Inspection on 14/09/06 for Aquarius Nursing and Residential Care Home

This inspection was carried out on 14th September 2006.

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

Aquarius Nursing and Residential... 10/03/09

Aquarius Nursing and Residential... 25/09/08

Aquarius Nursing and Residential... 07/05/08

Aquarius Nursing and Residential... 23/04/07

Aquarius Nursing and Residential... 09/05/06

Aquarius Nursing and Residential... 28/09/05

Aquarius Nursing and Residential... 27/04/05

Aquarius Nursing and Residential... 02/11/04

Aquarius Nursing and Residential... 29/06/04

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St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Aquarius Nursing and Residential Care Home 4 Spencer Road Southsea Hampshire PO4 9RN Lead Inspector Clare Hall Unannounced Inspection 12th September 2006 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 Aquarius Nursing and Residential Care Home DS0000011470.V305809.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. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aquarius Nursing and Residential Care Home Address 4 Spencer Road Southsea Hampshire PO4 9RN 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) Category(ies) of registration, with number of places (023) 92 811824 Qualitycare Management Limited Care Home 38 Dementia - over 65 years of age (38), Mental Disorder, excluding learning disability or dementia - over 65 years of age (38), Old age, not falling within any other category (38), Terminally ill over 65 years of age (26) Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three service users between the ages of 55 and 64 years of age may be accommodated at any one time in the categories DE and MD. 9th May 2006 Date of last inspection Brief Description of the Service: The Aquarius Nursing Home is a care home providing nursing care for 38 older people over the age of 65 years who suffer from mental frailty, mental disorder, excluding learning disabilities. The home is also registered to accommodate 26 older people with life limiting diseases. The Aquarius is the only care home owned by Quality Care Management Ltd. The home is located in a residential area of Southsea, close to the sea front and the local amenities of the city of Portsmouth. The home consists of three large houses that have been joined together to the effect of a large town house. The service user accommodation is located over three floors. There is a pleasant courtyard at the front of the house and a patio area at the rear for service users to use in the finer weather. Nine of the eighteen single bedrooms have en-suite facilities. There are ten double rooms seven of which have en-suite facilities. There is a passenger lift fitted from the ground floor to the first floor only. Chair lifts are in place on some of the other flights of stairs that access other floors. Rooms that have been identified as having only access via a flight of stairs can only accommodate service users who are fully mobile. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit to Aquarius Nursing and Residential Home took place on the 14th and 15th May 2006 and was attended by two inspectors over a period of 16 hours .The inspectors visited late evening, afternoon, and early morning. During the visits the managers and the provider were available, and the staff assisted the inspectors in general. The proposed managers, care staff, ancillary, and management staff, were spoken with. The provider had appointed two managers to undertake a joint management role, the previous manager having retired in November 2005. The two managers have not yet completed the registration process and during this visit one of the managers said she is now withholding her application to register. The judgements made in this report were made from information gathered pre-inspection from previous reports, the service history, the lack of Regulation 37 notices received, spasmodic reports sent to the CSCI by the provider who undertakes the monthly visits and reports, correspondence with the home, contact sheets, and reports and concerns relayed to the commission by staff. The manager did not, when requested assist the inspector by handing out relevant comment cards to care staff and service users pre inspection, despite this being requested twice. The Director completed the pre inspection evidence and responses without consultation with the managerial staff so information received was not accurate. At both previous inspections the inspectors discussed with the manager and provider the registration process for the managers, which was becoming urgent, as the home had had no manager since the previous year. This has now been raised again and the provider informed the CSCI might enforce this. This visit did highlight serious issues around care practices, and there have been issues in respect of allegations of abuse in the home, which has been referred to the adult protection team by the inspectors. The environment was audited but not in depth, as the previous visits had concluded that previous environmental requirements had been met and that the home was clean, hygienic and homely. The inspectors sat in the main lounge areas and observed the routines and care practices in the home, which were not person centred but task orientated to “get the job done”. The inspectors were very concerned at the routines and practices witnessed during this visit and will be considering what action will be taken due to the lack of consideration given to the previously raised concerns. Of the twenty requirements raised following the last visit 18 have not been met and a number of these have been raised on more than two occasions. A total of thirty three requirements have been made as a result of this inspection. What the service does well: Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 6 The home is clean and free from odours. The home employs separate housekeeping staff that are supervised daily by the personal assistant responsible for the health and safety of the home also cleaning and housekeeping audits and maintenance of the home. Records of these audits and of health and safety risk assessments were observed to be well maintained and current. The provider is striving to maintain a regular redecoration programme and has plans to extend the building to provide more communal space, a large kitchen and a new laundry area. What has improved since the last inspection? What they could do better: Residents and relatives have not been provided with up to date information regarding the home and these concerns have been raised previously. The homes practices are institutional and the services are not driven by the needs, abilities, preferences and choices of residents. The evidence gathered shows that there is a blanket opinion that residents with dementia and mental health problems do not have the capacity to make any choices. Pre inspection information and previous discussions with the proposed manager indicate that there is an ongoing institutional philosophy which neglects core values and undermines residents opinions and choices. The current residents are not having their NHS entitlements/services for ophthalmic and dentistry maintained. The assessment and care plans do not accurately identify the care needs of the residents and therefore do not fully meet the residents health, personal and social care needs. The residents are not fully protected by the policies and procedures of the home for dealing with medication. There are some serious gaps in best practice and meeting the needs of individuals. The institutional practice of the home, the lack of good management and adequate supervision of staff is to the detriment of the service users. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 7 The home does not provide a programme of meaningful activities tailored to the needs of the resident group but they do maintain links with relatives and friends who are welcomed to the home. It was also established that the residents are not provided with the necessary assistance to choose how to spend their day. Staff do not ensure residents receive appropriate dietary requirements and support at regular and acceptable intervals throughout the day. The processes and procedures in the home do not protect the residents.The management team are unaware of the adult protection procedures and have failed to protect service users from abuse. The home is clean and well maintained but the layout is not suitable for clients with mobility problems in areas upstairs.Despite this issue being raised during previous inspections, the home has continued to admit people to upstairs areas which are unsuitable. The home has not had a registered manager in place since January 2006.However the person registered as manager prior to this date had been on an extended period of leave. As a consequence ,the home has been without a registered manager in effect for some eighteen months.The outcome with regards to the standards of service are poor and staff are not receiving the training they need to ensure safe care practice for residents. The poor quality of the care provided in this care home is a result of inadequate quality management and the managers/ senior nurses poor relationship with the registered provider of the home. The failings and shortcomings identified are a direct result of a lack of clear job specifications and responsibilities. Non-nursing personnel are making nursing decisions. The manager is failing in his responsibilities by not familiarising himself with the National Minimum Standards and the inspection process, nor the role of the regulator.He also has a lack of knowledge regarding policies, which are there to protect the homes vulnerable client group. The homes’ philosophy remains institutional and dismissive of residents choices and preferences. It is neither transparent and nor all-inclusive and the ethos of the home is to keep all details of the running of the business within the control of the director and administrator/house keeper. The management have failed to ensure they foster an atmosphere of openness and respect, in which residents, family, friends and staff all feel valued and where their opinions matter. Nor is there a good quality assurance system in place, which formalizes this process. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 8 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. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. Service users and relatives have not been provided with up to date information regarding the home. The home practices are institutional and the services are not driven by the needs, abilities and choices of service users. The evidence gained shows there is a blanket opinion that service users with dementia and mental health problems do not have the capacity to make any choices. Pre inspection information, previous discussions with the manager and responses to service users comment cards indicate that there is an ongoing institutional philosophy which neglects core values, and undermines service users opinions and choices. The current service users are not having their NHS entitlements/services for ophthalmic and dentistry maintained. EVIDENCE: Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 11 Within previous inspection reports it has been identified that the homes Service User Guide needed to be updated and made available to potential service users and relatives.Despite being raised in two previous inspection reports, the manager has not submitted a reviewed guide when requested on previous occasions and the timescales that were made to address this were not met. During this visit to the premises the homes information provided to clients was not up to date or reflective of the current managerial arrangements.This has been raised on numerous occasions prior to this inspection. It was also established that there was a client who came into the home daily. There were no records for this lady, and the administrative staff were administering her medication, through-out the day.It was reported by care staff that the day client was abrupt, and bullied the other clients. As a result of the last visit the manager was informed that pre admission assessments must be developed to be more person centred and more specific to needs, and that assessments must identify that appropriately trained staff can meet the needs of the residents. Pre inspection information sent to the inspector indicated that only one resident (of 38) had a dental check up and the Director, in her response stated the remaining residents (37) would not be able to participate in dental examination. It has been stated that their oral status identifies they are without teeth, dentures etc. This response remains the same for optical appointment entitlements despite there being no evidence to support why residents cannot tolerate or partake in health checks, or when this was established and by whom. During the visit when the manager was asked regarding this he stated he had no records to demonstrate when clients last had dental, eye, and hearing checks.Service users with glasses have no records indicating they had received regular checks. Files audited did not reflect the current terms and fees of the accommodation and services provided or how payments to cover the costs including how top ups are arranged. It has been raised on previous occassions that the home does not employ a person-centered approach to care where core values are respected and encouraged. The client group has also been identified as needing a more specialist approach in respect of their needs by staff competent to care for them, and by staff who are sympathetic to their needs and aspirations. The inspectors were gravely concerned that the clients are not considered or supported and cared for, as they should be. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 12 It was identified that senior staff have not ensured clients are cared for in a secure and safe home. Through out the visit, the feedback from the staff, and pre inspection information identifies staff are dismissive of the clients as individuals with rights and choices.The service users also lack adequate representation. The practices within the home appear to be breach current best practice for advocacy which state it is assumed everyone has the capacity unless it is clearly documented and demonstrated why they cannot make decisions for themselves.Individuals must have someone advocating on their behalf and acting in their best interests.The information and statements made within the PIQ indicate that none of the 38 service users have capacity and none have guardianship, power of attorney or advocacy. Records state that the director has appointed herself as some clients’ representative/advocate and this is considered a conflict of interest. It was not apparent that those service users who lack capacity have an appointment of a power of attorney or court of protection. The pre inspection questionnaire response from the director stated, We are mindful of the fact that the majority of our residents cannot make informed choice, we advocate for any person who is unable to choose and strive to make the right decision at all times.This is not reflective of a service which is proactive in seeking outside assistance in matters such as these. When reading the clients terms and conditions there was a statement which reads, “The service provider reserves the right to introduce (in the case of rooms other than single rooms) other residents to share rooms.Also the service provider reserves the right to move the patient from one room to another within the home if the service user is best served by moving due to any deterioration of their illness. If the new accommodation is not in the service provider’s view of approximately equal value to the previous accommodation an adjustment in fees may be made. There must be some mode of consultation or advocacy in these circumstances as this may not in the best interests of the service users. The room to be occupied is not referred to in residents contracts. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. The assessment and care plans do not accurately identify the care needs of the service users and therefore do not fully meet the service user’s health, personal and social care needs. The service users are not fully protected by the policies, procedures and practice of the home for dealing with medication. There are some serious gaps in best practice and in meeting the needs of individuals in a respectful manner. The institutional practice of the home, the lack of good management and adequate supervision of staff is to the detriment of the service users. EVIDENCE: Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 14 Care plans reviewed during the inspection undertaken in March 2006 indicated that the care planning system did not effectively describe how the service user’s needs were being met and this remains unchanged. The care planning system does not easily describe the care issues and what actions are to be taken to meet the needs of individuals. Work has been undertaken to improve the documentation by one of the managers but this is not being reflected by the whole care team and the records still need substantial improvement. Care staff were observed having a handover and observed over a twelve-hour period.They did not refer to the care plans during this time. A Requirement was raised during the inspection undertaken in May 2006 stating that Service users routines and choices with reference to going to bed and rising in the morning, mealtimes, having a bath, taking breakfast in their rooms etc must be documented in individual’s care plans.The requirement also stated that staff must not work from day/night work allocation lists and work more with a person centred approach to service users care.There have been no changes evidenced in respect of this and this requirement has not been met. A further requirement raised, following the inspection visit in May was that the care plans needed to be developed further and staff should undertake training on how to use the plans as a working document to inform their care.Care plans were seen kept in the office of the Home. Discussion with staff identified that staff do not always refer to and access care plans in order to provide a basis for informing their practice. Senior staff were seen writing care notes without any discussion with those who provided the care. This was further evidence of the care being delivered by staff who do not refer to the care plans. Care was being provided in a task led operation within time constraints. The inspectors made an early morning visit and a late visit to observe care over a 12-hour period. It was established that staff start their day by waking clients at 5am by doing a “PAD round”. This entails service users being woken up by staff to have their incontinence pads changed ,irrespective of service users consent,preferences assessed needs and rights to sleep undisturbed. Then at 5.30 am the care staff began getting clients up. Care staff were observed turning on bedroom lights, waking up clients, moving them hurriedly and stripping them in front of the sink and washing them quickly. One client was distressed through-out this hurried intervention. No attention was taken to hair, eye or mouth care. