Inspection on 23/01/08 for Appleby Court

This inspection was carried out on 23rd January 2008.

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

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

Other inspections for this house

Appleby Court 12/03/07

Appleby Court 10/11/05

Appleby Court 11/05/05

Appleby Court 02/11/04

Appleby Court 22/06/04

Appleby Court 23/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Appleby Court Ellesmere Road Pemberton Wigan Lancashire WN5 9LA Lead Inspector Sarah Tomlinson Unannounced Inspection 07:15 23 , 24 & 25 January 2008 rd th th 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 Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 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. Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Appleby Court Address Ellesmere Road Pemberton Wigan Lancashire WN5 9LA 01942 215000 01942 215000 sheenathompson@cuerden.com 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) Mr Keith Lowe Mrs Sheena Thompson Care Home 80 Category(ies) of Old age, not falling within any other category registration, with number (80), Physical disability (4), Terminally ill over of places 65 years of age (4) Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 80 service users to include:up to 80 service users in the category of OP (Older People) up to 4 service users in the category of PD (Physical Disability under 65 years of age) up to 4 services users in the category of TI(E) (Terminal Illness over 65 years of age) 12th March 2007 Date of last inspection Brief Description of the Service: Appleby Court is a private care home. It is registered with us (the commission) to provide nursing and personal (‘residential’) care for up to 80 older people. Mr Keith Lowe owns the home, plus 3 other homes in the ‘north west’ (2 more in Wigan and 1 in Preston). The home is purpose built, on 2 floors, with a lift. It is divided into 4 separate units - a nursing unit and a ‘residential’ unit on the ground floor, and a nursing unit and ‘residential’ unit on the first floor. There are 20 single bedrooms on each unit, all with en-suite toilets. Each unit also has its own lounge, dining room and bathrooms. The home is on a main road, with local shops nearby and bus routes into Wigan town centre. The entrance is at the rear of the home, where there is a car park and outdoor seating area. Current fees range from £360.51 to £540.00 (hairdressing, dry cleaning and toiletries are extra). Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The visit, which the home was not told about beforehand, took place over 3 days. The pharmacy inspector went on the 1st day. The lead inspector visited on the 2nd and 3rd days, spending nearly 18 hours in the home. On the 2nd day a trained volunteer (an ‘expert by experience’) also came. We spent time on all 4 units, talking to residents (12) and visitors (6) and watching how staff cared for people. We spoke with staff from all 4 units. This included nurses and carers, plus the overall manager of the home, the activities co-ordinator, kitchen and domestic staff, the administrator and a visiting district nurse. We also looked at some of the home’s paperwork. Before the inspection, the home completed a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they feel they do well and what they need to do better. This helps us decide if the management of the home sees the service they provide the same way we do. Before the inspection, we also sent surveys to people that live, visit and work in the home. Nine residents, 8 relatives and 2 staff returned them. Their views are included in this report. What the service does well: What has improved since the last inspection? Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 6 There was enough staff on duty at night so residents got the help they needed. What they could do better: 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. The summary of this inspection report can be made available in other formats on request. Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 7 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 Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4 (Standard 6 is not applicable, as intermediate care is not provided). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. At times, the admission process had not always ensured the needs of residents would be met. Information about the home could be improved to help potential residents and their families make an informed choice. EVIDENCE: We looked at the Service User’s Guide (brochure). This provided information to potential residents and their families about the home. It was available in a standard format only. The type size and format varied - pages 12 and 13, which provided a lot of detailed and helpful information, were quite difficult to read. As the brochure was aimed at older people, a larger type size throughout (e.g. a minimum of 14) and a clearer format would be helpful. Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 9 The brochure, which was last revised in 2006, was about to be updated. Some minor changes were needed – it incorrectly stated that residents could not smoke and clearer information was needed about residents’ age range. Brief details of our role were also needed, referring the reader to where our most recent inspection report can be found (a copy was kept in the reception area). More information about how the home was run would be helpful. For example, giving the care manager’s name (Kath Winstanley) and more details about the home’s management structure (so a resident (or family) can easily understand who is responsible for the unit where they live). As a large home, having photograph/uniform boards for each unit would also help visitors identify members of the staff team (including domestic staff). We discussed how overwhelming the admission process could be for residents and practical ways of trying to minimise this and ensure a new resident received special attention. One new resident said they had not received a brochure; was finding the transition from their own home to living in a care home very difficult; and also had several minor practical problems with their room (which we passed to the home). To help new residents settle in, we advised the initial ‘welcome meeting’ could be repeated (in part) a week or so after admission. This would provide a way of checking with a new resident and their family about how they were settling in (e.g. the existing admission checklist could be used to guide and record this meeting, so it is used twice – first for the initial admission and then again at the ‘settling in meeting’). With regard to the Statement of Purpose, the address of the provider needs to be added when it is next reviewed. Also clear details about how the home is able to meet the needs of any resident below 65 years of age (particularly their social interests). Records and discussion confirmed before a potential resident moved in, information was received about their needs. Where possible, the manager also visited them in their own home or in hospital (to confirm whether Appleby Court could meet their needs). For people referred through Social Services, a copy of both the care management assessment and a copy of the care management care plan should be obtained. Whilst some files had very detailed pre-admission assessment information, others did not. We found both the assessment and the care plan were not always obtained. The home must insist on full assessment information being sent. However, our main concern was the inappropriate admission of at least one resident. This person’s primary care need was outside the home’s registration categories (e.g. the staff team did not have the skills or experience to meet this person’s specialist needs). This action potentially placed the home in breach of its registration. This matter was being followed up outside the inspection with both the home and Wigan Social Services (who had requested the placement). Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care records and care practices generally promoted residents’ health and wellbeing. Gaps in records possibly placed some residents at risk of their needs not being fully understood or met. Most medication was given safely and residents were not of significant risk to their health. Not all medication could be tracked and accounted for, some records were inaccurate and sometimes residents were not given medicines as prescribed. EVIDENCE: We looked at 8 care files. Care plans and risk assessments were generally in place and updated regularly. Pre-printed, general (‘core’) care plans were used, to which personal information had been added. Good practice was Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 11 noted, as pain diaries were used to monitor and respond to residents’ need for pain relief. However, some information was missing. Daily care records described some residents as very anxious or agitated. This was not always recognised in care plans, which need to provide practical guidance to help staff provide support (including possible triggers and how to minimise these). For some residents with epilepsy, information was needed about the frequency of seizures, when their last seizure occurred, a description of the seizure type and any supportive action needed/warning signs. For those residents living on the ‘residential units’, care plans about pressure sores needed practical guidance for care staff (e.g. how to dress, bathe, monitor the need for pain relief, in addition to the district nurse’s own treatment plan). Also, with regard to the resident who had been inappropriately admitted, their care needs were not fully addressed. We also advised that whilst the home carried out an initial risk assessment before introducing third party bed rails, their use needed to be monitored on an ongoing basis. We showed a bulletin from MHRA regarding the safe use of bed rails, which included a sample checklist. Although care plans and risk assessments did not show how residents and/or families had been involved with what was written in them, relatives felt they were “kept well informed” and the home “always rings if anything wrong”. The language in care files should be monitored, with more positive and everyday words used rather than diagnostic terms. This would make care plans more accessible to care staff and families, and show when staff have spoken to and understood the resident’s/relative’s point of view. A ‘yellow form’ in care files recorded family contact. A range of records was kept for each resident. Care plans were in a file in the ground floor main office. A key worker file and a general file, both of which were completed daily, were kept on the units. To reduce duplication, we suggested some of these records could be combined. For example, nursing and care staff could complete just one set of shared daily care notes. To make access as easy as possible and encourage familiarity with care plans, they could be kept on the unit (replacing the need for additional day and night care plans). We also discussed keeping one combined monthly care plan review checklist. Residents’ health was promoted and maintained through regular health care checks (e.g. from the district nurse, GP, tissue viability advisor, dietician, physiotherapist). One relative said, “[my relative has been] 3 years in bed with no bed sores or skin breaks of any kind, says it all”. Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 12 During the inspection the pharmacist inspector looked at all aspects of medication handling, to make sure that residents were being given their medicines safely and that their health was not at risk. There was a policy to guide staff on how to handle medicines safely, but some sections were out of date either because the law had changed or because the home had introduced some new and improved medicines handling systems. The policies and procedures should be reviewed so staff have up to date guidance to make sure they can look after residents and their medicines safely. The medication room was very clean and tidy and the storage of medication was organised and safe (including the storage of controlled drugs). The temperature of the medicines fridge was recorded daily. Medicines should be stored at temperatures between 2 and 8C, staff had recorded much higher temperatures, but the fridge felt cool. The drugs trolley in use on the first floor nursing unit did not have enough space for all medicines to be locked away in an emergency during the medicines administration round. We recommended the thermometer be checked for accuracy and a larger drugs trolley be provided. The standard of record keeping was variable. Most records were clear and could show most medication was given to residents as prescribed and that medication could be accounted for. However, there were some instances of poor record keeping when it was not possible to tell if medicines were given properly or to check that medicines could all be accounted for. Some residents chose to look after some of their own medication and they were supported to do this safely. Some residents did not home for a short time. prescribed at all times. from the home they do receive their medicines when they were away from the It is important medication is given to residents as The home must make sure if the residents are away not miss doses of vital medication. The manager made sure medication audits were done on a regular basis. These checks did not give enough information to show medicines were being given properly or medication was all accounted for. However, medication was mainly handled safely and residents were usually given their medicines as prescribed. The manger said the auditing system would be improved to help her check residents were given their medicines safely and to check the quality of medicines handling was good. With regard to maintaining residents’ dignity and privacy, good practice was noted, as each resident was allocated a key worker. Their role included providing intimate support to help residents bathe or shower. The key worker’s photograph and name was usually displayed in the resident’s room. However, whilst staff knew which residents they were key worker for, we found residents and relatives were not clear. The manager was aware of the need to Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 13 review this system to ensure its effectiveness. We suggested the relationship could begin from admission or at least from the suggested ‘settling in meeting’ (where it would be the key worker’s role to help the new resident settle in and feel special). With regard to how staff cared for residents, we saw staff treating residents in a warm, kind and respectful manner. We had feedback from 21 residents. Residents felt well looked after. One said they were “very satisfied”, another said they “can’t fault it, all carers are lovely”, whilst a third resident said they were “quite satisfied with their care”. One resident said, “some [staff] are OK”; another that “some staff are very friendly”. We had feedback from 14 relatives. All was generally very positive, with families happy with the care their relatives were receiving. Comments included “very caring”; “compassionate”; “very good at their jobs”; “all care staff always pleasant and agreeable”. With regard to practical ways to maintain dignity and privacy, we discussed bathroom door locks. Although provided on the ‘residential’ units, they were missing from bathroom and shower rooms on both nursing units. Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. To ensure the social needs of a very mixed and very large resident group were met, the range and frequency of social activities needed developing. The quality and choice of meals needed to be reviewed to ensure residents enjoyed their food. EVIDENCE: An activities co-ordinator worked in the home, covering all 4 units. We were impressed with her enthusiasm and conscientious and committed attitude. However, we were concerned about the frequency of activities provided on each unit – as one full time post was not enough to provide an adequate level of social activities across all 4 units, for an 80-bedded home. Care and nursing staff said they sometimes provided activities when time permitted, although there was no records to evidence this. Two relatives said the activity worker worked “more hours than she should”; “puts in a lot of time here”. Another relative said armchair exercises used to be organised “but they don’t Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 15 now”. An increase in staffing would enable the range of activities to be developed. Activities need to better reflect the very wide range of needs in the home - from very elderly, frail people with confusion, to mentally alert people in their early 60’s (the youngest resident at the home was currently 59 years of age). A programme of weekly activities should also be developed and advertised for each unit. We discussed the therapeutic benefits of supporting residents to be active and involved