Inspection on 23/04/07 for Avens Court Nursing Home

This inspection was carried out on 23rd April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Avens Court Nursing Home 22/01/08

Avens Court Nursing Home 25/05/06

Avens Court Nursing Home 03/05/06

Avens Court Nursing Home 06/02/06

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

CARE HOMES FOR OLDER PEOPLE Avens Court Nursing Home Broomcroft Drive Pyrford Woking Surrey GU22 8NS Lead Inspector Helen Dickens Unannounced Inspection 23th April 2007 09:45 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 Avens Court Nursing Home DS0000066356.V333105.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. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avens Court Nursing Home Address Broomcroft Drive Pyrford Woking Surrey GU22 8NS 01932 346237 01932 336686 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) Surrey Rest Homes Ltd To Be Confirmed Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Physical registration, with number disability over 65 years of age (10), Sensory of places Impairment over 65 years of age (5) Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. All service users required to have a dementia disorder as their primary condition. Service users who have a sensory impairment must have these needs fully assessed and provision of specialist aids and equipment provided to ensure needs are met. The minimum number of care staff on duty excluding the manager must be: 3RN and 12HCA in the morning 07.45-13.45 3RN and 10HCA in the afternoon 13.45-19.45 1RN and 6HCA at night 19.45-07.45 RN: Registered Nurse HCA: Healthcare Assistant 25th May 2006 Date of last inspection Brief Description of the Service: Avens Court is a large detached property situated in Pyrford, near Woking. It is located in a quiet residential area and provides accommodation and nursing care to up to 60 older people with dementia. The home is owned and operated by Surrey Rest Homes Ltd. The premises have been extended and has 46 single bedrooms, 22 of which have en-suite facilities and 7 shared bedrooms (twin) arranged over three floors, accessible by two passenger lifts or stairs which have safety gates fitted. Communal areas consist of adapted bathrooms, toilets, a large lounge combined with a dining area located on the ground floor and another room known as the library (used for private visits, meetings and religious services). There is also a large well-equipped kitchen, laundry/utility room and rest facilities for the staff team. There is ample parking available to the front of the building and a large, well-maintained and enclosed garden to the rear. The fees charged range from £449 to £750 per person per week. Additional charges apply for hairdressing, chiropody, dental and ophthalmic services. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over seven hours. The inspection was carried out by Helen Dickens and Kate Harrison, Regulation Inspectors. The manager and deputy manager represented the establishment. A partial tour of the premises took place. Discussions were held with some residents and relatives in the lounge area, and with four residents over lunch; two residents were also interviewed in their room. Feedback both on the day, and by way of comment cards, was received from five relatives. In addition, one inspector remained in the lounge area during the morning (and for 30 minutes during the afternoon) observing staff and residents, and the general routines of the home. Three resident’s assessments and care plans, together with a number of other documents and files, including three staff files, were examined during the day. The Commission for Social Care Inspection would like to thank the residents, relatives, manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: What has improved since the last inspection? There have been a number of improvements since the last inspection and since the new manager took over in August 2006. An action plan was drawn up by her detailing over 60 improvements, including health and safety concerns, which were necessary and this was given to senior management. To date over half of these improvements have already been made. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 6 The new manager has up-dated the Statement of Purpose and Service Users Guide to ensure they comply with the Care Homes Regulations 2001 (as amended) and the National Minimum Standards. The Guide is set out in a friendlier style which makes is more accessible to people with dementia. Arrangements for the administration of medication have improved and two outstanding Requirements from the pharmacy inspection in May 2006 have now been met. An audit of medication practices was also carried out. Some new activities equipment has been purchased and a member of the care staff is attending training in provision of activities; some dedicated time has been made available to co-ordinate some more activities. The new chef is reviewing menus and using resident and staff feedback on a daily basis to compile a new and more suitable menu for the home. The home has introduced the ‘Safer food better business pack’ on advice from the environmental health officer (EHO), and the three shortfalls identified at the last EHO visit have been addressed. A ‘Getting to know you’ form is being sent to relatives to enable the home to collect more information about residents, including more information on their backgrounds, and on their likes and dislikes. Ten new wheelchairs have been purchased for the use of residents, and an arrangement has been made to supply new beds