Inspection on 09/05/06 for Aquarius Nursing and Residential Care Home

This inspection was carried out on 9th May 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... 14/09/06

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

Similar services:

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 Portsmouth Hampshire PO4 9RN Lead Inspector Jan Everitt & Clare Hall Unannounced Inspection 08:30 9th May 2006 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.V288728.R01.S.doc Version 5.1 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.V288728.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Aquarius Nursing and Residential Care Home Address 4 Spencer Road Southsea Portsmouth Hampshire PO4 9RN (023) 92 811824 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) Qualitycare Management Limited Mr Ronald Charles Biddle Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Mental registration, with number Disorder, excluding learning disability or of places 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.V288728.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing notices apply Date of last inspection 28th September 2005 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.V288728.R01.S.doc Version 5.1 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 9th May 2006 and was attended by two inspectors over a period of 8.5 hours. One of the managers and the provider were available throughout the visit and the staff assisted the inspectors in general. The provider has 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. One of the managers has been in post as senior nurse in the home for a number of years, the other manager continues to work outside the home in another role and manages the home for a specified number of hours each week. 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 of a management meeting held with the registered providers, with references to environmental issues that had been continually highlighted as needing attention. These have now been complied with Further evidence was gathered at a monitoring visit that two inspectors undertook on the 20th March 2006 at which time it was 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 visit did highlight issues around care practices and documentation and the provider received a record of this visit in the form of a letter, which is available in the public domain if requested. These issues were looked at in depth at the most recent visit. The environment was audited but not in depth as the previous visit had concluded that the environmental requirements had been met and that the home was clean, hygienic and homely. The inspectors sat in the main lounge area and observed the morning routines and care practices in the home, which were not person centred but task orientated to ‘get the job done’. A sample of service users records was tracked, which did not reflect the practice observed. Recruitment records were viewed. Five staff were interviewed and two relatives and one visitor to the home was spoken with. A number of the service users were able to communicate with the inspectors but most have poor memory and are unable to detail their opinions or level of satisfaction with the service. The atmosphere in the home was busy with a slight tense atmosphere prevailed owing to the two inspectors observing the staff practices around the Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 6 care of service users and how they were treated. Some of the care practices indicated that although training might well have been provided, practices did not always reflect this. The staff on duty at the time of the visit were familiar with the home and the resident’s needs and showed a caring attitude. The visit focused on the core standards to be assessed on this site visit. Twenty-five standards were assessed, twenty-one being core standards and four standards in relation to the issues raised at the site visit. Eight of the standards assessed were met; 107standards had shortfalls, seven of which had serious shortfalls in meeting the minimum standards. Five requirements remain outstanding from the previous inspection report and further discussion took place with the provider and manager and is detailed in the main body of the report. What the service does well: What has improved since the last inspection? What they could do better: Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 7 A service user guide remains unavailable to service users and potential service users and their relatives/advocates. The statement of purpose must be reviewed to reflect correct and current information with regards to the services and the ages of service users admitted to the home. The preadmission and assessment process could be more specific to the client group and identify more person centred needs. The care planning system introduced by the new manager needs to be developed more and care staff should be trained to use the system effectively to inform their practices. The staff are at present working on a task orientated system and they obtain their daily work allocation from a book or notices. This demonstrates that there is a lack of continuity of care with no written guidance of how to care for residents. Care plans must be more detailed in how to care for all aspects of the service users needs, and identify their choices and preferences with regards to their daily activities of living. A staff member confirmed that they are implementing a key worker system but this is only in relation to ensuring residents have adequate supplies of clothing and toiletries. The key worker does not actively participate in care plan reviews. The home lacks a structured programme of activities that is designed around the service users capacities and their social histories. Care staff could not demonstrate an understanding for the