in the domestic routines of the home - doing ordinary, everyday tasks (e.g. helping set and clear tables at mealtimes; providing dusters and ornaments; folding towels/linen). Whilst some music was played, we noted televisions were on for a lot of the inspection, although most residents were not watching them (and could also not see or hear them). We advised the amount of recording the activities co-coordinator did was greatly reduced. Whilst brief records were needed, they should only be completed for those residents with whom she has spent significant one to one time with or residents who took part in or actively watched a group activity. We also advised separate activity records were not needed; entries could be made in daily care notes. This would also enable recording to be shared with care staff (e.g. when they have carried out an activity or helped with a group activity). Visitors felt they were made welcome. Residents and their families were able to personalise bedrooms. On the 2nd day of the inspection, several residents were up on each unit when we arrived. Night staff confirmed they were under no pressure to get people up, with residents being able to choose what time they got up and went to bed. With regard to the resident who had been inappropriately admitted, care records did not show any consideration had been given to their ability to make decisions or take risks (e.g. regarding managing their own finances and cigarette smoking). Each unit had its own dining room. These provided a pleasant setting with good quality furniture, with chairs with arm rests and glide rails. We joined residents for lunch. Tablecloths, placemats and paper napkins were used. Although we noted the presentation varied between units, with some tables appearing more attractive than others (e.g. posies of flowers as centrepieces and napkins displayed in drinking glasses). Although salt pots were provided, pepper pots were not always available. Also drinking glasses (to promote hydration) were not provided, with only hot drinks available. Melamine beakers and plastic glasses were used as standard. These had replaced Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 16 ceramic cups and saucers which many residents had found too heavy and awkward. We discussed whether other lightweight options were available. Feedback about food was mixed. Although some residents said it was good, many said it was just “okay” or “not good”. Although we saw some residents having different meals, many residents were also unclear that a choice was available. Nearly all residents had soup and sandwiches at lunch time (a light meal was served at lunchtime and the main meal at 4.30pm). Also, when some residents decided not to have the provided pudding, no alternative was offered. The menu indicated yoghurts were available, although they were not routinely sent each mealtime from the kitchen. Several residents said the toast was not very nice. The manager was aware of this – toast had previously been made on the units but had set the fire alarms off. No menu boards were displayed. An A4 menu sheet was displayed in some units on the staff notice board. However, this was difficult to read and did not detail a choice for every evening meal. We advised daily menu boards should be prominently displayed for residents and visitors. Good practice was noted as full fat milk was used, with some fortified bread also available. With regard to pureed meals, staff confirmed each item was kept separate (to maintain taste, texture and appearance). A new chef had been recruited and was about to start. We discussed training for the new chef and provided a copy of our bulletin regarding improving meals for older people in care homes. Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for protecting residents from abuse and for taking concerns seriously were in place. Encouraging concerns and complaints to be raised would strengthen this system. EVIDENCE: The home’s complaints procedure was detailed in the brochure (our contact details needed updating) and displayed in the main entrance. This was in small print and would be easier to read if in a larger type size. It should also be clearly displayed on each unit. We had received 2 complaints since the last inspection and a third was made shortly after this visit. The first concerned inadequate staffing levels at night. This had been partially upheld and we had required staffing levels must be maintained. The second complaint had been investigated under Wigan Social Services safeguarding procedures, with no concerns upheld. With regard to the third, current complaint, some issues had already been looked at during the inspection, whilst others were being investigated. Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 18 Residents and visitors generally felt able to raise any concerns and knew who to talk to. However, some had found it difficult to express their views and concerns. At the last inspection we had advised all staff receive training about abuse awareness and adult protection issues. The home had since informed us training had been provided by Wigan Social Services. This needed to be documented in individual staff training files, with domestic, kitchen and support staff also included in the training programme. We discussed the new Mental Capacity Act 2005, its impact on the home and the need to arrange staff training in this area (we showed a copy of the government’s easy read booklet about the act and gave details about ordering free copies). Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appleby Court was attractive and comfortable. Proper consideration of the needs of residents who smoke and proper maintenance of carpets was needed. EVIDENCE: Appleby Court was bright and welcoming with a good standard of furnishings and décor (including the use of wallpaper, which helped it appear homely). At the last inspection we had found doorways needed repainting and carpets were stained. Whilst an ongoing programme of redecoration had addressed the paintwork, we were concerned to find carpets in dining rooms; lounges and hallways remained heavily stained. An ongoing programme of internal carpet Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 20 washing was being carried out, including just prior to the inspection. However, despite the best efforts of the domestic team, it was clear this was not effective. After the last inspection, external carpet cleaners had been used to some success, but this had happened on only one occasion. At this inspection we noted the lighting by the lift on the first floor and in the dining room on the ground floor nursing unit was quite dim. We advised signs would be helpful, both to identify residents’ individual rooms (fixed at a suitable height and in large print) and to identify individual units (the manager was planning to name these after trees). Bathroom and toilet signs could also be lowered to be more helpful to residents. There was no private office space on the units, with staff using a corner in the dining room for files and notices. Whilst reasonably discreet, a domestic style lockable cupboard should be provided for client files. We were concerned to find a lack of smoking facilities, with residents having to smoke outside or in an unused bathroom (both at the convenience and discretion of staff). This was unacceptable. Contrary to the home’s current brochure, smoking was obviously permitted. Some residents were deemed too high risk to smoke in their bedroom. However, this was not documented in their care files and a smoking lounge was not provided. The home needed to decide what its policy was about smoking and then clearly state this in its brochure. With regard to the outdoor space available, we felt it was not to the same standard as the indoor facilities. It was quite small, not enclosed and adjacent to the home’s car park. It consisted of raised beds, shrubs and several benches. We were told the area was due to be developed. Building work was taking place in the grounds, near the car park entrance to the home. A new 18-bed home was being built. Although it planned to use Appleby Court’s laundry and kitchen, it was to operate as a completely separate care home. We found the home was clean and tidy and smelt fresh, which residents and visitors agreed was usual. The replacement of the carpets in ensuite toilets on the nursing units’ with sealed lino flooring would further promote hygiene standards. A malodour was noted in one bedroom, which the home was aware it needed to address. Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment practices and basic training protected residents. Staffing levels were improving to better meet residents’ needs. This would be further supported with additional training. EVIDENCE: Since the last inspection, a complaint had found, on occasion, inadequate staffing levels at night. These were now being maintained. Agency carers were regularly used to cover night shifts, (with consistency of care promoted through the use of the same agency staff). To improve night staffing levels an additional nurse had been recruited. This would ensure both nursing units would be staffed by a nurse. Their appointment would also free a carer to work as a ‘floater’ (providing flexibility within the staffing team and help cover any sickness). Night time staffing levels were currently 2 staff per unit. Day time levels were 2 carers and a senior carer on the residential units; 3 carers, a senior carer and a nurse on the ground floor nursing unit; and 4 carers, a senior carer and a nurse on the first floor nursing unit. Staff felt the use of a senior carer on Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 22 the nursing units worked well, providing support to the nurse in charge. With regard to communication, good practice was noted, as although no formal handover was built into shift patterns, staff were paid for the time they worked (e.g. coming in early or staying later). We looked at day rotas from November 2007. These showed generally adequate staffing levels, although at times levels dropped from 3 to 2 carers on the first floor ‘residential’ unit. This needs to be monitored as staffing levels must be maintained (staffing levels dropped to 2 carers on the this unit on the 2nd day of our inspection). The home also needs to closely monitor staffing levels on the first floor nursing unit as the workload was very high (e.g. regarding dependency levels and moving and handling support needed by most residents). With regard to NVQ training, 56 of the staff team had the NVQ level 2 award (although this did not take account of agency staff, which need to be included in the overall staff team). A further 10 staff were undertaking the award. We looked at 6 staff training files. These were not up to date. Whilst some mandatory training information was present (annual fire safety training), some was missing (details of annual moving and handling refresher training). Confirmation that all staff were up to date with this training was provided shortly after the inspection. With regard to additional, service specific training, files showed 2 staff had attended infection control training, a basic life saving course and another had attended a course on hearing loss. To supplement external training, we advised in-house should also be provided (this can often be more targeted, filling specific