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 15 The evening before staff were not providing mouth care to clients and caring for false teeth. Night staff informed the inspectors that they must get up 16 residents before 07.30am. Day staff were then observed coming on duty and after receiving a brief verbal report they then undertook their individual allocated jobs. Some staff were allocated to bed making, some to showering /washing /bathing service users.All clients were got up because the inspectors were told they must be up and downstairs for breakfast at 09.30am. Staff were observed walking around with a handful of communal brushes later and brushing service users hair as a task, and the men’s shaving equipment was also communal. Following the previous inspection, a requirement was raised stating that the care records must detail the action to be taken by care staff to ensure that all aspects of the health, personal and social care needs of service users are met with particular attention to nutrition, falls, pressure sores, continence, emotional, psychological needs and challenging behaviour.An audit of the files during this inspection indicated this has not been met. The manager was also required to undertake adequate pressure sore risk assessments, and provide the necessary equipment to support clients.A further requirement raised was that the home was to seek information and advice from a pharmacist regarding medicines policies within the home with reference to administration, crushing and prescribed timings. Despite this a concern was raised to the Commission reporting that a service user in the home was referred by GP with a grade 4.2 pressures sore on her sacrum. It was reported that the tissue viability nurse visited the next day and offered equipment, which the home refused because they had some on order but did not have any at that time.It was also stated that they were trying to get her pain under control and were found crushing medication that should not be crushed despite this issue being raised at the last inspection. Therefore the two requirements referred to in the above paragraph have also remained unmet. At the last visit it was identified that staff were not undertaking adequate risk assessments for service users in respect of nutrition, continence and mobility as a basis to identify what actions should be taken and what areas should be reviewed. The assessment and management of pressure sores was raised as an issue with the manager, as it was not undertaken in an appropriate risk assessment framework.Interventions for those clients identified as high risk, were not appropriate in relation to their risk. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 16 The care plans are not adequately updated and do not reflect current needs of clients in relation to pressure sore risk.Where specific equipment should have been provided to met service users needs in resect of pressure care and prevention of pressure sores,either no equipment or inapproriate equipment was provided. The manager states the home has now purchased some new beds and mattresses, which were seen being delivered on the day of the visit. At a previous inspections requirements were made stating that confidential information must be removed from the white board in the office which was on view to all service users and visitors.The information has now been removed except for one ladies care record. Also raised at the last inspection was the issue of staff not monitoring the effects of the medication they are giving. Service users are being administered medication without having the outcomes reviewed.It was therefore not possible for staff to establish the effectiveness of medication given,or its appropriateness. A number of service users were seen prescribed analgesia and other service users over 11 other tablets to be taken in the morning and there were no records to identify that regular review was undertaken to identify whether they are all necessary. Despite it also being raised at the previous inspection that the care interventions and records did not support that the service users psychological health is monitored regularly and preventive and restorative care provided, the records were still lacking the necessary information. One of the managers has attempted to implement nutritional screening but this requires some further work, as it does not identify the actions, in respect of risk, and the management of weight loss or gain. A further very serious concern was that during the last inspection the inspectors observed the manual handling of service users in an undignified and unsafe manner.Staff were observed being lifted out of their chairs and swung round by manual handling belts when they were non weight bearing and this was observed numerous times.This is unsafe practice for both the service user and staff. Non weight bearing service users should not be lifted using belts. Not once did the inspector see the use of the hoist, this considering that a number of the service users were non-weight bearing. Staff were observed throughout the morning wheeling residents around with no foot plates on chairs and the manager stated the plates were removed due to the injuries they caused. Floor surfaces were catching service users feet. During this inspection staff were again observed carrying service users in wheelchairs down stairs and pulling them backwards up stairs in their wheelchairs. One service user was noted to have a leg injury .Relatives of this service users decribed how the injury had been sustained.From this discussion ,it is the inspectors’ opinion that inappropriate use of footplates would have been the most likely cause of this injury. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 17 Trained nursing staff and care workers were observed moving clients from their wheelchairs without putting the brakes on. Sadly overall the poor care practices in the home remain unchanged. Observation and discussion clearly identifies a continuing institutional based approach to care with care documents lacking a comprehensive assessment drawn up to provide the basis for the care to be delivered. The care staff were observed disregarding any abilities the service users may have and their care plans do not reflect changing needs and current objectives for health and personal care. There remain concerns regarding the medication rounds.Staff continue to give medications three hours apart. A pharmacist should be consulted in respect of managing their administration times. The pre inspection information responses written by the provider states “pharmacist cannot give consent to crush medication as the multitude of manufacturers will not give consent.” This again reflects a ‘blanket approach’ to care delivery ,in this instance in respect of medication ,with no evidence of an indiuvidual approach being made to pharmacists in respects of individuals needs. This also identifies a lack of understanding regarding seeking pharmacist opinion on an individual basis,or what a pharmacist is able to authorise,and a misunderstanding of the properties of some medications.The statement was also a decision of the director who is non nursing. In terms of the provision of food and drink,it was identified at the last inspection that only those clients who are able to shout for a drink get one outside of the routine of the drinks trolley. A large number of service users went without access to a drink for long periods and there has been no improvement for the provision drinks or any improvement in access to call bells. The staff are still motivated by the work allocation book and not by the needs of the individuals . Staff are not allocated to care for any particular client during their shift so once all clients are in the lounges by 09.30am all staff oversee residents needs as a group task. Residents were observed being denied choices in respect of what they wore, the time they got up,what toiletries they had and wanted and are having to share socks, shaving and hair equipment. A staff member was overheard being dismissive and speaking disrespectfully to clients. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 18 Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 19 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 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. 13. 14. 15. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service The home does not provide a programme of meaningful activities tailored to the needs of the service user group. Service users do maintain links with relatives and friends who are welcomed to the home. The service users are not provided with assistance to choose how to spend their day. Nor are they given food and drink at regular and acceptable intervals through out the day. EVIDENCE: There have been a number of concerns raised in respect of these standards during previous visits. There was no evidence that service users have a structured activities programme provided to meet their needs based on the preferences of individuals. It did concern the inspectors when the manager stated he did not consider that activities and social interaction were an important aspect in the service users daily living as he felt that the patients cant and don’t have the ability to participate in social activities. He further stated that residents didn’t display emotional needs but if they did staff would meet them. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 20 The home does not employ an activities co-ordinator.The Director has arranged for the administrator attend a course on activities facilitation. Staff were not seen actively supporting residents based on their individual needs. Care records still require further development for identifying what the needs, likes, preferences and interests of individual residents are. The service must develop a more pro-active approach in relation to developing the service to meet the needs and preferences of residents with dementia. Again on this two-visit day visit a large number of residents were seen sleeping and slumped in chairs and the inspectors were concerned due to the lack of conversation and chatter between service users and staff. Staff only appeared to interact with residents when providing physical support. There was a music session on the second day. The pre inspection information asking the provider to submit evidence to support the fact that special therapeutic activities are provided to support people with dementia was returned stating that every Wednesday from 2.15 – 4.30 service users play “whose in the bag, reminiscence, bingo, cards, jigsaw, crafts and collages, ball play, exercises and they have an organist once every three weeks.” There was no evidence to identify how these were arranged to meet needs of individuals or what happens the remaining six days a week. There still seems to be a lack of understanding about driving activities from the individual’s needs, expectations and preferences and arranging activities to meet the identified and assessed needs of the individual. There was no evidence of that service users have choice of when they wish to go to the toilet or having breakfast in their rooms, get up or go to bed. The inspector read a listed record of staff night routines and it named the service users who must be got up and put to bed by day /night staff. The staff work patterns were led by a work allocation book and not by service users individual choices and needs. There was a concern raised following the last visit that nutritional screening for residents was not undertaken on admission to the home or subsequently on a periodic basis. Furthermore the inspectors observed residents calling out for long periods for food. Again staff were busy getting service users up and dressed and requests for food and drinks were ignored. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 21 A tray of toast and sandwiches was brought to those service users in the front lounge who were crying out for food at 7.30am. The inspectors couldn’t understand why, if the service users were being got up at 5.30 am, they hadn’t been given a cup of tea/drink or asked if they would like their breakfast. The home is run so rigidly by routines and the fact no one can have breakfast until everyone is up at 09.30am that they are filling in a small gap by giving those in ear range toast and sandwiches to “keep them going” when a complete change of the philosophy of care is necessary. The inspectors monitored the provision of food and drink and it was wholly unacceptable. At 5.30pm service users have their tea and at 6.30pm a hot drink. Service users don’t then have any food or drink until 09.30am the next day unless in the front lounge earlier than 09.30am when they will have some toast or a sandwich at 7.30am therefore service users are going 15 hours without a hot drink or food. Throughout the day there is a marked lack of fluids. Staff stated that service users do not have access to bowls of fruit and other snacks. This issue is not a new one and has been raised before. A requirement was made in the inspection report in May 2006 stating the timing between meals must be reviewed and service users must not have more than 12 hours between their last meal at night and the first one of the day. Priority must be given to service users reporting they are hungry and asking for food, over the ‘getting up’ routines of the morning. Current practice remains completely unacceptable. A letter from a member of staff felt practices in the home regarding the provision of food and drink were abusive. This letter will be referred to the adult protection team. The pre inspection questionnaire response returned to the commission stated a buffet style meal is provided so as to enable those who can manage finger foods to help themselves rather than having to be fed. The inspectors observed teatime and service users were given slices of uncut meat and sauté potatoes in a bowl. This was given to them on their laps. A number of these service users have no teeth or dentures due to a lack of dental provision and were left with slices of meat to feed themselves from their laps with no cutlery or serviettes. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 22 One service user had his bread and butter placed directly on the living room table without any plate. Service users looked dehydrated and were left without fluids for long periods and a letter from a staff member alleged that some service users were with held fluids because of the mess they make on the floor. It was also established that very little consultation is undertaken from other members of the multidisciplinary team such as the dietician, tissue viability nurse, wound care nurse and other multidisciplinary specialists. These concerns have been raised previously. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 23 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. The processes and procedures in the home do not protect the service users. The management team are unaware of the adult protection procedures and have failed to protect service users from abuse. EVIDENCE: The homes response to the pre inspection questionnaire was that there had not been any complaints in the home since the last inspection. This was found not to reflect the situation in the home during the visit. The administrative staff member is told to write and keep a log of complaints. The log seen stated that there have been no complaints since 2004. When asked staff reported there had been complaints but these had not been recorded. One of them was regarding allegations of physical abuse by care workers. The inspector was also informed that there had been other reports of alleged abuse since January 2006 to the management but no action had been taken until September 2006. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 24 Despite a staff member being suspended, no action has been taken to report the allegations to the Adult Protection Team as per local authority agency procedures. Despite the Director having the inter Agency Adult Protection Procedure in her office none of the managers or provider were aware of the procedures contents. It is suggested that the management of the home do not like to involve “outsiders in any of its business”, this also applies to members of the multidisciplinary team. A member of staff reported to the commission that service users do not get choices and that the management of service users valuables and possessions are not recorded. Furthermore it is alleged valuables aren’t always returned following death. When trying to establish whether records are made of valuables there is not an appropriate record/audit trail of possessions and returns made. Care records also identify that the homes director advocates on behalf of the service users. This would be considered a conflict of interest. The pre- inspection information identifies that 98 of the service users do not have capacity to make decisions. The manager has not ensured all service users have a representative. A further concern was that the pre-inspection questionnaire returned did not reflect the true situation in the home. It stated there had been no complaints, no POVA referrals, no deaths, no incidents and accidents and no pressure sores. It could not be established if the home has a whistle blowing policy. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 25 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The home is clean and well maintained. The layout of the home is not suitable for clients with mobility problems. Access to certain parts of the home is limited for persons with disabilities. This has been ignored despite being raised previously. The Director has improved the provision in respect of nursing beds and new mattresses. EVIDENCE: The visit to the home identified there is a high standard of cleanliness and maintenance of the environment. All bathrooms had been fitted with assisted baths and one shower room had been created for the convenience of some of the service users. In July 2006 the provider was requested to submit an annual development plan. The response stated, “ Our development plan is ongoing all the time.We seek to refurbish and change for the better where we can.” The inspector received relevant evidence with respect to the handling of hazardous substances pre inspection. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 26 The home does not provide signage, which aid this client group’s remaining capacity. Staff do not demonstrate that research based practice in relation to dementia care is undertaken. The inspectors observed the service users being moved around the home. It was observed that some clients with mobility problems are accommodated in rooms which are inaccessible by wheelchair. Staff were observed carrying clients in their chairs down the stairs. It was also observed that clients with mobility problems requiring hoists/handling belts were being moved between the stair lifts inappropriately as these areas cannot be accessed be a hoist. A number of service users doors do not have locks on them. Also a number of toilets have inappropriate locks for this service user group group. Despite being raised at a previous inspection the inspectors remain concerned due to the lack of pendants or call bell access in some areas of the home. During dinner time one service user was seen sat on a footstool in the lounge. A requirement will be made to have the environment assessed by appropriate therapists to ensure the environment is adapted to meet the needs of the service users. Poor manual handling, seating provision and toilet/bathroom access was identified. Again it was observed that the staff are not adhering to appropriate infection control measures. Staff were observed taking dirty pads out to the bins but continuing to wear the dirty gloves. Nether the staff or manager have access to the department of health’s guidance regarding infection control in care homes. Nor do the staff have access to the knowledge sets in infection control and dementia from the Skills for Care Council. The manager does have an infection control policy, which she has been working hard to put together, but this still requires further input. A concern raised at the last inspection was that the bedpan macerator is positioned in the same outbuilding as the laundry, (the DOH guidance in infection control states this should not happen). This was discussed with the manager during the last visit and it was stated then that a more efficient machine would be purchased and installed in a more appropriate sluice area during the planned building works to the home. There are no firm plans yet to do this so a requirement with a deadline will be raised. During the visit inspectors asked staff to remove soiled articles from the floor and to change dirty gloves. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 27 Since the last inspection there is now a new bathroom /shower room. Every bath now has a hoist. There are 5 new wheelchairs and 20 nursing beds with reform mattresses and some new domestic lighting in the bedrooms. In the kitchen there is a new fryer, new microwave, new fridge and 13 rooms including two sluices and a toilet have been re decorated. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 28 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. The home has not had a registered manager in place since January 2006 though even before this date the registered manager was on long- term leave. The outcomes with regards to the standards of service are poor. Staff are not receiving the training they need to ensure the safety of the service users. Staffing numbers have not improved. EVIDENCE: The last two inspection reports have required that the information stated in Schedule 2 of the Care Home Regulations must be sought before a new member of staff members employment commences. It was identified that the recruitment process is not as robust as would be expected. References are not always sought appropriately. During this visit it was also established that other full checks have not been undertaken. A worker with over twenty convictions (some serious) had not got a risk assessment in place to support the decision to employ her with this vulnerable client group. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 29 In the Pre inspection information the inspector requested the provider to provide to the commission, any strategies used within the home, which identify that service users are actively encouraged to develop the service and may be involved in the recruitment of staff were requested. The response was, unable to operate; all patients have dementia and cannot actively get involved in recruitment of staff. It was established when auditing records and reading the information provided pre inspection that the home does not currently have 50 or more care staff trained to NVQ level2 or equivalent. Neither of the proposed managers hold or are undertaking the registered managers award. Staffing rotas were viewed. It was raised in a staff comment card that shifts were always being changed and staff get little notice of any changes. The proposed manager showed the inspectors the duty rota, which was not on display. This was only written for the next three days and shifts had been “tippexed” and altered. When asked, staff stated that they did not feel there were enough staff on duty, especially at night. The inspectors observed there was only one trained member of staff and three care staff. It would be considered that if staff are stating they have to get service users up at 05.30 am the home is not providing the necessary amount of staff to meet the needs of the service users. Night staff do not give medications and work independently to get service users washed. There was no supervision of the other unqualified care staff, some of whom were observed giving poor standards of care despite in a gentle and considerate way. It was established when speaking to staff at the last visit and observing the practice in the home over two days this time that the current numbers and skill mix of qualified and unqualified staff was not meeting the service users needs considering the size, layout, purpose of the home, and complexity of needs. Compliancy issues and areas of concern which have been identified would also suggest that the ratios of care staff to service users must be addressed. This must be done in relation to the assessed needs of service users, especially at night. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 30 At the last visit it was established that,“Staff left in charge while the senior nurse is on a break, must be fully responsible and accountable for their performance and action”. These comments indicated that during the night, unqualified care staff are left for periods unsupervised. This situation remains unchanged, as there is only one qualified nurse at night. despite a requirement being raised following the last visit stating this , ‘You are required to ensure that staffing numbers and skill mix of qualified/unqualified staff are appropriate and sufficient to meet the assessed needs of the service users, with reference to the night shift and specific times of the day’. The previous registered manager was on long term sick for a year and has now retired. (10.01.06).This has in effect led to the home having no Registered Manager from Spring 2005 until now. The provider proposed to put forward a job share management post. Two qualified nurses working in the home were to be appointed. This has been discussed with the CSCI and all the relevant registration application forms were sent to the home on 10/1/06 along with a request for them to come to the CSCI office for their CRB checks as soon as possible and with details of how they were proposing to share the full-time post out so that the home would not be compromised. The application forms were never received by the CSCI and the two managers did not attend the office for their CRB checks. The inspector spoke twice to one manager and to the other to remind them they were to attend a CSCI office for their checks. At the visit on the 20/3/06 the inspectors again went through the registration procedure and again requested that the two managers attend the CSCI office for CRB checks. A requirement was made from the visit of 20/3/06 that the two managers submit their applications for registration by the 31/5/06. This has not happened. To date there is still no registered manager in this home despite a requirement being raised following previous visits and an immediate requirement letter being sent to the provider. The manager stated his CRB is still being processed after three months but he has not chased this. This will be the third time the provider has been served a requirement in respect of registering a manager. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 31 It was established during this visit that one of the managers will no longer be applying to register and the other proposed manager will now apply for the post alone. Despite letters from the commission this manager has still not provided the necessary information and had failed to chase up his CRB. The providers training matrix indicated that staff had not received updates manual handling and had not received fire training since 2004. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 32 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 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. 32. 33. 34. 35. 36. 37. 38. 