support of the service user’s emotional and social needs. Care staff and senior staff do not consider that clients have the abilities to benefit from activities and do not consider appropriate forms of support and understanding for the service user with dementia. The medication policies need to be reviewed and updated to include all aspects on the management of medicines with the involvement of a pharmacist for guidance. Trained staff that administer medication do not do so by their professional code of conduct and would benefit from further training. Service users continue to have a long gap between their last meal in the evening and breakfast the next day. On the day of the visit there were no care staff available until about 09.00-09.15, to commence serving breakfast, by which time service users were calling out for food and drink. This could be resolved by changes to care staff working patterns and routines and individual needs assessed. The staff and skill mix of the staff on duty during the busier times and at night must be reviewed. Staff require specific training in restraint and caring for a service user with challenging behaviours. The quality assurance system continues to need developing and expanding to ascertain the level of satisfaction of the services delivered in the home and also to measure the success of the home in relation to their statement of purpose. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 8 Formal staff supervision must continue to be developed for all levels of staff and records maintained in a secure environment. Information that is displayed on the notice boards in the office and just outside the office about how to care for a service user must be removed and be contained in a care plan. Regulation 37 notices required to be sent to the CSCI to report deaths, accidents, incidents that adversely affect the service users, infectious diseases, theft etc. are not being reported to the commission appropriately. A number of carers demonstrated unsafe working practices when transporting and moving and handling service users. Carers were using under arm lifts with handling belts to transfer service users from a wheelchair to a lounge chair. The use of wheelchairs without footplates was also observed. Male carers were transporting service users down a flight of three steps by bumping them down in the wheelchair. This is unacceptable practice. 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.V288728.R01.S.doc Version 5.1 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.V288728.R01.S.doc Version 5.1 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, 3 & 4 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service users, potential service users and their significant others do not have access to accurate and up to date information about the home in either the Statement of Purpose nor the service users guide. The systems in place to assess the service users suitability to be admitted to the home do not accurately reflect if the home can meet their needs. EVIDENCE: The Statement of Purpose was viewed and the information contained in this did not accurately reflect the service provision. The age range was not correct. The two new managers information had been put in on separate pieces of paper and the whole document was in need of reviewing. A copy of this document is maintained in each of the service users’ rooms. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 11 The service user’s guide continues not to be available for prospective service users and this has been a requirement in the last two reports and as such will be required again in this report. This requirement was made some time ago because the old brochure did not give up to date accurate information and was not in an appropriate format for service users to understand. The manager reports that the new service user guide is with the printer, which it has been for some considerable time. The two managers undertake pre-admission assessments based around the activities of daily living. The inspector viewed an example of this assessment tool and found a remark about the service users behaviour described in a very derogatory way, this was discussed with the manager. The home has admitted a service user, who is under 65 years of age. The age stipulation on the certificate is 65years and over. This gentleman is presenting with challenging behaviour and staff have no specific training to deal with his behaviour. The manager must ensure that before decisions are made about admitting a person that the staff are adequately trained to enable them to support and meet the specific needs of the service user. The registered person must develop a more person-centered approach in the assessment and planning of care. There is a very task led approach to the care being given and discussing routines with staff, reading guidance and observing practice evidence this. Overall the care tracking documents, records and observation of staff through out the day indicates an institutional based approach to care with care documents lacking a comprehensive assessment drawn up to provide the basis for the care to be delivered. St 6 This standard is not applicable to this service. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected 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 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 met the service user’s health, personal and social care needs. The service users are not fully protected by the policies and procedures of the home for dealing with medication. Service users are treated with respect generally; however there are aspects of care practices that indicate this does not always happen. EVIDENCE: The care plans audited indicated that the system needs to be developed further and staff should undertake training on how to use the plans as working documents to inform care. Care plans were seen kept in the office. These should be accessible to all staff in order to provide a basis for consistent planned care. 