Inspection on 03/05/06 for Avens Court Nursing Home

This inspection was carried out on 3rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Avens Court Nursing Home 22/01/08

Avens Court Nursing Home 23/04/07

Avens Court Nursing Home 25/05/06

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 Pat Collins Unannounced Inspection 3rd May 2006 08:00 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.V353514.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 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.V353514.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. All service users must 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 made 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 10th, 12th, 14th, 15th, 16th & 17th April 2006 Date of last inspection Brief Description of the Service: Avens Court is a privately operated care home with nursing providing dementia care for older people. The home is situated in a quite residential area within a short distance of the shops and community amenities. The premises comprise of a large detached house which has recently been extended. Car parking facilities are available at the front of the building and an enclosed, secure garden is provided at the rear. Single and shared bedroom accommodation, some with en-suite toilet facilities is arranged on three floors accessible by two passenger lifts. Communal lounges and a combined dining area are situated on the ground floor. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out by one inspector. It followed six other unannounced inspection visits in April 2006. The outcomes of those visits identified significant concerns regarding the general management of the home and quality of care. An improvement plan had been developed by the organisation and was being implemented to raise standards and ensure the safety of service users. At the time of this inspection work was in progress to incorporate the findings of the last six inspection visits into one draft report. Whilst management had not yet received this report the content had been fully discussed with them and the service manager was aware that there were 67 statutory requirements arising from these inspection visits. A number of these were of such concern that immediate remedial action was required and two serious concerns letters had been issued. The background to this unannounced visit is this was considered necessary following receipt of further information from professionals responsible for placements at the home. This information raised general concerns regarding the welfare and safety of service users. Observations as follows on what the service does well, what has improved and what could be better should be considered in the context of the narrow focus of this visit. For a comprehensive overview of the performance of this home this report needs to be read together with the latest inspection report. What the service does well: What has improved since the last inspection? There had been significant change within the management team since the last inspection. The home’s management had been briefly strengthened by the promotion of a senior nurse to a vacant deputy manager’s position. The second deputy manager had resumed work recently following a period of long - term absence. An internal investigation into the deputy manager’s practice on her return to work was being managed through direct supervision measures. Though necessary this effectively depleted the management team. A new Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 6 manager had just taken up post following the resignation of the former manager. The service manager was currently managing the home whilst the new manager undertook a period of orientation. Whilst it was evident that some improvement had been achieved in the home’s management it was evident that the service manager was overstretched in terms of competing pressures on his time. He retained line management responsibilities for four other care homes in addition to managing Avens Court. A new full time administrator was a further new development. Observations identified changes in handover procedures between shifts, specifically between night and day staff, which enhanced the safety of service users. Also improvement was noted in the organisation of mealtimes. Staff were more focused now on ensuring nutritional needs of service users were met. Menus had also changed and service users now received three cooked meals daily. Changes in care routines, whilst continuing to promote a flexible approach in the delivery of care, were more structured and systematic to ensure basic physical care needs were met. Supervision of care practice had improved and care delivery was better monitored. An improved care planning system was being implemented at the time of this inspection. Nurses were striving hard to transfer information from old formats to the new formats. Staff training sessions had been targeting areas of clinical care identified to be weak at the time of recent inspection visits. What they could do better: The home continued to experience problems with the heating system. Until this is resolved it is imperative that internal health and safety systems are sufficiently robust to identify areas of the home either too hot or too cold and to take remedial action. Observations identified inadequate procedures for responding to a recent missing persons incident. A full investigation into this incident is required and the procedure must be reviewed. Systems must improve to ensure this procedure is accessible to all nurses in charge of the home including agency nurses. An incident reporting system must be implemented and improvement achieved in