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): 31,32,33,35,36,37,38 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. The quality of care provided in a care home is strongly influenced by the lack of quality management and the manager’s relationship with the registered provider of the home. The failings and shortfalls identified are of a direct result of the lack of management structure and the lack of clear job specifications and responsibilities. Non-nursing personnel are making clinical decisions and the proposed registered manager is not exercising his responsibilities. The proposed registered manager has not familiarized himself with the standards and the inspection process nor the role of the regulator. He also has a lack of knowledge regarding policies, which are there to protect the homes vulnerable client group. The homes philosophy remains institutional and dismissive of service users choices and preferences. It is neither transparent nor all-inclusive and the ethos of the home is to keep all details of the running of the business within the control of the director and administrator/house keeper. The management has failed to ensure they foster an atmosphere of openness Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 33 and respect, in which residents, family, friends and staff all feel valued emphasizing that clients opinions matter. The quality assurance system in place is poor. Senior management have allowed abusive practice to continue and have dismissed their duty of care to this vulnerable client group. EVIDENCE: The proposed registered manager was asked what changes have been implemented to address the shortfalls raised following the previous visit. The proposed registered manager stated he could not recall the areas of concern that had been raised and whether he had actually seen the report. Further clarification identified that he was not aware of the National care Standards for Care Homes For Older Persons and did not have a copy.Later that day he informed the inspector he had got a copy of them but these were not the standards in full but only the key standards. During the whole process of the inspection it was very clear that the two managers are only responsible for clinical issues and nothing else. This was confirmed by the pre inspection questionnaire. The Director is taking on all the management responsibilities and it was discussed with her that despite her many years experience, she is not a nurse and shouldn’t be responding to nursing and care issues which she doesn’t have the knowledge about. This must be done by the manager. The managers must take responsibility for the care provision, as they do not currently manage any of these aspects. They managers state they are not always able to have access to the mail and if the Director is on holiday the mail is scanned by the administration assistant and not always forwarded to them. It was clear that the management and organisation is not working ,as it should be. The Director is addressing clinical issues and does not have any care experience.The administrative assistant and housekeeper is handing out medications, organising induction, updating policies and scanning the managers mail. The managers did not have any input into the pre inspection information provided to the commission. This was evident, as the questions were not responded to appropriately. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 34 Further more the Director is not allowing the management of the home to be undertaken by the managers so they are not aware of what is going on, have no insight into the failings of the service, what actions have been required by the commission, and what the inspection process entails. A further concern raised when chatting with the proposed manager was that he was not aware of adult protection policies and did not know what the core values for care are. The manager stated the homes philosophy was to ensure all service users have water and shelter and are looked after and these are the core values. It was further established that the proposed manager was aware of reported alleged abuse and did not address it himself. None of the management were aware or had an understanding of the recent changes to CSCI inspection process. When auditing one of the proposed managers training records they identified he had not undertaken any training relevant to his position as a senior manager. The records seen did not identify he had kept himself abreast of best practice issues or relevant managerial topics. Records lacked evidence of professional development and updating in line with his role as head of care /manager/registered nurse. Further more when the manager was asked about the staff training and induction programme he stated I would need to talk to the administrative assistant about it. It was clear throughout the inspection process that the Director and administrative assistant are managing all aspects of running the home and the proposed manager has very little knowledge and control. The director involves herself in clinical issues and decision making of which she does not have the qualifications to undertake. The senior nursing staff should be updating and improving the staffs care practices through evidenced based practice and they should be driving the policies and procedures within the home but they are clearly not. Staff reported that drawer sheets are put on airflow mattresses because “The director said they have to be.” This is clearly detrimental to the clients pressure sore management and such decisions are beyond her expertise as this is considered poor practice. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 35 The senior staff are aware of staffs poor practice issues but are not managing it or addressing it either through the supervision process or the homes disciplinary processes. The homes housekeeper and director have too large a job specification and get involved in responsibilities, which are clearly the managers. There are no clear written job specifications for the senior management and they do not meet to discuss issues. Conversations held with managers indicate they are unable to address issues they may have with the director and be open and honest. The homes staff induction process also falls short of the Skills For Care guidance and is not ensuring the staff receive the necessary input for induction and training. Again the homes policies and procedures were looked at. Since the last visit the provider has been asked to review the documents. It was apparent that the policies had been date stamped but the content in the majority remains the same.These policies lack updated references for best practice and are outdated. When asked, the proposed manager stated staff supervision had not been undertaken and that he nor his counterpart had received supervision. With regards to the information received pre inspection and discussions with staff it appears that the homes policies do not encourage openness and transparency in terms of what is happening within the home. Information is withheld and not divulged and staff accuse each other of hiding and not divulging information, and also giving false information. The proposed manager was inconsistent when the inspector asked him whether the pre inspection comment cards sent pre visit had been distributed to the care staff as requested twice. He said he wasn’t aware as the director was on holiday and she receives all the mail. The inspector asked the manager directly pre visit to give out staff comment cards. Despite the comment cards having already been sent once before non of the two packs were circulated. The manager could not explain why these had not been distributed and the inspector had to do it one to one on the day. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 36 The Commission also did not receive any responses from service users relatives or health and social care workers pre visit. Only two service users responses were received which the Director said she had written on their behalf as they were the words of the clients. Pre- inspection information requested by the inspector asked the provider to forward any evidence stating that service users are consulted about their care, the home etc and have meetings. The comments received from the provider were that “our service users are unable to take part in meetings because of their dementia and related disorders also problems with concentration and inability to make informed decisions. Pre inspection questions also asked the provider to provide evidence to indicate staff have meetings and are kept informed. The response was a copy of attendance of a staff meeting dated 1.12.05 and a comment written on it to say, “yearly poorly attended”. The Director was also requested to send copies pre inspection f strategies to indicate how service users and relatives are consulted. A blank service user /relative questionnaire was submitted and no outcome of any audits undertaken. The comments written on the response was “ blank two returns “ with four returns enclosed of 38. At the end of the two day visit relatives questionaires were shown to the inspector. The format was considered to be poor as the statements were more leading than questioning to seek peoples opinions.These will need some improvement and the outcomes of any surveys recorded. This issue was raised previously and a requirement was made in the inspection report of May 2006 for the provider to expand the quality assurance programme to include a service user/relatives satisfaction survey and analyse the responses to measure the success of the service in meeting the aims and objectives of the Statement of Purpose. The policies and procedures that guide practices in the home were also to be reviewed to reflect new and updated practices. The current process and standard of internal audit can only demonstrate that the managers and provider do not understand the process of audit. Requirements made by the commission on more than one occasion have not been addressed and the registered provider is showing continuing non compliance and little effort to address the issues.The care provision and Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 37 service in this home, the standards of practice and the general outcomes for service users are very poor. A further requirement was raised after the last visit stating that all staff must receive formal supervision at least 6 times a year. This has been raised since visits undertaken in 