for the home, the first five arrived during the week of the inspection. Six care staff have started NVQ training and some of the nursing staff have started a distance-learning course covering dementia and palliative care, nutrition, and equality and diversity. There are now regular nurses meetings and staff have been given a number of additional responsibilities within the home. There are nurses practice sessions to offer group supervision and support to trained staff. What they could do better: Care plans need further work especially in regard to having the correct assessments in place in relation to falls and nutrition. Arrangements for activities must be reviewed urgently in order to provide purposeful activities and stimulation for the current residents. Staff training and resources must be made available and specialist advice sought. Specialist advice must be sought regarding suitable environments for people with dementia, as there are a number of shortfalls in this regard at Avens Court. In addition, there are a number of outstanding decorative issues which need attention. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 7 The safety of the environment must be reassessed and action taken regarding any shortfalls identified, this must include the safety gates on stairs and the external ramps. The arrangements for controlling malodours in the home must be reviewed as a few areas had stale smells, including one where there was a slight smell of urine. Staff files must contain all the information set out in Schedule 2 of the Care Homes Regulations (2001) as amended, in order to fully protect residents. One file had no evidence of a CRB check and an Immediate Requirement was made. A training and development plan must be devised as soon as possible to ensure that suitably qualified and experienced persons are working at the home at all times. All staff who work at this home must have some form of dementia care training and the majority should have the extended course i.e. not just an introductory half-day session. The process for reviewing the quality of care must be revised as it currently does not highlight the shortfalls in the service, nor ensure that shortfalls are dealt with in a timely fashion. The provider must carry out and document monthly visits to the home as set out under regulation 26; only two such visits were on file at the home. Advice must be sought from the environmental health department in relation to shortfalls regarding water temperatures, the prevention of legionella, and the kitchen and storeroom areas. In addition to the above Requirements, a further 8 Recommendations were also made and are listed at the end of this report. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. Avens Court Nursing Home DS0000066356.V333105.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 Avens Court Nursing Home DS0000066356.V333105.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about this home is available for prospective residents and residents are assessed prior to being admitted. EVIDENCE: The new manager has up-dated the Statement of Purpose and Service Users Guide. The latter is set out in a friendlier style which makes is more accessible to people with dementia. The manager said that staff (or relatives) would read parts of the Guide to prospective residents if they were unable to do so themselves. Both documents are being used by the manager as the previous versions were unsuitable and did not meet the Care Homes Regulations or National Minimum Standards – however, the registered provider has yet to agree these changes. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 11 Three residents files were checked to see how assessments are carried out prior to residents being admitted to the home. One resident who had been admitted over a year ago had a documented assessment from the senior person from the home and their care needs had been assessed. The other two files examined had information from the care managers and the NHS but the homes own assessments were not available. The manager and deputy manager said that both residents had been visited by senior staff prior to moving in to the home and would locate the missing documentation and return them to the files. All three files examined showed that the pre-admission assessments (either from the home or from health and social services) had been used to draw up each resident’s care plan. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health and social care needs are set out in their care plans but more work needs to be done to ensure all needs and risks are properly identified. Arrangements for the administration of medication have improved. More staff training is needed to ensure residents are treated with dignity and respect at all times. EVIDENCE: The home uses a commercially available set of documents for care planning and these have been modified to suit the needs of the home. Care plans are drawn up to meet identified needs of residents. Three care plans were sampled and these demonstrated that resident’s needs with regard to their personal care needs and mobility, nutrition, and sensory impairments were documented. It was noted that care plans were clear and gave good guidance for staff in a number of areas, for example on dealing with MRSA. A revised ‘Getting to know you’ form is now being given to relatives to assist in gaining information about residents, their preferences and backgrounds. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 13 However, not all the necessary risk assessments had been carried out, for example, two resident’s files did not have falls risk assessments yet a risk of falling had been identified. Another resident’s weight had not been recorded. It was also noted that not all care plans were signed by the resident or a relative; this is recommended as it demonstrates that the resident and their family have been involved in the care planning arrangements. A photograph of each resident must be kept at the home and two resident’s files were without photographs on the day of the inspection. Health needs are documented on resident’s care plans and there were risk assessments in place for pressure areas, safe moving and handling and nutrition. Resident’s are registered with local GPs and one resident said that the GP visited every Thursday, and the chiropodist every couple of months. Visits from health professionals were documented on resident’s files. However, not all residents had had nutritional risk assessments carried out on admission and the nutritional risk assessments being used were not the most appropriate. The inspector recommended the Malnutrition Universal Screening Tool (MUST) should be used, as this is a well-recognised evidence based tool. One resident whose foot was bandaged had their calf pressing on the end of a footrest with the sore foot hanging downwards off the end. The deputy manager arranged for this to be remedied but other staff in the room had not identified this as a problem. The majority of residents at this home have some form of dementia and better staff training in regard to this very specific health need is required – this is discussed under Standard 30 below. Arrangements for the administration of medication continue to improve and now all the Requirements from the CSCI pharmacy inspection in May 2006 have been met. Evidence was seen that the final two Requirements, followed up at the July 2006 Random Inspection, have now been met. Guidance is available for staff on the administration of ‘as required’ medication, and there was evidence of involvement from the multi-disciplinary team regarding the covert administration of medication. A medication policy is in place and records sampled were well kept. Two resident’s records had no photograph and this is covered in Standard 7 above. During the inspection there were many instances when staff were observed to treat residents with dignity and respect. Some relatives commented positively to the inspectors on the helpfulness and caring attitude of staff. Staff were heard to knock on bedroom doors before entering, and the laundry staff have arrangements in place to ensure that resident’s own clothes are returned to them. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 14 However, some comments received were less favourable and there were instances during the inspection when staff could have been more respectful towards residents. For example one resident who said their meal was too large was ignored by the member of staff who just left the meal and walked away. Other residents wanted salt to put on their meal and commented that there were never any condiments on the table. Though it may not be appropriate to leave condiments on all the tables, those who are capable of adding seasoning to their own food should be offered the opportunity to do so. There were some clean incontinence supplies within view in communal bathrooms and bedrooms, and plastic aprons and gloves in large quantities throughout. Whilst this is excellent from the point of view of hygiene and prevention of infection, seeing these displayed where other residents and visitors may see them does not promote privacy and dignity and is institutional. It is recommended that more discreet ways of storing such items be considered. During the afternoon one inspector observed staff and resident interaction in the main lounge and there were several instances where residents were observed to be agitated and needing either reassurance or diversion and staff were not responding well. A Requirement about more appropriate staff training will be made under Standard 30. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are some activities available for residents but more work needs to be done on this including more staff training. Residents are encouraged to maintain family contacts. Residents have some opportunities to exercise choice and control over their lives. Arrangements for meals and mealtimes have improved but more work needs to be done including offering more food choices. EVIDENCE: There are some activities available in the home and some staff were seen to be mingling with residents and talking to them. The new activities organiser has left but the deputy manager said that a member of the care staff has been doing training on activities and had been given dedicated time in the afternoons for this work. This staff member is co-ordinating other care staff to get involved in activities and is currently working on an activities plan. Some new items of equipment have been purchased and the deputy manager said that though staff have not really been inspired to use them yet they have also ordered some reminiscence equipment and a songbook and tape. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 16 One resident had suggested and arranged for some magazines to be brought in and on the day of the inspection several residents were seen to be looking through the magazines – other residents had a newspaper. One inspector noted that there was old time music playing in the afternoon, and another resident was listening to the radio in the reception hall. There are occasional events at the home for residents for example the local church provides carol singers and a keyboard player each Christmas; the manager said the chef provided some festive food and relatives were invited to join in. Other events include the Rah Rah theatre who have visited before and are coming on the bank holiday weekend, and last summer there was a barbecue in the garden. There is much work to be done on finding suitable activities for residents. The carpets in the home are largely patterned which is confusing for people with dementia and the manager said residents sometimes bend down to try to pick up the pattern – the unsuitability of the carpet has been identified in the managers action plan and in previous CSCI reports. Also, the layout of the home does not lend itself to having small groups or one to one activities and on the day of the inspection there was a lot of noise. The doorbell sounds like a siren, and the telephone on the nurse’s station in the dining room is very loud and distracting. Staff said it had to be loud enough for staff to hear it at the other end of the connecting lounge. The manager was asked to think about alternative arrangements. There was a TV on at one end of the lounge and a radio with pop music playing at the other. Most residents were not facing the TV though staff said one resident had asked for it to be put on. The radio was then turned off without reference to any residents nearby to ask if they were listening or not. As the area is open plan all comings and goings by staff or residents are seen by everyone and provide constant movement – it would be difficult to engage residents with such distractions. The manager’s action plan from last August had recommended some screening be provided to break up the large open plan arrangement and allow discreet areas for activities etc. One visitor to the home before Christmas had written to CSCI on a number of matters including lack of activities and purposeful stimulation for residents. Only two comment cards were returned from relatives and one returned just prior to this inspection said ‘There is absolutely no stimulation.’ Even relatives who had other good things to say about the home said there wasn’t enough for residents to do. On the day of the inspection those residents who were able to comment did not think there was much going on – several specifically mentioned they would like to go out more, though obviously they would need support to do this. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 17 Proper stimulation is essential for people with a cognitive impairment in order to preserve the capacities they already have for as long as possible therefore a Requirement will be made that the registered person takes advice and urgently reviews the situation with regard to the lack of purposeful activities and stimulation for residents, and that staff training and resources are made available. One inspector recommended the Alzheimer’s Society as a good source of information and guidance, and there are also a number of companies offering specialised advice and input on suitable environments and meaningful activities for people with dementia. Resident’s families and visitors are encouraged to keep in contact and a number of very positive comments were received from families. In a recent episode at the home, the manager and staff had gone to a good deal of effort to support a resident and their family member in very difficult circumstances. One relative, when asked what the home could do better, said they were already doing things very well and there was nothing they would like to improve. Another had written in to thank staff saying they had displayed ‘..countless acts of kindness.’ Some comments from families suggested that the home do not always communicate with them if there is a problem with their relative and the home will need to review the systems they have in place for liaising with friends and relatives. It is also recommended that the home make contact with any local community groups specialising in the welfare of people with dementia as set down in Standard 13.6. The majority of residents at this home have some form of dementia and therefore their capacity to exercise choices may be impaired to varying degrees. It was noted that residents have some of their own personal belongings in their rooms. For a variety of reasons it was difficult to identify areas where residents were given specific choices and some areas which need more work include menu choices and options for different activities, as well as reconsidering setting up resident’s meetings or a suitable alternative. Inspectors observed a lunchtime service at Avens Court and spoke with residents and visitors about the food. A number of positive comments were received about meals both from residents and their families. Food is mainly home cooked and meat is sourced from the local butcher. The deputy manager said that the new chef and assistant chef had started to compile new menus and were testing out food choices to see which were popular with residents. On the day of the inspection the main course was a beef casserole with rice and three vegetables (spinach, broccoli and cauliflower in a sauce). Staff were available to help residents who needed assistance and a member of staff quickly covered up one spillage on the tablecloth with a linen napkin. The manager said food is liquidised for those residents who needed this though she was doing more work with the chef to produce a ‘soft diet’ as well. There were mixed comments from residents some of whom expected to have potatoes rather