recording incidents. The use of an unacceptable form of restraint was observed at the time of this inspection. This was drawn to the attention of management and the practice immediately stopped. There was no evidence found to suggest this was common practice. The inspector invoked the local multi-agency adult protection procedures in response to this observation. Also referral made in relation to the home’s management of the missing person incident. There are Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 7 currently seven adult protection incidents in total under investigation in respect of Avens Court Nursing Home. The need to improve communication systems at the home was identified. Also additional training needs were identified during this inspection for the whole team. Risk assessments and care planning practices must improve also security arrangements for external doors. Arrangements for meeting social care needs required improvement and a more individualised approach in this area of care. A review of the needs of two service users was required to ensure the home can meet their needs. Attention was required to infection control practices; also to practice when serving cooked breakfasts in the dining room. A number of immediate requirements were made at the time of this inspection and a further serious concerns letter served on the home. 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.V353514.R01.S.doc Version 5.1 Page 8 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.V353514.R01.S.doc Version 5.1 Page 9 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): 3 Pre-admission assessment procedures required improvement to ensure admissions are at all times within the home’s conditions of registration. Failure to compile life history information about service users with details of interests and likes and dislikes inhibited provision of social care activities to meet individual needs. EVIDENCE: Observations identified individual service users, at least one of whom did not appear to be accommodated within the home’s conditions of registration (categories). The inspector was concerned that the individual needs of both these individuals were not currently adequately met. This was indicated by directly observing arrangements for their care and through feedback from them. By coincidence, a care management review of their placement was convened on the day of the inspection. Though stated to have been prearranged this had not been recorded in the diary and staff and service users were unprepared. It was agreed at the review that referral would be made via the general practitioner for a mental health needs assessment for both service users. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 10 Observation of the preadmission documentation underpinning the admission of these individuals identified shortfalls in the home’s assessment procedures. Attention was also necessary to admission procedures to ensure adequate lifestyle/history information is obtained. This would enable staff to plan and offer opportunities for suitable stimulating activities to meet social care needs. It was noted that both service users expressed mostly positive feedback on their experience of life in the home. They acknowledged feeling socially isolated however in terms of there being few other service users with capacity to hold a conversation with them. At the time of the last inspection visit the inspector suggested consideration be given to the benefits of grouping service users to target care, resources and activities appropriate to individuals’ level of functioning and capacity. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 11 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, 10 Risk assessments and care plans were not being updated at all times to reflect changes in need. Improvement was also required to infection control procedures and practices. Though examples of good practice were observed in staff’s approach towards service users there were some practices that were of concern and warranted further staff training. EVIDENCE: There were 42 service users present in the home and 2 service users in hospital. Management had agreed with CSCI to voluntary suspend admissions since 13th April 2006 until such time as sustained improvement in standards of care was demonstrated. Observations identified positive changes in routines and care practices to the benefit of service users. Though care delivery was flexible there were now structures and systems underpinned by record keeping and monitoring systems to be able to more accurately assess the quality of care. A new care planning system was being implemented. Examples of friendly, caring exchanges between staff and service users were noted. Service users were clean and tidy in their appearance and dress. It was positive to observe improvement in handover procedures since the time of the last inspection. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 12 Whilst noting effort made in recent weeks to improve infection control practices, the inspector requested review of the new practice of overt labelling of bedroom doors of individuals diagnosed with infectious conditions. This was in breach of their right to privacy and dignity. Though it is accepted that management may wish to discreetly label these rooms with symbols of common understanding to staff, this is not essential provided all staff practice universal infection control procedures at all times. The nurses who labelled these doors evidently needed further training in infection control based on the content of the signs. It was agreed with the service manager that disposable protective aprons and gloves and bins in bedrooms of service users who have known infectious conditions would be in future positioned inside bedroom doors. Consideration could be given to supplying all staff with individual anti bacterial alcohol based toggles. The service manager’s attention was also drawn to observation made of two commode pots covered in faecal matter left on top of a sluice machine in an unlocked sluice room. This was first noted at 08.10 hrs by the inspector. No action had been taken to clean them when again observed in the same position at 13.30 hrs. Observation of care records identified failure to ensure all risk assessments and care plans were updated expediently in response to changes in the needs of service users. A recent incident in which a service user left the home unobserved one night had been inadequately recorded. A full chronology of events was not recorded. It was concerning that the agency nurse on duty had not alerted internal managers to the situation and no external agency notified in the 90 minutes this very vulnerable service user had been missing. Whilst the service manager stated he telephoned the home during this period this was not recorded. A breakdown in communication between the service manager and the agency nurse resulted in failure to follow appropriate missing persons procedures. This service user was eventually returned to the home from hospital unharmed. The inspector was concerned at the failure to adequately investigate and follow up this incident. Also despite this taking place days prior to this inspection a risk assessment and care plan was not in place to reduce the risk of this person going missing again. It was noted that this service user had a history of falls and a risk assessment and care plan was in place to address this problem. This required 30-minute observations of this individual at all times which clearly had not been followed when he went missing. It was also subsequently established this service user had a history of going missing from a previous placement yet this had not been identified or addressed through Avens Court’s assessments and care planning procedures. Observations identified changes in handover procedures between shifts, specifically night staff and day staff which had enhanced the safety of service users during this period. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 13 Also improved was the organisation of mealtimes which was focused more on ensuring nutritional needs of service users being identified and met. Changes implemented for achieving this objective had further benefited service users by promoting generally a more flexible approach to care routines. An improved care planning system was being implemented and nurses were striving to transfer information to new documentation. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 15 The home’s activity programme required further development and the approach to be more individualised and underpinned by life history information. An unacceptable practice identified during the inspection indicated need for further training for the whole team to ensure service users autonomy and choice is respected. Menus had improved since the last inspection visit. Dining room practices ensured service users received adequate support to meet their nutritional needs. Some improvement was necessary however to arrangements for serving cooked breakfasts. EVIDENCE: Significant improvement was required to arrangements for meeting service users leisure and social care needs. Though positive to note staff in the afternoon taking time to talk with individual service users and staff sitting outside with two service users, enjoying the sunshine, much more must be done to ensure provision of an appropriate, stimulating activities programme. The practice of an unacceptable form of restraint was observed. The inspector referred this incident for review under multi-agency adult protection procedures at the time of the inspection. Staff had understood this practice to be the explicit instruction of the service manager and that it had been agreed with a care manager to safeguard this individual. The service manager strongly Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 15 refuted this was the case and it appeared a breakdown in communication systems was responsible for this practice. It was concerning that the home manager and nurses did not seek to clarify their understanding of this perceived instruction given the legal implications of their actions. It was evident that the whole team required further training in this area of care. Of concern also was the failure of staff to record risk assessments and update care plans in response to the related risk management framework for the two service users involved in this matter. This resulted in covert practices of restraint and failure to meet the needs of both vulnerable service users implicated. Since the inspection it is acknowledged these issues have been examined within a multidisciplinary forum and an action plan for meeting the needs of both individuals agreed. Personnel issues were affecting the smooth operation of the kitchen. The assistant cook had left recently and the kitchen was operating mostly with two staff instead of three despite a significant increase in work productivity. The cook also tendered her resignation on the day of the inspection though later this was retracted. There was noted to have been one day recently when it had been planned for the cook to work on her own. Responsibility for the staff rota had been delegated to the training manager who had not planned adequate minimum staffing levels at all times for the kitchen and domestic work. The inspector was assured that care staffing levels exceeded