knowledge gaps). For example, the current resident group included people who suffered with anxiety and agitation; residents who could be physically aggressive; plus residents with confusion (dementia), diabetes, epilepsy and pressure area care needs. Topics could also include end of life care, using the new bed rails assessment checklist and the key worker role. Brief in-house training sessions could be delivered as part of extended handovers or in staff meetings (and recorded in individual training files). Expert staff within the home or company could be used to deliver these sessions (which would also help nursing staff achieve their own professional learning requirements). We looked at the recruitment files of 4 recently employed staff. All appropriate checks had been made. The manager confirmed issues from a reference and from a CRB disclosure had been followed up. We advised a written record should be kept of such action. Proof of relevant qualifications and training and identity were kept. A recent photograph was not routinely taken for staff files and needs to be addressed. Appropriate CRB disclosures and PovaFirst checks were seen. We advised to meet Data Protection regulations; disclosures should only be kept to show us. Once we have seen them they should be Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 23 destroyed. Before doing so, a record must be kept on the individual’s staff file of the date the disclosure was requested, the date received and the disclosure reference number. We confirmed, unless being followed up by the home, all CRB disclosures currently held in the home should now be destroyed (after the above reference details have been recorded). All CRB disclosures and POVAFirst checks obtained for staff employed after this visit must be kept until our next inspection. We advised the application form design be reviewed as it did not encourage applicants to provide start and finish dates for current or previous employment (‘to’ and ‘from’ dates were not requested or columns provided). This made it difficult for the home to confirm full employment history and seek explanations about any gaps. Good practice was noted, as new carers undertook an extensive 3-month induction, during which time they were usually supernumerary and shadowed the senior carer on duty. We were impressed with the time provided for a new worker to settle in, which they said had been helpful. However, we advised this time would be more useful if it was structured around the Skills for Care induction. New staff currently completed this alone, with written work. This did not allow the home to assess actual work performance. Specific care tasks and approaches could be demonstrated and observed by the senior. The new starter and the senior would then sign off each task as complete once competence had been demonstrated. In addition to increasing the skills of new staff and improve the quality of care for residents, a structured, competence based induction should also improve retention. Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff benefited from a well managed home. Fire safety practices need to improve to maintain the health and safety of both residents and staff. EVIDENCE: The registered manager, Mrs Sheena Thompson, was a qualified and experienced general nurse and had been in post since 2005. The owner and registered provider, Mr Keith Lowe, was based at the home and had regular contact with the manager. Mr Lowe nominated another person to carry out his monthly, unannounced quality assurance visits. At the last inspection we had Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 25 found reports of these visits were not being produced. We were concerned to find at this inspection these visits were not being carried out at all. The manager had tried to remedy the situation by instigating her own monthly quality assurance checks. The home also checked out the quality of its service through relatives’ surveys. We were told a new quality assurance package had recently been bought and was due to be introduced. We advised staff should also be able to complete confidential surveys. Also, the quality assurance system should be flexible – able to monitor the success of any changes made (e.g. to food quality and understanding of menu choices available; the frequency and choice of social activities; knowledge of and contact with key workers). We found residents’ monies were looked after safely and securely. Appropriate records were kept. Three balances were checked at random and found to be correct. We discussed the storage arrangements. The manager said more secure facilities had recently been ordered. With regard to formal staff supervision, good practice was noted as regular 1 to 1 meetings were held. To provide more support and feedback on their performance, we advised new starters should receive more regular supervision sessions (recent new starters had only received 1 formal session in their first 4 months). A range of staff meetings was held. The introduction of more regular meetings for senior carers was planned. Accident records were being completed appropriately. Good practice was noted, as individual accident tracking forms were used to monitor residents at high risk of falls. Prior to the inspection, we were not being notified when residents were taken to A&E after serious accidents. Notifications were now being completed appropriately. Before the inspection, the home provided details showing all safety and maintenance checks were up to date. During the inspection we confirmed those for the electrical wiring installation (re-test due 11/2011) and the fire alarm and fire fighting equipment. The fire alarm was also