than rice with their beef casserole, and some who thought the Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 18 casserole and vegetables were very ‘sloppy’. One resident who wanted a smaller portion and said she couldn’t chew the meat was brought a large plate of liquidised meat on its own. It is recommended that efforts be made to offer food choices to residents, even if only a minority can make those choices. There should be two choices of main meal each day – if sandwiches are on offer they should not replace a second main meal option. It is also recommended that the kitchen staff have regard to the size of portions (several said there was too much on their plates) and the way the food is presented. Further staff training will improve the way staff deal with residents in general but at mealtimes in particular. Some observations were made regarding the kitchen area and these are detailed under Standard 38 on health and safety. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints at the home are properly recorded though not all complainants were confident their concerns would be acted upon. Residents are protected from abuse though more work needs to be done to ensure all staff are properly trained in this area. EVIDENCE: The new manager has revised the complaints procedure including providing a simpler version which would be more accessible to residents who have a cognitive impairment. The complaints log was properly completed and the manager had identified any complaints which had also been referred to social services as potential safeguarding adults issues. One relative said the manager had dealt very well with a complaint they had made and wrote a proper written apology in response. The home has also received a number of compliments since the last inspection and these are incorporated elsewhere in this report. Some comments from relatives suggested that their concerns were not always listened to and the home needs to think about how to remedy this matter. A manager from another of the Surrey Rest Homes investigated one complaint about Avens Court and this will need to be discussed in more detail with the provider. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 20 As mentioned above, any safeguarding adults referrals are clearly documented in the complaints log and the manager and deputy manager were both very clear about what might constitute a referral to social services. A number of safeguarding referrals have been made since the last inspection and these have been dealt with by social services. However, staff at the home have not always recognised when a potential safeguarding issue has arisen and of the three staff files sampled, it was not possible to determine if all three had received safeguarding adults training. A Requirement will be made on this issue under Standard 30. In addition, one member of staff had not been checked against the list of those prevented from working with vulnerable adults, as set down it the Regulations, and an Immediate Requirement was made. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents live in a pleasant environment but more work needs to be done to ensure their safety and a better quality of life. The home has improved arrangements for hygiene and infection control but more work needs to be done to maintain a fresh smell throughout the home. EVIDENCE: The home offers a pleasant environment and many of the fixtures and fittings are of good quality. The dining room is set with proper tablecloths and there is plenty of room for residents to move around in the lounge/dining area. A whiteboard in the dining area shows residents the day and date, and the menu for that day. Most residents have their name and photograph on their bedroom door. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 22 There is a full time maintenance man who carries out regular checks for example on bedroom and water temperatures, and works to a maintenance programme for routine work throughout the home. He is also on site for any repairs which need attending to more urgently, for example a loose handrail was discovered during the inspection and this was remedied immediately. The manager said an order had been placed to replace the old hospital-type beds at the rate of 5 beds per month. The garden is fenced off and kept tidy, and there were some plastic tables and chairs for the use of residents. However, there are a number of shortfalls relating to the environment. The interior of the home has not been designed with the needs of residents with dementia in mind. There are patterned carpets in many areas of the home and this can be confusing for people who have a cognitive impairment. The safety gates on the stairs need to be reviewed, as they would not be that difficult to open if a resident was determined enough. The manager said this had been identified in her action plan in August 2006 and she recommended that the company’s health and safety worker should reassess the safety gate arrangements to reduce the risk to residents; so far this work had not been completed. It was also noted that the wooden ramps to the garden and kitchen do not quite reach the ground so an extra plank has been placed in font of each ramp; these are not secure and could slip when walked on. The lounge and dining room are very open plan which, whilst giving plenty of room to move around, is also a thoroughfare for staff and residents and provides constant movement and noise, as already set out earlier in this report. It would be difficult to find discreet areas for activities where residents could be