minimum levels and care staff had mostly been deployed to undertake ancillary duties. Requirement was made for care staff deployed on catering and domestic tasks to be suitably trained and for this to be clearly identified on rotas. The menu had been recently revised and service users now had three cooked meals a day. There was a choice of food on the menu. A change since the last inspection was that most service users now ate their breakfast in the dining room. Staff were aware of those service users who required assistance with eating and drinking. Staff were allocated responsibility for ensuring service users had adequate food and fluid and nurses monitored food and fluid records closely. The inspector queried the reason why breakfast was not served using the heated trolley and no explanation established. It was unacceptable to observe porridge served tepid from a dish and fried eggs brought from the kitchen on open plastic trays. These trays were left on the nurse station uncovered and eggs were not all served at the correct temperature. The practice of serving marmalade sandwiches with savoury food, on this occasion on the same plate with a fried egg, needs review. Lunch on the day of the inspection was nicely presented and substantial. Staff gave adequate time to this activity. It was noted that there was a shortfall in bedside tables in some bedrooms where service users were served lunch. A care assistant confirmed this was a problem as staff moved these from room to room. The need for armchairs in some bedrooms was also noted. The cook informed the inspector that new fridges purchased since the last inspection visit were not working properly. This feedback was drawn to the attention of management by the inspector. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 16 Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 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): These standards were not inspected at the time of this inspection. EVIDENCE: Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 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, 25, 26 The home was clean and odour control satisfactorily managed. Long standing problems persisted with the home’s heating system. EVIDENCE: The home was clean and odour well controlled. There was noted to be ongoing problems with the heating system causing extreme fluctuations in temperature in some bedroom. It was evident that the engineers had been called out again since the last inspection to investigate the faulty system. The concern was that this had been in response to this deficiency being drawn to the attention of management by a visiting professional. Requirement was made for management to commission a full assessment of the heating problem and for a solution to be found and remedial action taken. In the interim until this work is carried out, the home must ensure robust systems to identify significant variations in room temperatures and take appropriate action. A thermometer must be available in all bedrooms and all staff assume individual responsibility for reporting concerns about room temperatures and problems with hot water Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 19 temperatures, which is another long-standing problem affecting some bedrooms. There were holes in various doors created by removal of locks. This rendered these doors less effective in the event of a fire. It was of concern that the home’s fire risk assessment and health and safety tools did not identify this hazard and others in the environment. Examples of these included unguarded secondary heaters with hot surfaces in bedrooms and another heater noted to be unstable and a potential fire risk. Some staff were living in bedrooms on the second floor. They were noted to use basement staff facilities. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 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): 27, 30 Staffing levels for nursing and care staff exceeded minimum requirements. Catering staffing levels were depleted however and some days domestic staffing levels reduced. It was stated that care staff had been redeployed to undertake ancillary tasks though this was not evidenced. The inspection outcomes identified areas of unmet staff training needs in addition to those previously highlighted. EVIDENCE: The home’s staffing levels for nurses and care staff exceeded minimum levels. Minimum staffing levels for catering and domestic however were not always planned in advance and care staff stated to be deployed on these duties. It was clarified by the inspector this was only acceptable provided minimum care staffing levels were maintained at all times. Also only if staff were trained appropriately to undertake these duties. It was positive to note some training sessions for staff since the last inspection visit. Specifically, refresher training to update nurses clinical knowledge and skills regarding tissue viability and diabetic care. Some staff had attended a training workshop on the nutritional needs of older people. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 21 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, 37, 38 Since the last inspection visit there had been significant changes within the management team. The home’s management was under significant pressure, which reduced its effectiveness at times. Attention was required to some records and policies and procedures in need of revision. Health and safety and fire risk audits must be more robust to identify and respond to hazards in the environment. EVIDENCE: The home has not had a registered manager since registration in November 2005. Since the last inspection the home manager who was being processed for registration, had resigned and been replaced by another manager who was new in post. The home was currently managed by the service manager in addition to his line management responsibilities of four other care homes. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 22 Though the management structure appeared to have been strengthened by the promotion of a senior nurse to the vacant deputy manager’s post and return of the other deputy manager from long-term leave, other factors mitigated against the effectiveness of the management team. These circumstances were the need for the home manager and recently appointed deputy manager to undertake a period of orientation into their new roles and responsibilities. The other issue was that the existing deputy manager was required to work under direct supervision in connection with allegations against her under investigation. Though evident that managers were working hard to provide direction and leadership to staff and striving to raise standards there were weaknesses identified in the home’s management at the time of this inspection. The inspection identified that the staff rota was not being maintained up to date and was not a clear record of staff deployment. The missing persons procedure required further development and areas for improvement and revision in this matter discussed with the service manager. This procedure must in future be accessible to all nurses left in charge of the home who must be familiar with its content. A full investigation into the missing persons incident was also required. Whilst care plans and risk assessments were in place and new systems and formats being introduced, observations identified these were not all maintained up to date to reflect changes in needs. The need to implement an incident record keeping system and for improvement in communication systems was also discussed. A review of the home’s health and safety and fire safety audit tools and systems is necessary. These must be more robust to immediately identify and address hazards in the environment. A full assessment and remedial action was required into the ongoing problems with the home’s heating system. In the interim a robust system for responding to significant variations in room temperatures must be in place. Action must be taken for making safe secondary heaters used in bedrooms. The new procedure for ensuring security of the front door was not known to all staff at the time of the inspection. It is acknowledged that the service manager took action to address this with immediate effect once this was drawn to his attention by the inspector. There is a need to ensure the home’s fire evacuation procedures takes account of staff living in on the premises. Consideration should be given to use of a fire register in and out system. Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 23 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 x 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 x x x x x 1 2 STAFFING Standard No Score 27 2 28 x 29 x 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x x x x x 1 1 Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 24 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 OP3 Regulation 14(1)(a) (b)(c)(d) Requirement For pre-admission assessment procedures to be improved in order that new service users are admitted on the basis of full needs assessments carried out by people trained to do. This is necessary to ensure compliance with the home’s admission criteria and to ensure needs can be fully met. For admission/assessment procedures to cover social interests and care planning ensure adequate attention to meeting social care needs. An activity programme must be implemented which is suitable to respond to individual needs, preferences and capacities. For robust, formal systems to be implemented for monitoring both service users whose behaviours currently pose concern for the safety of one individual. For a risk assessment and care plan to be immediately implemented for the service user who was the subject of the DS0000066356.V353514.R01.S.doc Timescale for action 04/05/06 2 OP3 14(1)(a), 15(1), 16(2)(m) (n) 04/05/06 3 OP3 12(1)(a) (b), 13(4)(c) 03/05/06 4 OP7 12(1)(a) (b), 13(4)(b) (c), 13(6) 03/05/06 Avens Court Nursing Home Version 5.1 Page 25 5 OP7 14(2)(a) (b), 15(2)(b) 12(1)(a) (b), 15(2)(b) (c)(d) 6 OP7 restraint practice. The care plan must reflect the agreed interventions for maintaining the safety of this individual. Diversionary activities and strategies expected of staff must be recorded in the care plan and shift allocation records delegate staff responsibility for implementation of the care plan and monitoring arrangements. For risk assessments and care plans to be revised at any time when it is necessary to do so having regard to any changes in circumstances. Unless it is impracticable to carry out such consultation, the registered person shall, after consultation with the service user, or representative of his or her, prepare a written plan as to how the service user’s needs in respect of health and welfare is to be met. Review the care plans of the two named service users discussed in consultation with them to ensure their social and physical needs are fully met. Arrange reviews of the mental health needs of the same two service users to clarify both have a primary condition of dementia. Also arrange nursing needs assessments. To ensure a risk assessment and care plan is in place for the service user who was the subject of a recent missing persons incident. A formal monitoring system must be instituted for this individual. For review and improvement in infection control procedures. Also service users privacy and dignity