2005.This has not been done. A copy of the five-year electrical wiring certificate was received by CSCI after being required in the past three reports. The fire authority has visited the home and the home has complied with their recommendations. Thermostats have been fitted to all hot water outlets. The Commission are still not receiving all the necessary notifications of incidents under Regulation 37. The proposed registered manager has worked in the home for over nine years and has so far shown no interest or commitment to upholding the National Minimum Standards or addressing the issues raised in the report. The managers are not demonstrating a commitment to meeting the requirements raised by this visit, or to ensuring that despite their back grounds being in large hospital environments that the practice undertaken in the home reflects best practice for dementia care in a social setting. The Director and not the proposed manager has completed the pre inspection questionnaire. It was noted at the last inspection that the home’s policies and procedures have not been updated as required at the last visit. The home lacks up to date policies and procedures in relation to care practice including health and safety, infection control, medications, restraint and abuse. Generally the homes policies and procedures still require review by qualified persons to update them and incorporate best practice and recent guidance. The managers must start quality monitoring and to measure their success in meeting the aims, objectives and statement of purpose of the home. An internal audit must be undertaken annually, and visits made under the provision of regulation 26 must reflect thorough audit in relation to the standards so that the provider monitors issues raised at this visit. Consideration must be given to CSCI initiatives and moves towards Inspecting for Better Lives (2), as the home is not yet applying adequate processes to monitor quality of the service. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 38 There is a distinct lack of quality and commitment shown by the provider in the information sent to the commission pre inspection to demonstrate a commitment to quality initiatives and improvements. A requirement raised following a visit undertaken in May 2006 was that all information about service users must be handled in accordance with the Data Protection Act and confidentiality. The requirement was raised stating all information about the service users must be removed from the notice board on view to other service users/ visitors and be contained in care plans. This has been partially met but the provider was informed that the current screened area used by staff, as an office, is not fit for purpose. The inspectors were able to hear the handover report and intimate details regarding service users during the report as this room is not closed. The nurse managers do not have a confidential space to speak with relatives and staff. The only access the senior nurses have to a phone is via a pay phone in this area. Senior staff are not able to have a discreet conversation without having to move the director or administrative assistant out of their office. This leads to nursing staff discussing/divulging health matters in front of non- nursing / care staff. The senior staff must have an office in which to conduct supervisions, discussions, handovers and meetings. The staff personnel files were also seen open on the office shelf. The provider was asked to submit the homes risk assessment for the building pre visit. This has been done but this has been poorly completed. There have been risks identified but a lack of hazard management recorded to address the risks. During the visit it was established that the portable electric certificates expired in July 2006. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 39 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 2 1 1 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 1 18 1 3 3 2 2 3 2 3 2 STAFFING Standard No Score 27 1 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 x 2 1 1 2 Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 40 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 Reg 5(1)(2)(3) Requirement A Service User Guide must be made available for all potential service users and/or their relatives. A copy of this document must be submitted to the CSCI within the stated timescales. OUTSTANDING; The initial timescale of 30/6/05 was not met. This was a requirement of a further previous report with a timescale that was not met of 15/12/05 and not met after another extended timescale of 15/07/06. Timescale for action 10/12/06 2. OP1 Reg 4 The Statement of Purpose must be reviewed to ensure it contains up to date and accurate information. This requirement has not been met and has been raised again from a previous compliance date of 31/07/06 10/12/06 3 OP2 5 The philosophy of the home DS0000011470.V305809.R01.S.doc 10/12/06 Version 5.2 Page 41 Aquarius Nursing and Residential Care Home must promote core values, respect the preferences of individuals, seek their opinion and choices were they have capacity and consult them in respect of their accommodation. Terms and conditions must reflect this. The agreements must also clearly identify the fees to be paid and the breakdown of the charges in respect of funding and top ups from social services. Any service user without capacity must have a named representative /advocate who does not have a stake hold in the home. 4. OP3 Reg 14(1) Reg 12(1)(a) Pre admission assessments must be developed to be more person centred and more specific to needs. The assessment must identify that appropriately trained staff can meet the needs of the service user. This requirement was not met by the timescale of 31/07/06 and has been raised again Service users health needs and NHS entitlements must be maintained and the service users must have access to relevant specialists with regards to continence, tissue viability and nutrition. The home must not admit service users with immobility problems who cannot access the rooms which are not accessed by a shaft lift /chair seat. Service users needing hoisting must not be carried or lifted between the stir lifts. The routines of the home must DS0000011470.V305809.R01.S.doc 10/12/06 5 OP4 12 10/12/06 6 OP4 12,13 05/10/06 7 12,13,14 31/10/06 Page 42 Aquarius Nursing and Residential Care Home Version 5.2 OP7 OP8 OP10 be service user led and encompass the preferences of the service users. Service users must not be got up at 5.30 to fit in with the homes routine. Service users meals must be provided as they need and not as the discretion of staff at the rigid times imposed by the home. Care must be holistic person centred and the care workers supervised in respect of their actions. This requirement was not met by the timescale of 15/07/06 and has been raised again 12,13 Any member of staff speaking in a derogatory manner or ignoring the wishes and protests of service users must be subject to disciplinary actions. Staff must be made aware of their duty of care and the whistle blowing policy. Service users must have their own belongings and own toiletries, which they have chosen, and they must not share clothes, hairbrushes, toiletries and shaving equipments. All service users must have access to funds so as to be able to have the necessary supplies without these being handed out to them without consultation by the home. The identified risks identified in the assessments in respect of nutrition, continence, pressure sores and manual handling must identify what action is being taken in respect of that risk. These actions must reflect the level of risk identified. Audit of DS0000011470.V305809.R01.S.doc 8 OP10 OP16 OP14 OP18 05/10/06 9 OP10 OP35 12 31/10/06 10 OP4 OP7 OP8 12,13 31/10/06 Aquarius Nursing and Residential Care Home Version 5.2 Page 43 risk must be under taken and the manager monitor this especially in respect of pressure relieving devices. 11. OP7 Re 15(1) Care plans must be developed further to reflect individual current needs of clients. Staff must be trained to use the plans as working documents to inform their care practices and not to work on a task led basis. This requirement was not met by the timescale of 31/08/06 and has been raised again The care records must detail the action to be taken by care staff to ensure that all aspects of service users health, personal and social care needs are met with particular attention to nutrition, falls, pressure sores, continence, emotional, psychological needs and challenging behaviour. This requirement was not met by the timescale of 30/07/06 and has been raised again 13 OP9 Reg 13(1)(2)(4) You are required to seek information and advice from a pharmacist regarding medicines policies within the home with reference to administration, crushing and prescribed timings of drugs. This requirement was not met by the timescale of 30/07/06 and has been raised again Medications must be reviewed Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 44 30/11/06 12 OP8 Reg 16(1)(2) 30/11/06 15/11/06 regularly especially with consideration to how much medication is being taken. Staff must also monitor and record the effect of medication i.e. e analgesia. The routines of the timings of the administration of medications must be reviewed. Only staff who are trained are to administer medication and medications must not be secondary dispensed. All medications given must be recorded and prescribed. 