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 Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 13 who provided the care. This gave further evidence that the care is being delivered by staff that are not referring to the care plans. The inspector read an exert in the staff ‘allocation of work’ book which stated “ Please at all pad changing and toileting times please wash thoroughly all over her groins and apply liberally coloplast cream until the excoriation heals”. When the inspector asked the manager about this she stated that the service user did not have excoriated groins and nothing was noted in the care plan that this was so. This gave evidence of lack of communication and accurate recording. Staff are not undertaking adequate risk assessments 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 is not undertaken in an appropriate risk assessment framework so interventions for those clients identified as high risk, was not appropriate in relation to their risk. The care plans are not adequately updated and do not reflect current needs of clients. The notices around the office indicate that some service users’ needs are still addressed generally, rather than as an individual need. Care in relation to bowels, meals, support, allocation of baths/showers, nail care, exercise and weight is still being provided on a notice for all /book basis which does not identify individual needs. Moving and handling notices for named service users were displayed on the board on the wall and instructions regarding diet on notice boards rather than reflected in the care plans. It was discussed with the manager that any assessed need of the service users should be addressed through their plan of care and not written as reminder notes displayed in the home. Observations of the staff working throughout the day and case tracking demonstrated that the staff lack the understanding of a service that is person centred rather than task lead. The inspectors observed that staff were motivated by the work allocation book and not by an allocation to an individual and their needs. This was demonstrated by one service user, who was very unwell and remained in bed and unable to alert staff for help, did not have her care needs attended to for a period of over five hours despite three visits from the inspector. Staff did not support her hygiene needs, mouth care and turns until lunchtime. Records indicated that she had not had a drink since 02.00 the previous morning and when a member of staff was asked who is looking after the service user she stated ‘no one in particular’. However, staff were observed to be interacting well with service users in a kindly way and demonstrated that they were familiar with some routine care needs. The medication policies and procedures were audited and were found to be out of date and did not reflect best practice. The inspectors observed the trained nurse undertaking the morning medicine round. It was observed that in some cases medication was being crushed and there was no supporting documentation for this nor the home’s own policy guidance. Staff were observed to be administering medication from trays around the home and not Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 14 taking an appropriate lockable container with them or the MAR sheets. The medication round was protracted and medicines were still being given out at 11.00am. The next round indicated 14.00, therefore, the time between rounds is less than 4-6 hours. The medication hours stated are 10,2,6,10, but this does not reflect the support of medications which are given four times over a twenty four hour period and should be given over particular intervals. This must be reviewed with the pharmacist. The inspector identified when case tracking that staff are not monitoring the effects of the medication they are giving. Service users are being administered medication without having their health needs addressed in their care documentation or having the specific effects and whether it is appropriate and required, noted. The inspectors observed manual handling of service users in an undignified manner, wheeling chairs backwards, on the back wheels and bumping them down stairs. Residents were lifted out of their chairs and swung round by manual handling belts when they were non weight bearing and this was observed numerous times. At no time did the inspector see the use of the hoist, considering at least four 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 manger stated the plates were removed due to the injuries they caused. The accident book did identify that skin flaps had been sustained by service users but this could indicate other poor practice. Staff confirmed that the safe use of wheelchairs is not included in their manual handling training Service users eat their meals in various parts of the communal space. Those that need assistance with eating take their meals in the dining room area. There is a choice of food at meal times and the inspector observed service users being given choice of what to eat if they chose not to have what was on the menu. It was observed that service users were wearing large toweling bibs but during the visit, staff were trialing new serviettes, which are considered more dignified. The inspectors did not observe cold drinks available throughout the day. Again only those clients able to ask for a drink got one outside of the routine of the drinks trolley and the staffing of the lounge areas was not considered satisfactory during the lunch time period. One lady was sick during this period and vomited after calling for someone, but there were no staff in earshot and she had no way of facilitating help. The service users did not have access to a call bell in this area of the home. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is poor. This judgement has been made using 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 home provides nutritious wholesome food, however the manager must ensure service users are provided with assistance to choose how to spend their day and ensure residents receive appropriate dietary requirements and support at regular and acceptable intervals throughout the day. EVIDENCE: The care interventions and records would not support that service users psychological health is monitored regularly and preventive and restorative care provided. The home does not employ an activities co-coordinator and there was no evidence to suggest that any member of staff had been trained to support the staff dealing with service users with specific mental health issues so as to provide meaningful stimulation. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 16 Discussion with staff did not identify an understanding by them for the support of the service users emotional and social needs. Even senior members of staff do not feel that clients have the abilities to benefit from activities and do not consider other appropriate forms of support and understanding for clients with dementia and mental health illness. One staff member did describe how talking to clients and listening to them was a way of supporting their needs but no special therapeutic measures are undertaken. Life histories of clients have been gathered from relatives and the inspectors saw these. The content of these profiles was very good but these were not being used in a way to support clients. Staff were not seen actively supporting clients based on their individual needs. Care records did not identify what those needs, likes preference and interests were. A more pro-active approach in relation to developing the service to meet the needs and preferences of clients with dementia is needed. Through out the day a large number of clients were seen sleeping and slumped in chairs and the inspectors were concerned due to the lack of conversation and chatter between clients and staff. Staff only appeared to interact with clients when providing physical support. The inspectors observed that one service user was causing other service users to be agitated and one care worker demonstrated some effective diversional therapy that she had learnt when attending a training session on dementia. She was able to rationalize how and why she was interacting in this way with this service user. The inspectors did not observe any structured activities taking place on the day of the visit. There were a group of people sitting around a dining table and were interacting with one another occasionally. The visitor’s book evidenced that there are visitors daily to the home. The inspector spoke to two relatives visiting the home and observed other visitors being made welcome to the home. The family members spoken with confirmed that they were quite happy with their sister’s care but that she had mentally deteriorated since being admitted to the home. A visitor from the early onset dementia group, based at the local psychiatric hospital, visited the home to take a client out to lunch. She reported that she attends the home weekly to do this and did this for this gentleman when he was living in the community. There was no evidence 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 observed and obtained a copy of a record of staff night routines. This stated which service users got up with the night staff and who went to bed with the day staff with a remark next to one name stating ‘optional’. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 17 It was stated it was at the discretion of the nurse in charge, there was no mention that this should be at the choice of service users. Staff work patterns were lead by the work allocation book and not by service users individual choices and needs. The inspector noted when case tracking one lady service user, on her admission to the home had stated that she wished only to have her care given to her by the same gender. This was reported by the staff, to be respected as much as possible, the service user was unable to communicate with the inspector to confirm this. Nutritional screening is not undertaken on admission to the home or subsequently on a periodic basis. Since the last visit the manager has put together a very good pen picture of the needs of certain clients in relation to their diet but this has not been undertaken in a risk assessment framework. The inspectors arrived at 09.00 and service users were sat at the table waiting for their breakfast. A further three service users were in armchairs calling out for their breakfast and reporting they were hungry. Staff were busy getting service users up and dressed and these requests were ignored. Records written by staff identify that there is less than four hours between breakfast and lunch, four hours between lunch and tea. Service users who retire early to bed have to wait from 5pm in the evening until the next morning for breakfast which can be up to 09.30, which is so late that on the day of the site visit some of the clients did not want their lunch as they were no longer hungry after late breakfast and coffee at 11.00am. This is of some concern as it was noted that service users go for long periods without food. The service users spoken with reported that the food was good. The inspector observed that staff were giving service users the choice of what they wanted to eat at breakfast time. The inspectors observed that those service users able to ask for drinks did receive one outside of the routine drinks trolley but those unable to ask for drinks were not offered them. The staffing in the lounge areas was not considered satisfactory during the lunch time period. Service users did not have access to a call bell. The inspector spoke to the cook and she identified that she had not received training in the provision for special diets. The kitchen staff were not provided with accurate information and guidance on the provision of food for a diabetic. Staff did not recognise that an individuals needs may range in not only calorie requirements but also the management of appropriate amounts of fat, protein, fruit and even milk. There were no records to identify food sources and the quantity or numbers of servings from each food group. When discussing diversity issues the cook could not identify any understanding or reference to or training in special diets. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 18 The inspectors were informed and shown the new Environmental Health Office guidance provided to care homes called the safer food, better business guidance by the Food Standards agency. This guidance is self-explanatory and guides providers in how to reduce cross contamination by providing records for cleaning, chilling, cooking, management of catering facilities. The EHO has not undertaken an inspection for over a year. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 19 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 & 18 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The home takes all complaints and allegations of abuse seriously EVIDENCE: The logbook indicated there had been no complaints investigated since the last inspection. The complaints procedure is displayed on the wall in the hallway. A complaint was received by the CSCI in July2005. This was investigated by the CSCI to the satisfaction of the service user and relative. The home has a policy on abuse that needs reviewing. No allegations of abuse have been reported. Staff report that they have received training on the abuse procedure. A training matrix will be requested. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 20 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, 22 & 26 Quality in this outcome area is adequate. This judgement had been made using the evidence including a visit to the service. Service users live in a clean, comfortable environment, however the environmental décor and signage in identified areas of the home could be made more conducive to the client group to aid their remaining capacity. The home does not have an infection control policy although training for staff is provided. The home’s aids and equipment do not fully meet the needs of the service users in residence. EVIDENCE: A tour of the home found it to be clean with no offensive odours. Following a management meeting with the providers and the CSCI on the 10th June 2005, with regards to issues highlighted in previous reports and appertaining to certain areas of the home in need of maintenance, these issues have now been complied with. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 21 A subsequent visit by the inspector in August 2005 with the fire authority identified a room in the home that had been flooded. There was no electricity available to the service user and the switch was covered with cardboard. This followed a complaint made about these issues. All these issues and those identified by the Fire Authority have now been resolved and complied with. A maintenance man is employed to undertake the day-to-day maintenance of the home. He was observed to be doing odd jobs about the home on the day of the visit. Although the home is a large building with a number of corridors and sitting/dining areas the ethos is not to operate smaller personal units each with its own communal focus, due to the lack of staff. This has a direct effect on the supervision of clients. Considering the client group provision is for people with dementia and associated mental health problems, further consideration must be made to the staffing, décor and layout of the communal space. The home does not provide signage which aid this client group’s remaining capacity and staff do not demonstrate that research based practice in relation to dementia care is undertaken. The provider must ensure that the physical environment and staffing matches the requirements of the service user group. The courtyard garden at the back of the home is well maintained and has seating areas provided for service users in the finer weather. It was observed that the staff are not adhering to appropriate infection control measures. Staff were observed wearing blue aprons for care and then going straight into handling food. Soiled pads were placed in white bags on the toilet floor. The manager could not provide the inspector with an infection control policy. All rooms have hand washing facilities and paper towels. The bedpan macerator is positioned in the same outbuilding as the laundry. This machine is old and this was discussed with the manager as to a more efficient machine being purchased and installed in a more appropriate sluice area during the planned building works to the home, which is to include the laundry. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide the appropriate skill mix of staff at specific times of the day and night. Staff numbers need to reflect the dependency of the service users at busier times of the day to ensure service users’ needs are met. An appropriate training programme is made available to all staff, however, the manager must ensure all staff receive training to aid them to have a better understanding and support in relation to specific needs of the service users. The service users are protected by the home’s recruitment practices. EVIDENCE: Staffing rotas were viewed. From observations throughout the day and speaking with staff members this would suggest that the current numbers and skill mix of qualified and unqualified staff is not meeting the service users needs, taking into consideration the size, layout and purpose of the home. Compliancy issues, accidents, incidents would also suggest that the ratios of care staff to service users must be addressed according to the assessed needs of service users especially at night. It was a concern to the inspectors when a note to night staff read, “The nurse in charge will instruct each carer which residents she would like them to put to bed. The nurse in charge will make this decision only. Each resident to be washed, changed and made comfortable. Staff left in charge while the senior nurse is on a break, will be fully responsible and accountable for their performance and action”. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 23 These comments would indicate that during the night, care staff are left for periods unsupervised and that service users choices are disregarded. It was also evident to the inspectors that during the busy morning period, service users had to wait for their breakfasts and were calling out that they were hungry and thirsty. This would indicate that staffing levels at this time of day and allocation of staff is inadequate. Records indicated that 75 of care staff either hold a care qualification or are working towards one. With regards to the home’s recruitment policy and practices the proposed registered managers are still waiting a CRB check and one staff member appeared to have started work prior to CRB being returned. All other documents checked were completed appropriately The inspector identified when case tracking that some service users demonstrate periods of challenging behaviour. Staff have not been provided with appropriate training to support them with this. There was evidence of moving and handling certificates in the staff personnel file; however, practices observed throughout the day were not in line with safety guidelines. The catering staff demonstrated a lack of knowledge in respect of special diets but did hold an up to date food hygiene certificate. Posters and records would indicate that the provider is providing staff with training in infection control, food hygiene, manual handling, abuse and communication in relation to people with dementia. Follow up supervision must monitor the level of knowledge gained at the training sessions and ensure that it is put into practice. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has been without a registered manager for 6 months. The home has a programme for staff training but does not demonstrate more specific training. Service users’ monies are not managed by the home. Staff do not have regular supervision. The home has no quality assurance system in place to monitor service user/relative satisfaction with care. Policies and procedures are out of date. An audit system is in place for the housekeeping and health and safety aspect of the home. EVIDENCE: The home has been without a registered manager for 6 months, despite the provider and the prospective job share managers being requested to supply the commission with the necessary documentation/applications on three Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 25 separate occasions. This has been made an immediate requirement at the site visit, followed by a letter stating time limits for the application forms to be received by the CSCI following clearance notification from the CRB. Neither of the proposed managers holds an NVQ level 4 in management but one manager is a qualified RN and RMN and the other holding the RMN qualification. Both managers will need to undertake the appropriate management qualification. It will also be necessary for the managers to demonstrate a commitment to meeting the requirements raised by this visit and to ensure 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. It was noted that some of the procedures in the home are more suited to a hospital setting. 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. Some of these procedures were not available. Effective quality assurance and monitoring systems based on seeking the views of service users must be improved to measure 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 audits in relation to the standards so that the provider monitors issues raised in this visit. Consideration must be given to CSCI initiatives and moves towards Inspecting for Better Lives (2), the home is not yet applying adequate processes to monitor quality of the service. The home does not handle any of the service users monies. Discussion with staff and the lack of records would indicate that formal supervision is not yet undertaken on a regular basis. Service users records are not adequately monitored and up to date. A number of incidents and accidents noted in the accident book indicated that events where service users are sustaining injuries are not being notified to CSCI through Reg37 notifications. There was an incident reported where a service user ‘thrashed out’ when his beard was being trimmed and was cut by the scissors, this was not included in a risk assessment or a care plan written to guide practice. It was also identified that a service users was entrapped between the bedside and the mattress. Despite the inspectors providing guidance on a previous visit in respect to bedrails and risk assessments, none had been undertaken and no consent sought from service users oar discussion recorded with relatives. Also noted in the accident book was service users being injured whilst be moved by chair and when their personal needs were being dealt with. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 26 The home does have a comprehensive quality assurance programme with regards to the housekeeping and services in the home and audits are undertaken regularly. These were seen by the inspectors and included water temperatures monitored regularly and quality control of cleaning. A risk assessment of the home has also been undertaken. The inspectors throughout the day witnessed poor manual handling practice and service users needs were not reflected through an appropriate risk assessment tool for manual handling. Service users were seen to be lifted under the arms with handling belts when it was established in care records they were non-weight bearing. It was observed by the inspectors that cleaning materials were left in an unlocked cupboard under the kitchen sink and in the laundry area. An immediate requirement will be made to ensure the COSSH regulations are adhered to and that cleaning materials are locked away when not in use. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 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 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 2 1 1 Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 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 OP1 Regulation Requirement Timescale for action 15/07/06 Reg A Service User Guide must be 5(1)(2)(3) made available for all potential service users and/or their relatives. A copy of this document must be submitted to the CSCI with the stated timescales. The initial timescale of 30/6/05 was not met. This was a requirement of the previous report with a timescale that was not met of 15/12/05. 2. OP1 Reg 4 The Statement of Purpose must be reviewed to ensure it contains up to date and accurate information. 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 and that their admission will not impinge on the care of other service users in residence. DS0000011470.V288728.R01.S.doc 31/07/06 3. OP4 Reg 14(1) Reg 12(1)(a) 31/07/06 Aquarius Nursing and Residential Care Home Version 5.1 Page 29 4. 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. 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 are met with particular attention to nutrition, falls, pressure sores, continence, emotional, psychological needs and challenging behaviour. 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. Service users routines and choices with reference to going to bed and rising in the morning, mealtimes, having a bath, have breakfast in their rooms must be documented in individual’s care plans. Staff must not work from day/night work allocation lists and more with a person centred approach to their care. 31/08/06 5 OP8 Reg 16(1)(2) 30/07/06 6. OP9 Reg 13(1)(2)( 4) 30/07/06 7. OP10 Reg 12 (2) (3)(4)(a) 15/07/06 8. OP12 Reg.16(2) (n) The home must employ or 31/08/06 provide information and training to a designated person to undertake and 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 care plan. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 30 9. OP15 Reg 14(2)(i) 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. The cook must undertake training to gain understanding and knowledge on special therapeutic diets or gain information from the dietetic specialist at the PCT. 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. Pressure relieving equipment must be reviewed to make provision for those service users having been assessed as high risk of tissue breakdown. 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. 31/07/06 Reg 12 (1)(a) 10. OP22 Reg 16(1)(2)c 31/08/06 Reg 22(3)(n) 11. OP27 Reg 18(1)(a) 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. 31/07/06 Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 31 12. OP30 Reg 18(1)(c) You are required to ensure the staff receive training in restraint and caring for service users with challenging behaviour. 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 of managers. This was a requirement from the previous site visit and a timescale set for 31/5/06. 31/08/06 13. OP31 Reg 9 31/08/06 14. OP33 Reg 24 (1)(a)(b)( 2) A quality assurance system must 30/08/06 be expanded to include a service user/relatives satisfaction survey and analysed 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 must be reviewed to reflect new and updated practices. This was a requirement from the last inspection with a timescale given of 31/12/05. 15. 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 the previous report with a timescale of 30/11/05 and has not been fully complied with. 31/08/06 Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 32 16. 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. 15/07/06 17. 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 well-being or safety of the service user. • 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. 30/06/06 Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 33 18. OP38 Reg 13(4) All cleaning materials must be 31/05/06 kept in a locked environment when not in use. The cook and laundry person must adhere to the COSSH guidance on storage of materials hazardous to health. An immediate requirement was issued with regards to these findings You are required to ensure safe working practices with regards to moving and handling of the service users and the trained nurses are undertaking the appropriate use of equipment following a risk assessment. 30/06/06 19. OP38 Reg 13(2) C 20. OP38 Reg 13(2) You are required to ensure that 30/06/06 risk assessments are undertaken for the use of bedrails and consent is sought from the service user, or if the service user is unable to consent for their use, this is discussed with a relative/next of kin for their consent and recorded in the care plans. 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.V288728.R01.S.doc Version 5.1 Page 34 2. OP26 It is recommended that the existing bedpan macerator, housed in the laundry, be replaced and one installed in a more appropriate sluicing area within the home. Aquarius Nursing and Residential Care Home DS0000011470.V288728.R01.S.doc Version 5.1 Page 35 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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