DS0000066356.V353514.R01.S.doc 03/05/06 03/05/06 7 OP7 12(1)(a) (b),12(2), 15(2)(b) (c) 14(2)(a) (b) 05/05/06 8 OP7 03/06/06 9 OP7 13(4)(c), 14(2)(a)( b), 15(2)(b) (c)(d) 12(4)(a) 13(3) 03/05/06 10 OP8 04/05/06 Avens Court Nursing Home Version 5.1 Page 26 11 OP14 18(1)(a), (c)(i) 12 OP14 10(1), 12(1), 13(7) 18(1)(a) (c) (i) 13 OP15 16(2)(i) 14 15 16 OP19 OP19 OP19 16(2)(c) 16(2)(j) 23(1)(a), 23(2)(b), 23(2)(p) 17 OP19 12(1)(a), 13 (4)(c) 23(2)(p) must be safeguarded in the operation of these procedures. To provide training for the staff team to improve understanding of the complex issues relating to capacity in dementia care. Staff must be aware of their responsibilities to appropriately balance their duty of care and service users rights to exercise choice and control in the daily lives For the home to have an explicit policy and guidelines specific to restraint practices and staff aware of the same. There is a need to ensure all staff receive training to enable understanding of the legal implications of the use of restraint. For review of arrangements for serving breakfasts in the dining room to ensure food is served at the correct temperature. A choice of bread and butter without marmalade should be offered with savoury cooked breakfasts. For provision of sufficient numbers of bedside tables and armchairs in bedrooms. To ensure fridges are operating at the correct temperature for the safe storage of food. To arrange for an engineers report assessing the cause and providing solutions to ongoing problem with the heating system. A copy of this report must be sent to the CSCI with timescales for any work programme. The deadline for any necessary work to be completed being 31/08/06. For robust systems to be instituted to daily identify and respond to significant variations in room temperatures DS0000066356.V353514.R01.S.doc 19/05/06 19/05/06 04/05/06 03/06/06 04/05/06 10/05/06 03/05/06 Avens Court Nursing Home Version 5.1 Page 27 18 19 20 OP19 OP19 OP19 23(2)(b), 23(4)(c) (i) 13(4)(a) (b)(c), 23(4) 18(1)(a) (c)(i) throughout the home. All occupied bedrooms to be fitted with thermometers. For holes in doors to be filled in to improve their fire resistance. For secondary heaters used in bedrooms to be made safe. For care staff deployed in the kitchen and engaging in serving food not to do so unless they have received basic food hygiene training. Care staff deployed to undertaken cleaning and laundry duties must have received relevant moving and handling training and COSHH training. They must also be in receipt of adequate supervision. To make application for variation of the home’s conditions of registration if necessary to continue to accommodate both named service users discussed if one or both service users have been placed outside the home’s categories of registration yet the placement considered appropriate to meet their needs. For staff to cease the involuntary confinement of a named service user to her room with immediate effect. The registered person shall ensure that no service user is subject to physical restraint unless of the kind employed is the only practicable means of securing the welfare of that or any other service user and that there are exceptional circumstances. On any occasion on which a service user is subject to physical restraint; the registered person shall record the DS0000066356.V353514.R01.S.doc 04/05/06 04/05/06 03/05/06 21 OP31 10(1) 03/06/06 22 OP31 12(3)(4), 13(7) 12(1)(a) (b), 13(7) 03/05/06 23 OP31 03/05/06 24 OP31 13(8), 17(1)(a) Sch3. (p) 03/05/06 Avens Court Nursing Home Version 5.1 Page 28 25 OP31 13(8) 17(1)(a) Sch3. (q) circumstances, including the nature of the restraint. A record of the use of any physical restraint must be kept and of any limitation agreed with a service user as to the service user’s freedom of choice, liberty of movement and power to make decisions. For review of management arrangements and systems to ensure the management of the home is more effective. For a full investigation to take place into the recent missing person incident and a report compiled and sent to the CSCI. For management to review the security of external doors and systems for ensuring service users safety. For the missing persons procedure to be revised and further developed in accordance with requirements set out in the letter of serious concerns. This procedure must be fully understood by all nurses taking charge of the home and accessible to them including agency nurses. For improvement in communication systems within the home. To implement a suitable system for recording incidents. 03/05/06 26 OP31 10(1) 15/05/06 27 OP31 10(1), 13(4)(a) (b)(c) 13(4)(a) (b)(C), 23(1)(a) 10(1) 13(4)(a) (b)(c), 18(1)(a) 03/05/06 28 OP31 03/05/06 29 OP31 10/05/06 30 31 OP31 OP31 10(1) 17(1)(a) Sch3. (j) 17(2) Sch4. (12) 17(2) Sch4. (7) 05/05/06 05/05/06 32 OP37 For the staff rota to be maintained up to date at all times and clearly identify where staff are deployed. The home must not operate below minimum staffing levels for all departments. DS0000066356.V353514.R01.S.doc 03/05/06 Avens Court Nursing Home Version 5.1 Page 29 33 13(4)(a) (b)(c) 34 23(4)(c) (iii) Fire safety and health and safety 04/05/06 risk assessment tools and audits must be sufficiently robust to ensure the safety of the environment at all times. Fire evacuation procedures must 04/05/06 take into account residential staff in the roll call register. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Avens Court Nursing Home DS0000066356.V353514.R01.S.doc Version 5.1 Page 30 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.V353514.R01.S.doc Version 5.1 Page 31 - 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. 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