14. OP12 Reg.16 (2)(n) The home must plan and provide 10/12/06 plan a programme of activities and social interactions for service users appropriate to their mental capacity and needs. These must be documented in a specific plan. This requirement was not met by the timescale of 15/07/06 and has been raised again All information in respect of the home must be transparent and the Provider must ensure any information provided to the commission is true and reflects the current situation. 10/12/06 15 OP32 12,24 16. OP15 Reg 14(2)(i) Reg 12 (1)(a) 31/10/06 The timing between meals must be reviewed. Service users must not have more than 12 hours between their last meal at night and the first one of the day. Priority must be given to service users reporting they are hungry and asking for food, over the ‘getting up’ routines of the morning. This requirement was not met by the timescale of DS0000011470.V305809.R01.S.doc Version 5.2 Page 45 Aquarius Nursing and Residential Care Home 31/07/06 and has been raised again Service users must be provided food in a dignified manner and with consideration to their needs. Service users must have regular access to cold fluids, as they require. 17. OP22 Reg 16(1)(2)cRe g 22(3)(n) The call bell system must be made available to service users in all areas of the home used by them with special reference to the lounge areas. All service users rooms must have a lock provided and the toilets and bathrooms must have locks suitable to the needs of the service users. An occupational therapist must be consulted regarding service users access to their rooms for all service users who have mobility problems and for their manual handling. Service users must be provided with appropriate seating and appropriate risk assessments must be in place for service users nursed on the floor with regards to safe manual handling consultation and consent. You are required to ensure that staffing numbers and skill mix of qualified/unqualified staff are appropriate and sufficient to meet the assessed needs of the service users, with reference to the night shift and specific times of the day. This requirement was not Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 46 10/12/06 18 OP22 OP24 14,16,23 10/12/06 19. OP27 Reg 18(1)(a) 10/10/06 met by the timescale of 31/08/06 and has been raised again You are required to write to the commission and enclose a copy of the homes duty rota to identify how the staff arrangements have been reviewed and show adequate numbers of staff are employed especially at night by the date given. Staff must receive a written rota planned one month in advance, which is clearly displayed. There must be a period of notice given to staff if their duty is to be changed and this must be agreed and recorded. The duty rota must not be tippexed. Enough senior nursing staff must be employed so that the care staff are worked along side with and their practices supervised and monitored. 20. OP30 Reg 18(1)(c) You are required to ensure the staff receive training in restraint and caring for service users with challenging behaviour and updates in manual handling and fire training. This requirement was not met by the timescale of 31/08/06 and has been raised again 21. OP31 Reg 9 An immediate requirement letter has been sent to the provider following this site visit to require that the two appointed managers commence the registration process within one week of receiving CRB clearance under the CSCI policy for registration DS0000011470.V305809.R01.S.doc 10/12/06 10/12/06 Aquarius Nursing and Residential Care Home Version 5.2 Page 47 of managers. This was a requirement from the previous site visit Timescales set for 31/5/06 and 31/08/06 were not met. There is still no registered manager for this home. 22. OP37 Reg 17 (1)(2)(3) All information about service users must be handled in accordance with the Data Protection Act and confidentiality. All information about the service user must be removed from the notice board on view to other service users/ visitors and be contained in care plans. This was identified in a previous inspection report of 27th April 2005 at which time this was made an immediate requirement and was subsequently raised again on a visit of 20 March 2006. This requirement has not been fully met by the timescale of 15/07/06 and has been raised again 23. OP38 Reg 37 (1)(2) You are required to give notice to the Commission, under the requirements of this regulation details of any of the following; Death of a service user must be reported including the circumstances of this death, The outbreak of any infectious disease, Serious injury to a service user, Any event in the care home which adversely affects the wellbeing or safety of the service user, DS0000011470.V305809.R01.S.doc 15/10/06 15/10/06 Aquarius Nursing and Residential Care Home Version 5.2 Page 48 Any theft, Any allegations of misconduct by the registered person or any person working at the care home, Any notification given orally shall be confirmed in writing. This requirement has not been met by the timescale of 30/06/06 and has been raised again 24 OP29 Reg 7,9,19 Schedule 2 All staff recruited must have the necessary checks undertaken and there must be a clear audit trail of the recruitment process, interview and selection, health declaration and evidence that staff have the necessary immunisations, terms and conditions of employment, job description, induction and service users specific training. There must be evidence of Skills for Care Council Induction foundation and offer of NVQ training. Staff with issues identified in their references or criminal record checks must have this clearly recorded with a specific risk assessment demonstrating how this is being managed. The home must ensure that over half the staff hold an NVQ 2 in care or equivalent. 25. OP38 Reg 13(2) C 15/10/06 You are required to ensure safe working practices with regards to moving and handling of the service users. Trained nurses must undertake the appropriate use of equipment following a risk assessment. This requirement has not Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 49 15/09/06 been met by the timescale of 30/06/06 and has been raised again 26 OP36 Reg 18(2) You are required to ensure that persons working at the care home receive formal supervision at least 6 times per year and records of this taking place, be maintained. This was a requirement from previous reports with timescales of 30/11/05 and 31/08/06.This has not been fully complied with. 27 OP26 12,13,23 The provider must inform the commission of the date the work will be undertaken to move the macerator from the laundry and refurbish this area. The waste bins must be managed to avoid spillage of waste and staff must receive infection control training and implement control and methods. The provider must not get involved in decision making in respect of nursing and clinical issues and must allow the managers to manage the home and have the necessary control. The managers must have appropriate confidential office space and a phone so they can make confidential and discreet calls, interview and support staff and conduct service users reviews and handovers. 10/11/06 31/10/06 28 OP32 12,24 31/10/06 29 OP32 OP31 12,9 31/10/06 All staff including the director, housekeeper and nurse managers must have written job specifications and must keep DS0000011470.V305809.R01.S.doc Version 5.2 Page 50 Aquarius Nursing and Residential Care Home within their remits. The housekeeper must not get involved in managerial and clinical issues outside of her remit. The organisational structure of the running of the home must be clear honest and transparent. Managers must not feel intimidated and dismissed with regards to their opinions and meetings must be held to discuss issues and joint strategies so as to improve communications. All home staff must be able to attend regular meetings. 30 OP33 24 10/12/06 Quality audits must be undertaken and outcomes recorded for all aspects of the care within the home in relation to the standards and compliancy. Service users must be protected by the policies procedures and actions of the staff. All staff must read and be aware of the Hampshire inter-agency protection procedures and all staff must be aware of their duty of care and the whistle blowing policy. Referrals to the adult protection team must be made as appropriate. All staff must have received adult protection training abuse training and the manager must address all concerns raised in respect of poor practice through the appropriate disciplinary procedures. Pressure relieving equipment must be reviewed to make provision for those service users having been assessed as high risk of tissue breakdown. 10/12/06 31 OP18 13 32 OP8 17 10/11/06 Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 51 33 OP22 16 Wheelchairs must be fitted with appropriate footplates. If they are unable to be used a risk assessment of the service user must be recorded as to reasons for these not being in position. This requirement was not met by the timescale of 31/08/06 and has been raised again Staff must receive training in respect of using wheelchairs safely 10/11/06 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 OP19 Good Practice Recommendations It is recommended that the staffing, décor and layout in the communal area be reviewed to reflect current good practice for the care of service users with dementia. Signage in the home could also be improved to aid this client group’s remaining capacity. Aquarius Nursing and Residential Care Home DS0000011470.V305809.R01.S.doc Version 5.2 Page 52 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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