tested weekly, with different zones activated each time. We advised different staff should help with this (to encourage familiarity and confidence). We were concerned to find the home was not following its policy regarding the frequency of fire drills. Monthly drills were expected, but these had been missed on 4 occasions in the last year. The home must follow its policy or review and amend it (the frequency of fire drills should only be reduced under guidance of the fire safety authority). Further to fire safety, we were concern to find dining room and lounge doors were kept open with wedges and sandbags. Many bedroom doors were also kept open with sandbags. To allow access, particularly with wheelchairs and hoists, communal doors needed to be held open. Many residents who spent Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 26 time in their rooms also wanted their doors kept open (to reduce isolation and allow them to participate in the life of the home). However, fire doors should not be restricted with wedges or sandbags. Prompt action was taken in response to this - at the end of the inspection, Mr Lowe said he had requested an electrician to fit magnetic door releases through out the home. Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 27 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 2 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP4 OP3 Regulation Care Standards Act 2000, Section 24, 14 (1) (b) Requirement To ensure the needs of potential residents can be fully met, the home must obtain full assessment information and comply with their conditions of registration (only admitting people whose primary needs fall within their registration categories). To ensure residents receive the care they need, care records must include all relevant information (and be of sufficient detail to guide staff). To ensure residents’ safety, the use of third party bed rails must be risk assessed on an ongoing basis. All records regarding medication must be completed accurately including any omissions, variations or errors in the administration of prescribed medication and the reasons why. This is to show that medication can be accounted for and that DS0000005668.V358140.R01.S.doc Timescale for action 31/03/08 2 OP7 OP8 12 (1) (a), 15 (1) 31/03/08 3 OP8 13 (4) (c) 31/03/08 4 OP9 13 (2) 31/03/08 Appleby Court Version 5.2 Page 29 residents are being given medicines as prescribed. All medicines must be administered in strict accordance with the prescribers’ directions to make sure residents’ health is not put at risk. 5 OP12 12 (4) (b), 16 (2) (m) (n), 18 (1) (a) 16 (2) (i) To better meet the diverse social needs of all residents, the frequency and range of activities must be developed. Additional staff resources must be provided to achieve this. To ensure residents enjoy good quality, appealing meals, with clear choices available, a review of menus and food provided must be carried out (with any necessary action taken). 30/06/08 6 OP15 30/06/08 7 OP19 16 (2) (c), To provide an attractive place to 31/03/08 23 (2) (d) live, the stained carpets in dining rooms, lounges and corridors must be effectively cleaned or the carpets replaced. (previous requirement, in part, from last inspection). For the comfort of residents who smoke, appropriate smoking facilities must be provided. To promote the effective running of the home, monthly, unannounced quality monitoring visits must take place. Copies of the visit reports must be provided to us each month. 8 OP20 23 (2) (a) (e) 26 (3) (5) (a) 30/06/08 9 OP33 31/03/08 10 OP38 23 (4) (c) (i) (e) To ensure the safety of residents and staff, fire doors must not be wedged and fire drills must be carried out in accordance with the home’s policy. DS0000005668.V358140.R01.S.doc 31/03/08 Appleby Court Version 5.2 Page 30 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 Refer to Standard OP1 Good Practice Recommendations To ensure information about the home is correct, the Service User’s Guide and Statement of Purpose should be updated (with regard to the points identified in the main body of this report). They should then be kept under review and revised where appropriate. CSCI and residents should be notified of any revision within 28 days of any change. 2 3 OP7 OP10 OP9 To ensure its effectiveness, the key worker system should be reviewed. The medication policies and procedures should be reviewed to reflect actual expected practice. The fridge thermometer should be checked for accuracy or a new thermometer purchased. A larger drugs trolley should be provided on the upstairs nursing unit. The medication audit process should be expanded to show all medication is given as directed and all medicines are accounted for. 4 5 OP10 OP15 Door locks should be fitted to bathroom and shower rooms on both nursing units. To help residents remember what meals were to be served, a daily menu should be displayed in a helpful format. To promote an open culture, views and concerns should be welcomed, with the complaints procedure clearly displayed around the home. In addition to external training and to better meet DS0000005668.V358140.R01.S.doc Version 5.2 Page 31 6 OP16 7 OP30 Appleby Court residents’ needs, an in-house training programme should be developed. A competence based training checklist should be developed to guide new starters during their induction period. Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: 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 © 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 Appleby Court DS0000005668.V358140.R01.S.doc Version 5.2 Page 33 - 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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