All medicines that are no longer required must be removed from the premise. A contract must obtained from a registered clinical waste company The temperature of the medication rooms must fall below 25°C at all times to ensure the stability of the medicines and DS0000024817.V269157.R01.S.doc 12/12/05 12/12/05 12/12/05 12/12/05 05/01/06 12/12/05 12/12/05 05/01/06 Amberley Court Nursing Home Version 5.0 Page 28 22 23 OP9 OP9 13(2) 13(2) 24 OP9 13(2) 25. OP12 16(2)mn 26 OP13 16(2) 27 OP14 12(4) a 28. OP16 22(1)(2) that they are stored in compliance with their product licences. Then installation of air conditioning systems may be required. The Controlled Drug cabinets must be reserved solely for the storage of Controlled Drugs only All controlled drugs must be recorded accurately in the CD register and a witness signature recorded following each administration The medicine refrigerator must be kept locked at all times and must be reserved for medicines only. The home must adopt a comprehensive and cohesive approach to the provision of inhouse and external activities that takes into account residents’ preferences. Not assessed in full requirement carried over. (Previous requirement 31/10/05 timescale The organisation must ensure that there are adequate resources provided to fulfil the recreational expectations of all residents. Not fully assessed requirement carried over. (Previous requirement 31/10/05). The home must provide documentary evidence that residents are consulted and that regular meetings are held with minutes produced and circulated accordingly. Reinstated under the temporary management arrangements November 2005. The system of recording complaints must be expanded to include monitoring and subsequent reviews. Complaints received by the provider must be logged. DS0000024817.V269157.R01.S.doc 12/12/05 12/12/05 12/12/05 31/03/06 31/03/06 31/12/05 31/12/05 Amberley Court Nursing Home Version 5.0 Page 29 29. OP18 13(6) 30. OP21 23(2)j 31 OP22 23(1)a 32 OP22 23(1) a 33 34. OP24 OP26 16 (2) c 16(2) k 35. OP27 18(1)a The homes written adult protection, missing persons and physical restraint policies and procedures must be further developed and amended. All staff must receive training in these aspects of care. The home must demonstrate and make provision for residents to make choices regarding their preferred method of bathing. Some bathrooms required refurbishment and re-decoration. This work had just commenced. The registered person must address the gaps identified by the inspectors following an assessment of the premises by an occupational therapist. Specific areas that require attention are the lack of wheelchair access to the garden from the dining room, lack of an audible nurse call system and residents inability to open their bedroom and communal doors. Some progress had been made further work required. Immediate interim action is required to resolve the failure of residents to summon assistance at all times. Some progress made further work required. A chair in a resident’s bedroom was heavily soiled and required replacing. Attention to the hygiene levels and odour control of the home is required. A schedule of deep cleaning must be produced and implemented. The organisation must carry out a review of the staffing levels out in consultation with CSCI, which takes into account the changing needs and dependency levels of residents. A formal response was received from the provider in DS0000024817.V269157.R01.S.doc 28/02/06 31/03/06 31/03/06 31/01/06 31/12/05 31/12/05 31/01/06 Amberley Court Nursing Home Version 5.0 Page 30 36 37. OP28 OP28 12(1)ab 18(1)a 38. OP29 19(1) 2 39 OP30 18(1)c 40. 41. OP31 OP33 18(1)a 24(1)(2)( 3) 42. OP36 18(2) 43. OP36 17(1) 44. OP38 13(4)abc November 2005 further discussions were required. The arrangements for the formal handover of information between shifts required review. The home must ensure that 50 of the carers possess training certificates in NVQ level 2 or equivalent. The registered person must ensure that robust recruitment practices are adhered to at all times. The registered person must ensure that all mandatory, refresher and other training to meet the needs of the current client group are provided for all staff. NB. This remains outstanding from the two previous inspections. The organisation must complete the process of recruitment of a manager and deputy manager. The registered person must produce and implement a quality assurance system that takes into account the opinions of residents, relatives and external professionals. Not assessed at this inspection requirement carried over. Staff must receive supervision when on duty as well as formal supervision at least six times per year with a record of such maintained. Staff must have annual appraisals. The registered person must develop and amend all written policies and procedures regarding all practices including specialised procedures the home provides. Evidence must be produced of regular reviews being carried out. The registered manager must DS0000024817.V269157.R01.S.doc 31/01/06 31/05/06 31/12/05 31/03/06 31/03/06 31/01/06 31/01/06 28/02/06 31/12/05 Page 31 Amberley Court Nursing Home Version 5.0 45. OP38 13(4)abc 46. OP38 13(4)abc 47 OP38 23(4) 48 OP38 23 (4)(e) 49. OP38 13(4)abc 50. OP38 13(4)abc 51 OP38 37(1)a-g supply CSCI with evidence that Leigonella testing recommendations has been carried out. The risk assessments in respect of environment must be reviewed at least annually or when circumstances change. The temporary electrical sockets supplied to resident’s rooms must be risk assessed in order to ensure there is no risk of overload. Some progress further work required. The provider must comply with The Fire Precautions Act 1971 and Fire Precautions (workplace) Regulations 1997 as amended. Required fire records must be maintained and must be available for inspection. Fire drills must take place six monthly and records must be kept of the drills and details of the outcome and any action taken in light of the drill. The weekly testing of the fire alarm and monthly testing of the emergency lighting must be resumed. Records of these test must be kept in the home The home must provide documentary evidence the required repairs have been carried out to three hoists that were determined to be in a poor condition. Manual Handling arrangement must be reviewed. The provider must ensure that any incidents or accidents that occur in the home are reported as required and that staff in the home are fully aware of their responsibilities to record and report such incidents. All care staff employed at the home must have knowledge of and comply with their responsibilities within DS0000024817.V269157.R01.S.doc 31/12/05 31/01/06 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 Amberley Court Nursing Home Version 5.0 Page 32 this Regulation. 52 OP38 13(4) COSHH items must be kept secured at all times. 25/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP31 OP13 OP22 Good Practice Recommendations The registered person should develop and implement a formal and proportional on call system. The home should develop a running log of the Regulation 37 reports forwarded to CSCI. The home should make an inventory of the specialist equipment, which would provide a tool for crossreferencing purposes such as servicing dates. Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 33 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Amberley Court Nursing Home DS0000024817.V269157.R01.S.doc Version 5.0 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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