CARE HOMES FOR OLDER PEOPLE
Avens Court Nursing Home Broomcroft Drive Pyrford Woking Surrey GU22 8NS Lead Inspector
Marianne Barham Announced Inspection 25th May 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Avens Court Nursing Home DS0000066356.V298056.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.V298056.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.V298056.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 3rd 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 close to local shops and amenities 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 recently been extended and comprises of 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 spacious 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 parking for several cars to the front of the building and a large, well-maintained and enclosed garden to the rear. The fees charged range from £650 to £750 per week. Additional charges apply for hairdressing, chiropody, dental and ophthalmic services. Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was undertaken to follow up on the progress made by the service to the 101 requirements made at previous inspections carried out on 10th April 2006 and 3rd May 2006. This was an announced inspection undertaken on 25th May 2006 at 10.00am by Marianne Barham, lead inspector for the service and Kathy Martin, regulation inspector, and was carried out over a period of six hours and fortyfive minutes. Dr Ajit Prasad who is the registered provider and Kalem Choda, service manager were present, records relating to the care of the service users and management of the home were examined and a tour of the premises was undertaken during this inspection. Owing to the number of requirements to be evidenced, the inspectors were unable to speak individually with any service users or members of staff for any length of time, however observations were made that service users appeared comfortable and well groomed, and the staff were positive and cooperative throughout the inspection process. The inspectors would like to thank the service users, staff team and management of the home for their time, cooperation and courteousness displayed during this inspection. The overall assessment of this inspection was that the provider is compliant with the requirements made and is willing to invest the time and resources needed to provide a good quality service to the service users, their families and purchasers of care. All requirements made at the previous inspections on 10th April, and 3rd May 2006 have either been met or are in process of being met, with the exception of one requirement. This has been carried forward until 5th June 2006. What the service does well:
There was a calm, welcoming atmosphere on arrival at the home. All areas seen were clean, comfortably furnished and pleasantly decorated. Members of staff spoken with said it was a nice place to work. Some service users, when asked said they were happy living in the home. The provider has acknowledged the serious concerns and failure to meet minimum standards highlighted in the previous inspections since the home was purchased in November 2005 and has worked in cooperation with the Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 6 Commission and Social Services to comply with requirements made and improve the standards of care, services and facilities provided by the home. What has improved since the last inspection?
The home now has a formal handover period, during which any relevant information concerning service users is handed over and also duties for each individual member of staff are allocated, making sure that all staff know what they are supposed to be doing. The home has now introduced a system at mealtimes where staff members are allocated to a designated group of service users, all service users, unless bedridden, take their meals in the dining room and there are sufficient numbers of staff, informed of the service users dietary needs to support them. Brightly coloured tablecloths have been put onto the dining room tables as part of a coding system advised by an advocate from the Alzheimer’s Society. This appears to be working well, with service users finding it easier to remember where they sit and members of staff knowing which group of service users they are allocated to care for, including their individual feeding and nutritional needs. All service users now have their weight monitored weekly, nutritional assessments in place, reviewed monthly, and referral made to dietician or speech and language therapist as necessary. The cook is now aware of all service users’ dietary needs and individual likes and preferences through improved communication systems between the nursing staff and the kitchen staff. A heated serving trolley has now been purchased to ensure that cooked breakfasts are served at the correct temperature. There are already commercial size trolleys in place for main meals. Assessment processes and procedures have been reviewed and updated to ensure that all care, social and emotional needs of each service user are addressed before they are admitted to the home. The home has now appointed an activities coordinator who has begun the process of finding out each service user’s individual likes, dislikes, hobbies and past history in order to provide activities more suitable to their needs. Each service user now has a programme of planned activities in place. All members of staff have received training in the care of people with dementia and further training is planned in May and June 2006 in the rights of older people, discrimination and equality, human rights and communication skills, to further improve the staff team’s knowledge and skills in the care of people with dementia. Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 7 All members of staff who do not have adequate English language skills have been enrolled on a course to improve these skills. Those staff spoken with said they were pleased to be attending the course and were able to speak easily with the inspector. Signs have been put on all bathrooms and toilets indicating their use and it was pleasing to see that the noise level from TV’s and radios has been significantly reduced, though some service users will turn up the volume, care staff are more aware of the detrimental effect this may have on the majority of service users and take appropriate steps to limit this. Staff recruitment files examined showed that the home is carrying out necessary checks and procedures to protect the service users in its care. A programme of planned training for all members of staff has been introduced with individual records kept for each person. The complaints procedure has now been made available to all service users and their families, with copies in the service user guide and also on the notice board in the entrance lobby. All complaints are now recorded with actions taken and outcomes. The previously appointed manager has left the home and a new manager has subsequently been appointed. The new manager has experience of managing a nursing home providing nursing care to 70 older people to a high standard and will commence at Avens Court on 19th June 2006. Until the new manager takes up post the home has put into place acting arrangements comprising of a temporary manager with clinical nursing skills and a service mnanager for managerial duties. The heating system throughout the home has been serviced and repaired and a copy of the engineer’s report is to be forwarded to the Commission as soon as it is received. A full investigation was undertaken into the circumstances surrounding a named service user leaving the home, unobserved, security systems have been improved to prevent a recurrence and the incident and accident reporting and recording systems have been reviewed and updated, with all staff being made aware of the changes through team meetings and read and sign policies. In order to improve communication within the team, the home has introduced a formal handover period and also a written shift planning system, whereby each member of staff on duty is allocated a set number of duties to perform and service users to care for. This system provides continuity of care for service users and accountability for the staff team, both essential for the smooth running of a care home. A communication book has also been introduced to further better communication within the staff team. All the above measures either meet or are in progress of meeting requirements made at previous inspections carried out on 10th April 2006 and 3rd May 2006,
Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 8 also, several requirements were made concerning the safety of the environment for service users and members of staff, for full details please refer to the main body of this report. What they could do better:
The home has introduced a new system for care planning and needs assessment that covers all aspects of each individuals care, however the nurses completing the care plans and risk assessments had not signed and/or dated all of them. A requirement has been made that this is done in order to ensure accountability of the nurses and continuity of care for service users. It is acknowledged that the home has reviewed and updated most of the policies and procedures and made them accessible to all members of staff, however the procedures are not indexed or compiled in a systematic way and therefore are not easily and quickly accessible to staff when they are needed. A recommendation has been made that this is addressed. Though the home has made significant improvements in the management of infection control and has restored service users’ dignity and privacy through removal of signage stating ‘MRSA’ displayed on individual service users bedroom doors, the policy and procedure for infection control is outdated and in need of review. A requirement has been made that this is done, with a view to having specific instruction on the management of MRSA infections and HIV/Aids. Though the home has made improvements in the provision of daily activities and has appointed a designated person for this role, further provision needs to be made to address the specific needs of older people with dementia. A requirement has been made to address this. The home has reviewed and updated the home’s complaints procedure, however it is too long and written in small print, making it hard to understand or read for service users and their families. The procedure needs to be reviewed to make sure it is easily accessible to all. A recommendation has been made to address this shortfall in the minimum standards. A requirement was made at the previous inspection on 3rd May 2006 that members of staff employed on student visas must abide by the working hours determined by the Home Office. This has not been met. Staffing rotas show that these members of staff have been exceeding their permitted working hours. A further requirement has been made that Home Office requirements for working hours are complied with. The registered person has been asked to inform those staff members affected at the earliest opportunity of the reduction of their working hours in order to comply with the working hours stipulated on their visas. Owing to the half-term break, these will come into effect on 5th June 2006.
Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 9 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. Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 10 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.V298056.R01.S.doc Version 5.2 Page 11 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have enough information to make an informed choice about where they live and they do not move into the home without having their individual needs assessed. EVIDENCE: The home has recently reviewed and updated it’s Statement of Purpose and Service Users Guide to include admission criteria, facilities and services offered, fees charged, what is included in the fees and what is not and a copy of the complaints procedure. A copy of the most recent inspection report is posted on the notice board and is made available to service users and relatives on request. This meets requirements made at a previous inspection carried out on 10th April 2006. The home has introduced a pre-admission policy that states the home must carry out it’s own assessment of service users’ needs prior to admission. A new pre-admission assessment has also been devised that covers all aspects of
Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 12 the individual’s needs, the inspectors were able to see a sample assessment, however has not yet been used owing to there being no new admissions since it was introduced. This meets requirements made at a previous inspection carried out on 3rd May 2006. Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 13 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ health, personal and social care needs are set out in an individual plan of care, however these need to be signed by, the person completing them. The health care needs of service users is being met by the home with specialist support when required, however the home’s infection control policy needs updating. The home treats service users with dignity and respect. EVIDENCE: All service users have an individual plan of care. The home has recently introduced a new system of care planning that is holistic in approach covering all areas of the individual’s physical, emotional and care needs. The home has introduced policies and procedures for nutritional needs of service users including, hydration, weight monitoring and individual dietary needs. Care plans sampled contained assessments and guidance for swallowing difficulties and dietary requirements for those with diabetes as well as records for fluid intake, weight charts and blood and urine monitoring for
Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 14 those with diabetes. There was evidence of consultation with specialists in this area. All service users now have pressure care assessments completed and care plans completed as necessary. A central record of pressure sores and pressure relieving equipment is maintained and photographic assessments are in place for some service users. All registered nurses have now received training in tissue viability and care and reference materials have been made available to them in the home. These measures meet requirements made at a previous inspection on 10th April 2006. Named service users have now had risk assessments completed regarding their individual behaviours and guidelines put into place to manage them, this includes a named service user subjected to restraint practices. Measures implemented include diversionary tactics and increased levels of planned activities. The named service users have had a full review of their individual care needs and have been referred to the consultant psychiatrist for a psychiatric assessment to determine the suitability of their placement in the home. This meets a requirement made at a previous inspection on 3rd May 2006. It was observed that some risk assessments and care plans had not been signed and/or dated by, the nurse completing them. In order to ensure accountability by the nursing staff, a requirement has been made to address this. The home has removed the signs stating MRSA on bedroom doors and replaced with a coded sign known to the staff. Appropriate infection control measures were seen to be in practice for example protective disposable aprons and gloves, clinical waste bins and hand washing materials were available in the rooms as needed. The home has an infection control policy and procedure in place, however it is dated and does not contain reference specific to MRSA or HIV/Aids. A requirement has been made that this policy is reviewed and updated to include procedures specific to MRSA and HIV/Aids. Avens Court Nursing Home DS0000066356.V298056.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Much improvement has been made by the home in meeting the social, cultural and religious needs of the service users, however activities need to be tailored to the specific needs of people with dementia. Service users are supported to make choices and they receive a balanced diet that takes into account their individual dietary needs and preferences. EVIDENCE: The home has now introduced an allocated activities coordinator. This person is currently in the process of collating information on each service users’ social history, hobbies and interests in order to further develop activities provision in the home and has been booked to attend activities training run by the Alzheimer’s Society. Each service user now has an individual timetable of daily activities in place and records of activities undertaken are maintained. This meets requirements made at a previous inspection on 10th April 2006. Whilst it is pleasing to see that efforts have been made in the provision of activities, this needs to be more tailored to the needs of people with dementia in order for it to be meaningful to them. A requirement has been made to
Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 16 further develop activities specifically for people with dementia, using guidance from people with specialist knowledge. The home has introduced a privacy policy and has allocated a dedicated area of the home for people to receive visitors, hold care reviews or religious services. This meets a requirement made at a previous inspection on 10th April 2006. Each service user now has had a nutritional assessment completed with guidance on managing any identified issues written in individual care plans, referrals have been made to dietician or speech and language therapist as necessary. The cook has a list of all dietary requirements and likes and dislikes of the service users. Care staff are now allocated to set groups of service users at mealtimes and given information on how to meet the dietary and feeding needs of each person. The tables are now colour coded with brightly coloured cloths to assist service users to know where they sit, the colour of tablecloth links to the allocated care group, providing better continuity of care. Service users are offered a choice of bread and butter or marmalade and jam etc at breakfast. It was pleasing to see that a heated serving trolley has been purchased for the breakfast meal, ensuring that cooked breakfasts are served at the correct temperature. These improvements meet requirements made at a previous inspection on 10th April 2006. All staff members have received training in the care of people with dementia. Further training on the rights of older people, communication skills, human rights and discrimination and equality has is to be carried out in May and June 2006. A policy and procedure on restraint has been put into place of which all members of staff have been made aware. This meets requirements made at a previous inspection on 3rd May 2006. Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. 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. The concerns and complaints of service users and their families are listened to and acted upon by the home, however the complaints procedure needs to be made easier to read and understand. The policies and procedures of the home and training given to staff members, protects the service users from abuse. EVIDENCE: The home has reviewed and updated the complaints procedure and copies can be found in the service users guide and also posted on the notice board in the front entrance lobby. Records are kept of all complaints, actions taken and outcomes. This meets a requirement made at a previous inspection on 10th April 2006, however the procedure is very long and written in small print making it difficult to follow. A recommendation has been made that the complaints procedure is produced in a more accessible format. All members of staff have received training on adult protection procedures and their individual responsibilities in this area. The home now has policies and procedures in place for whistle blowing and adult protection that are accessible to all members of staff. This meets a requirement made at a previous inspection on 10th April 2006. Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home now provides service users with accommodation that is comfortable, clean and suitable to their needs and the necessary maintenance, repairs and checks are completed to ensure the safety of the service users is promoted and upheld. EVIDENCE: A tour of the home was undertaken to assess progress on several requirements that were made at previous inspections on 10th April 2006 and 3rd May 2006. The following actions have been taken to meet these requirements. Copies of safety certificates for gas and electricity installation and service have been sent to the Commission. A new industrial use electrical dishwasher has been purchased and installed. The passenger lift is in good working order.
Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 19 New freezers and refrigerators have been purchased and a record of temperatures for these is maintained. The bathroom on the first floor of the original building has been taken out of use, as it does not meet the needs of service users, there are sufficient bathrooms in the home to accommodate this action. The home has introduced a policy for the provision of religious services to service users and the library has been identified as a dedicated space for this. The door from the dining area is now kept closed when not in use and all holes in the fire doors have now been filled. The home has purchased new bedding that is of good quality and in sufficient amounts for the needs of the service users. An extra member of staff has been employed to work in the laundry, all clothing is now named, and service users’ wardrobes and drawers are tidied weekly. There is a thermometer in all rooms and the temperature in each room of the home is taken daily and recorded, by the maintenance worker employed at the home. All secondary heaters have been removed from the home as the heating system has now been repaired and serviced. The provider is to forward a copy of the engineer’s report once it is received. The home has ordered 30 bedside cabinets for service users rooms that do not have them and all bedrooms have an armchair in them. Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 20 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): 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home’s recruitment policies and practices do protect service users, however some staff members have been allowed to work in excess of the hours stipulated by their student visas issued by the Home Office, despite a requirement being made to prevent this on 10th April 2006. Staff members are provided with sufficient training to carry out their jobs. EVIDENCE: Staff recruitment files were examined and found to be in order with all necessary checks undertaken, references and medical information obtained and work permits/visa requirements documented where appropriate. Application forms, interview records, job descriptions and contracts of employment were also held on these files. This meets a requirement made at a previous inspection on 10th April 2006. A further requirement made at that inspection was for staff working on student visas to not exceed the working hours stated by the Home Office has not been met. The provider has been asked to inform those staff members affected at the earliest opportunity that their hours will be allocated according to Home Office guidance immediately following the end of the current half-term break (5th June 2006). The requirement has been made again with compliance by 5th June 2006.
Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 21 The home has now implemented a programme of planned training for the staff team that includes induction, moving and handling, food hygiene, COSHH training and fire safety. A copy of the training programme has been supplied to the Commission. All members of staff have received a copy of the GSCC code of conduct. The home has employed an NVQ trainer/assessor to oversee those care staff enrolled on the NVQ level 2 and 3 training in care, who will be commencing the post on 29th June 2006. These actions meet requirements made at previous inspections on 10th April 2006 and 3rd May 2006. Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 22 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, 37 and 38 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 at present have a registered manager, however adequate acting arrangements are in place until the commencement of the newly appointed manager. Significant improvements have been made to the care, services and facilities provided in the home demonstrating that it is now run in the best interests of the service users. The policies and procedures in the home are designed to safeguard the rights and best interests of service users, however the layout needs to be reviewed in order to make them easily accessible to all members of staff. The health, safety and welfare of service users and staff is promoted and protected by the home. EVIDENCE: Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 23 Most policies and procedures in the home have been reviewed and updated, the National Institute for Clinical Excellence (NICE) have been contacted for guidance on clinical procedures and are currently awaiting a reply. The procedures were contained together in one file and accessible to all staff, meeting requirements made at a previous inspection on 10th April 2006, however they were not indexed or put in any order making it difficult to obtain information quickly or easily. A recommendation was made to address this. The provider is now carrying out quality audits in the home on a weekly basis and is updating the Commission of the outcomes in writing each week. All staff members are now receiving regular formal supervision sessions. A residents and relatives forum has been arranged for 26th July 2006 at which a representative from the Alzheimer’s Society will be speaking and there is now a daily and weekly checklist for the manager to complete to ensure proper care and services have been delivered. The home has appointed a new manager who will be commencing on 19th June 2006. The manager is experienced and well qualified and has been registered with the Commission as manager of a 70 bedded nursing home until taking on this post. The home has put into place adequate acting arrangements until the new manager commences. All fire notices throughout the home have been replaced and displayed prominently following guidance from the fire officer. Risk assessments are in place for the use of bed rails. The hooks to the stair gates have been adjusted and notices put up to remind staff to close them after use. All staff have been instructed not to disable the digi-pad security system on the cellar door – this was seen to be in working order throughout this visit. All outside areas have been cleared of rubbish and other hazards. Oxygen cylinders are now stored in the locked treatment room and the rooms with missing smoke detectors have been taken out of use until they are replaced. The home currently has three nurses who have undertaken the first aid at work course, with a further three nurses booked to attend in the near future. All members of staff are having basic first aid training on 30th May 2006. All members of staff have received health and safety training and health and safety audits are carried out monthly. The home has been notifying the Commission of all accidents and incidents occurring at the home. These actions meet requirements made at a previous inspection on 10th April 2006. At the previous inspection on 3rd May 2006, members of staff were observed to be confining a service user to their room without consent. An immediate requirement was made for this practice to stop and for a risk assessment to be completed and restraint policy and guidelines to be put into place. This has been done and the service user referred for psychiatric assessment as detailed previously in this report.
Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 24 The home has introduced a missing persons policy and procedure following an incident of a service user leaving the home unobserved recently. This was investigated by the home, however the actual circumstances surrounding the incident are not known. Extra security measures have been implemented to prevent a recurrence. A policy has been put into place for the recording and reporting of all accidents and incidents and a folder maintained for this purpose. The home has reviewed the staffing rotas and these now clearly show the staff on duty at any given time and their designation. All members of staff have been informed that they are not to alter the staffing rota under any circumstances. The home has introduced a formal handover period and shift planning which gives greater direction and information to all grades of staff. A communication book has also been introduced to ensure information gets passed on. The home carries out fire safety audits weekly and fire evacuation drills record all members of staff in the building, including those living in. Health and safety audits are completed monthly. All these actions meet requirements made at a previous inspection on 3rd May 2006. Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 25 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 3 3 STAFFING Standard No Score 27 X 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 2 3 Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 26 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 OP29 Standard Regulation 10(1) Requirement When compiling staffing rotas the registered person must ensure that those staff working on a student visa, do not exceed the working hours stipulated by the Home Office under any circumstances. The registered person must ensure that all care plans and risk assessments carried out in the home must be signed and dated by, the nurse completing them in order to ensure accountability of that nurse and continuity of care for the service users. The infection control policy and procedures must be reviewed and updated to reflect current best practice and include specific instruction for the management of MRSA and HIV/Aids. The registered person must further develop the activities provided to ensure they are suitable and pertinent to the needs of people with dementia, seeking guidance from people with specialist knowledge in this
DS0000066356.V298056.R01.S.doc Timescale for action 05/06/06 2 OP7 14 (2) (a) (b) 15 (2) (b) 05/06/06 3 OP8 13 (3) 05/06/06 4 OP12 16 (2) (m) (n) 25/06/06 Avens Court Nursing Home Version 5.2 Page 27 area. 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 OP16 Good Practice Recommendations It is strongly recommended as good practice that the complaints procedure be reviewed in order to simplify its contents and make it more accessible and easier to read by service users and their families. It is strongly recommended as good practice that the layout of the policies and procedures file is re-organised to include an index and systematic order to make it easier for members of staff to access information quickly and efficiently when needed. 2 OP37 Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Avens Court Nursing Home DS0000066356.V298056.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