undisturbed and have the opportunity to concentrate on what they were doing. The home must get specialist advice on the environment and provide CSCI with a timeframe for remedying the current shortfalls. They must also review the health and safety arrangements to ensure there are sufficient safeguards in place to protect residents, staff and visitors. A number of decorative shortfalls were identified throughout the home including peeling and damaged paint, and one staircase had three different colours of paint along the same wall. Also a light on the staff rest room staircase was not working, and a resident had no privacy screening or nets on his windows yet the ground floor room faced out onto the drive. A Requirement will be made that decorative shortfalls are assessed and an action plan, with timescales, is devised. The laundry arrangements were inspected and found to be well organised with a dedicated full time staff member, assisted by another part time worker. During the discussion with the manager it was stated there had previously been two workers and this was the ideal, as the laundry was kept very busy. A disinfection system was in place on two machines which were specifically used for soiled or infected laundry. The floor was washable and noted to be clean. There are good hand washing facilities throughout the home as well as Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 23 antibacterial hand gel for the use of staff. A new policy and procedure was introduced last year regarding the control of infection. On arrival at the home, and on a few occasions during the day, it was noted that some areas of the home were not fresh smelling and had either a stale smell, or a faint odour of urine. This must be reviewed to ensure the highest standards of hygiene and to protect the privacy and dignity of residents. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Resident’s needs are not completely met by the numbers and skill mix of staff. More work needs to be done on recruitment practices in order to fully protect residents. Staff training needs more work particularly in regard to dementia care and activities training. EVIDENCE: There is a documented staff rota and the ratios of care staff to residents is currently set down on the home’s Registration certificate with CSCI. There are additional staff on duty at peak times during the day. There are domestic, maintenance and kitchen staff employed at the home, tough there are no administrative staff employed. Staff were observed to be doing their best within their capabilities to care for residents. However, there were a number of instances observed where either poor communication or lack of awareness regarding dementia care among staff had a detrimental effect on residents. The majority of staff at this home have a first language other than English and come from different cultures and backgrounds to the residents of the home. The provider has previously arranged English language classes for some staff but more needs to be done in this regard. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 25 The skill mix of staff needs to be reviewed to ensure that there are sufficient staff on duty with dementia care training and good communication skills to meet the needs of residents. A Requirement is being made under Standard 30. On every shift there are at least two trained nurses plus the manager or deputy manager who are also Level 1 nurses. The remaining staff are healthcare assistants. It was difficult to ascertain exactly which staff have had what training as the deputy manager is currently compiling a list, however the manager stated that the home does not currently have 50 of its staff trained to NVQ Level 2 or above as recommended in Standard 28.1. However, in addition to five care staff already having this qualification, she said several more are starting at the end of this month. Recruitment files are well organised and three were sampled as part of the inspection process. The new manager had carried out an audit of all 60 staff files to ascertain which documents were missing, in order to comply with the Care Homes Regulations 2001 (as amended). She was following up on missing documentation. However, on the day of the inspection one of the three staff files sampled showed no evidence of a CRB or pova check being carried out and an Immediate Requirement was made in this regard. Of the three files, not all had a full employment history and one had only one reference. There have been improvements in arrangements for training and the new manager and deputy manager are compiling a matrix of the training already completed by staff at the home. There is also a list of the mandatory training courses provided by the company and the deputy manger is ensuring that all existing certificates are on staff files and gaps in their training are booked in. However, of the three staff files sampled, it was not possible to identify if staff had already had their mandatory training, for example one had no evidence of safeguarding adults training. A training and development plan must be finalised in order to ensure that all staff have had the necessary training to carry out the work they are asked to perform, as set out in the Regulations. Though some staff have had short dementia care training courses, not all staff have had some training in dementia care. A more appropriate three-day course is available and it is recommended that the majority of staff be given this training. Since the activities co-ordinator left, a care worker is doing an activities training course and co-ordinating some activities. However much more staff and training resources need to be deployed as soon as possible to improve the quality of life of residents by providing them with more meaningful ways to spend their time. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current manager is managing the home well but will be leaving in the near future. There are some quality assurance processes in place but they currently to not identify shortfalls within the service. Resident’s financial interests are safeguarded. Some health and safety risks are being managed well but more work needs to be done to ensure the safety of residents, staff and visitors to the home. EVIDENCE: The current manager took over in August 2006 and has instigated a number of improvements in both systems and practices, which have improved the lives and safety of residents. These improvements are set out in the first section of this report and under Standard 33 below. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 27 She is a Level 1 registered Nurse and has the background and experience to run this home. However, by the time of the inspection the manger had already resigned and will have left before this report is published. This will mean there is still no registered manager for this service. There are a number of quality assurance systems in place including a number of audits carried out by the new manager. She completed a detailed action plan in August 2006 highlighting shortfalls in the service in order of priority and taking into account the safety of residents, and making over 60 recommendations. She has since also carried out a medication audit and a recruitment files audit to determine which documents are missing from these files. There have also been some Regulation 26 visits on behalf of the provider. There are currently no resident’s meetings, as the manager does not believe this is the best way to get feedback from these residents. She said that she and the deputy manager talk with and observe residents, and are using ‘Getting to know you’ forms with relatives to get more information on each resident. It is recommended that some form of meeting, even on a small scale, be explored. Alternatively gathering of views from residents on a one-to-one basis as happens now should be properly documented to ensure resident’s choices and opinions are fed into the quality assurance process. The development plan recommended by the new manager last August has yet to be fully met though the manager has completed all the items within her remit and that of her staff. The outstanding issues concern the environment and some health and safety matters such as a proper assessment of the safety gates on stairways. There were only two Regulation 26 visits on file, one for November 06 and one for March 07 and these should be carried out on a monthly basis as set down in the Regulations. It is concerning that the systems in place are not identifying or addressing the current shortfalls. The manager said that the home does not keep money on behalf of residents and those residents who have the hairdresser for example, do not pay directly – a separate bill is sent to whoever is managing the resident’s money. One resident confirmed that the bill for her hairdressing went to her son. A resident who had concerns about getting access to her personal expenses allowance spoke with the inspector, who subsequently spoke with the home manager who will follow this up with the resident’s care manager. The company has a dedicated health and safety worker to cover all the homes, and has a maintenance man working full time at Avens Court. Water and room temperatures are monitored regularly. The home has an up-to-date insurance certificate and was displaying their CSCI Registration certificate in the hallway. The Regulation 26 visits on behalf of the provider mention a health and safety inspection during the visit in March. The new manager’s action plan from August 2006 also identified a number of health and safety concerns. There were risk assessments in place relating to both the home in general, and to individual residents on their own files. The home has started the Safer Food Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 28 Better business pack following a visit and advice from an Environmental Health Officer in January. The manager said that three requirements made at that visit have now been met including the fitting of fly screens. There was a plentiful supply of plastic gloves and aprons for staff use, and good hand washing facilities to prevent the spread of infection. A recent small outbreak of infection had been successfully dealt with by the home. A number of shortfalls were noted in relation to health and safety. The Action Plan devised in August 2006 by the new manager identified a number of issues relating to health and safety and some of those requiring support from senior management have still not been addressed. The previous health and safety audit by the company representative is overdue for review. One example mentioned earlier is the safety gates on stairs which have only a heavy duty ‘hook and eye’ catch which could easily be undone by a determined resident. Of the three resident’s files sampled, not all had all the necessary risk assessments, including falls risk assessments. One communal bathroom had a liquid hand wash with no lid and a bottle of shampoo on the shelf which were immediately removed by the manager as they could have posed a risk to residents. Though hand basin water temperatures are regularly monitored, one tap in a communal bathroom had very hot water and the maintenance worker said he would alter the thermostat immediately. He said water is controlled to 38C; this is not what is recommended in the National Minimum Standards, or by environmental health advisers. Though there had been a recent legionella bacteria check, there were no steps in place to prevent legionella and a risk assessment commissioned by the company last year was filed and no apparent action taken. A number of shortfalls were identified in the kitchen and food store and these were brought to the attention of the manager and deputy manager, and later discussed with the local environmental health department who were due to revisit the home. Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 29 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 X 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X X 2 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 30 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 OP7 Regulation 15(1) 17(1)(a) Sch. 3 Requirement Timescale for action 30/05/07 2. OP8 14(1)(a) 3. OP12 12(1)(a) 16(2)(m) (n) 18(1)(a) 4. OP19 23(1) (2)(a) Care plans must be reviewed to ensure that they identify all the areas of potential risk and that corresponding risk assessments are then carried out. Residents must be weighed regularly and this information documented and monitored in their care plans. A photograph of each resident must be kept at the home as set out in Schedule 3. Residents must have their 30/05/07 nutritional needs assessed on admission to the home. The home must ensure that they are using the most appropriate assessment tool for this purpose. Arrangements for activities must 30/05/07 be reviewed urgently in view of the lack of purposeful activities and stimulation for current residents. Staff training and resources must be made available and specialist advice sought. Outstanding from 25/06/06 Specialist advice must be sought 30/05/07 regarding suitable environments for people with dementia. An DS0000066356.V333105.R01.S.doc Version 5.2 Avens Court Nursing Home Page 31 5. OP19 23(2)(d) 6. OP19 13(4)(a) (b)(c) 7. 8. OP26 OP29 23(2)(d) 19 Sch.2 18(1)(a) 9. OP30 10. OP30 18(1)(a) 11. OP33 24(1) 12. OP33 26(2) action plan, with timescales, must be drawn up regarding the current shortfalls. The decorative shortfalls within the home must be identified and an action plan, with timescales, must be drawn up to address these. The safety of the environment must be reassessed and action taken regarding any shortfalls identified, this must include the safety gates on stairs and the external ramps. The arrangements for controlling malodours in the home must be reviewed. The information set out in Schedule 2 of the Care Homes Regulations 2001 (as amended) must be sought for all staff. A training and development plan must be devised as soon as possible to ensure that suitably qualified and experienced persons are working at the home at all times as set down in this Regulation. Those found not to have had the mandatory training courses must have these arranged as soon as possible. All staff who work at this home must have some form of dementia care training and the majority should have the extended course i.e. not just an introductory half-day session. An outline of these arrangements must be sent to CSCI. The processes for reviewing the quality of care must be revised as they currently do not highlight the shortfalls in the service, nor ensure that shortfalls are dealt with in a timely fashion. The visits set out in this Regulation must be carried out on a monthly basis. DS0000066356.V333105.R01.S.doc 30/05/07 30/05/07 30/05/07 30/05/07 30/05/07 30/05/07 30/05/07 30/05/07 Avens Court Nursing Home Version 5.2 Page 32 13. OP38 23(5) Advice must be sought from the environmental health department in relation to shortfalls regarding water temperatures, the prevention of legionella, and the kitchen and storeroom areas. 30/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP7 OP10 Good Practice Recommendations The home’s own pre-admission assessments should be kept on resident’s files and available for inspection. It is recommended that residents and/or their relatives sign their care plan to demonstrate their involvement in the care planning process. It is recommended that more discreet ways should be found of storing incontinence supplies, and the plastic aprons and gloves, to protect the privacy and dignity of residents. It is recommended that the home review the way it communicates with relatives as a number of families raised concerns in this regard. It is recommended that the home investigate and set up links with local community organisations specialising in the welfare of people with dementia. It is recommended that a second main course is on offer each day to give residents a choice of lunch. It is also recommended that staff have regard to suitable portion sizes and the presentation of food. It is recommended that the home review how complaints are handled as some relatives felt their concerns were not acted upon. It is recommended that some form of meeting, even on a small scale, is explored, or else the gathering of views from residents on a one-to-one basis as the manager said happens now, is properly documented to ensure residents choices and opinions are fed into the quality assurance process. 4. 5. 6. OP13 OP13 OP15 7. 8. OP16 OP33 Avens Court Nursing Home DS0000066356.V333105.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Oxford Hub Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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