CARE HOMES FOR OLDER PEOPLE
Avonmead Nursing Home 11 Canal Way Devizes Wiltshire SN10 2UB Lead Inspector
Susie Stratton Unannounced Inspection 16th January 2006 10:25a 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 Avonmead Nursing Home DS0000015890.V275590.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. Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Avonmead Nursing Home Address 11 Canal Way Devizes Wiltshire SN10 2UB 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) 01380 729188 01380 729299 avonmead@fshc.co.uk Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) Sharon Cottrell Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability (4), Terminally ill (4), of places Terminally ill over 65 years of age (4) Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. No more than 4 service users with a terminal illness may be accommodated at any one time The minimum staffing levels set out in the Notice of Staffing issued by Wiltshire Health Authority and dated 28 May 1999 must be met at all times No more than 4 service users over 55 years of age who are in receipt of Intermediate Care are accommodated at any one time. 21st July 2005 Date of last inspection Brief Description of the Service: Avonmead is a purpose built care home situated on the outskirts of Devizes, within a private housing development, providing nursing and residential care. The home has single and double en suite accommodation for up to forty-five persons, distributed over two floors and served by a passenger lift. On the day of the inspection, there were 39 persons resident in the home. The home has an enclosed garden and patio area. The owner of the home is Laudcare Limited, a wholly owned subsidiary of Four Seasons Health Care Limited, a national provider of care. The manager of the home is Mrs Sharon Cottrell, she has been in post since the home opened. She is supported by two senior sisters. Two qualified nurses are on duty at all times, supported by care assistants. An activity person is employed. Catering, cleaning, maintenance and laundry services are also available. Shops and local facilities are a short driving distance from the home in the Wiltshire market town of Devizes. There is ample parking on site. Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on Monday 16th January 2006, in the presence of Mrs Sharon Cottrell. The Inspector for the service was accompanied by the Pharmacist Inspector. During the inspection, the inspector met with seventeen residents and observed care for fourteen residents who were unable to communicate. The Inspector also met with three visitors, three registered nurses, three carers, the chef, two catering assistants and the laundress. The Inspector reviewed records relating to eleven residents in detail. She toured the home and reviewed equipment. A range of records were inspected, including staff employment, training, supervision and home management records. The previous inspection took place on 21st July 2005. An immediate requirement certificate relating to cleanliness and adequate staffing was issued following this inspection and a range of other issues identified. A meeting was also held with the area manager and home manager. A follow-up inspection took place on 8th August 2005. At this inspection the home demonstrated that it had addressed the requirement relating to staffing but had not addressed the requirement relating to cleanliness, further requirements and a recommendation were also identified. A further unannounced-follow-up inspection took place on 15th September 2005. At that inspection, of the requirements reviewed, four had been addressed, eight showed progress but six were unmet. Additional requirements and recommendations were also identified. An immediate requirement certificate relating to infection control, notifying the Commission of events and correct use of equipment was issued. A review meeting was held with the area manager and registered manager to discuss outcomes of inspections on 29th September 2005. An unannounced follow-up inspection took place on 22nd November 2005 with the Care Services Director for Four Seasons Health Care Ltd. At that inspection, progress was noted across a range of areas but new requirements were again identified. What the service does well:
Staff spoken with knew the needs of their residents well and were committed to work with them, to meet their care needs. Staff were observed to be consistently helpful and supportive to residents. Registered nurses had a detailed knowledge of their residents and effective systems for management of clinical areas. Residents particularly commented on the effective service from the laundress. The managers for Four Seasons Healthcare respond well to the inspection process, producing detailed action plans and have been keen to work with the Commission, to improve service provision. Residents expressed their appreciation of the service provided by the home, one said that the home was “generally very nice.” another said “It’s very nice
Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 6 here.” and another described the home as “friendly”. Residents were also appreciative of the staff, one said “They’re all very nice people”, another said that they liked their lead nurse “very much”, another said “all here are very kind” and another described staff as “very thorough”. Relatives commented on how well the home kept in touch with them, to inform them of any changes in their relative’s condition. One said that staff were willing to talk to them at any time. What has improved since the last inspection?
Twenty four requirements and fourteen good practice recommendations were identified at the previous inspection. Two further requirements and one recommendation were identified at the first follow-up inspection. At the second follow-up inspection, five further requirements and two recommendations were identified. Three new requirements were identified at the third follow-up inspection. These were all reviewed at this inspection. All residents are now issued with a contract on admission. Complaints and concerns are now investigated and records maintained. Records relating to residents’ moneys are kept clearly. All residents who are assessed as being at risk of pressure damage have a care plan in place. Equipment which does not prevent pressure damage is no longer used and the equipment which is in place, is being used in accordance with manufacturers’ instructions. Care plans for diabetic residents are clear and detail all relevant matters. Residents’ care plans which are no longer relevant are archived. Where residents wish to self-medicate, a suitable secure facility has been provided. Communal use of residents’ clothing does not take place. An audit of whether residents wish to have locks on their room has taken place and relevant actions taken. British Standard signage is used on doors of any rooms where oxygen is in use or stored. The damaged bath on the first floor of the home has been repaired and is to be replaced shortly. An audit of residents’ needs for variable height bed has taken place and some new beds provided. Additional grab-rails have been installed in residents’ en-suites. New commode chairs have been provided. The kitchen has new pots and pans to replace old and deteriorated stock. Sterile procedures are now used for all aseptic procedures, this prevents a major risk of cross-infection. All items in the home, including the undersides of dining-room tables and chairs are now clean. The sluice room on the first floor has been fully cleaned and a new washer disinfector is on order. A supply of disposable gloves and aprons have been made available in all sluice rooms. All clinical waste is placed in appropriate waste bins. Safe systems for the management of potentially infected laundry have been provided. All cleaning materials are securely stored. Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 7 A review of staffing levels has taken place. Staff rosters detail when the activities coordinator is performing other roles. Staff are receive formal supervision. Systems have been put in place to ensure that residents’ clothes are marked. Some staff have attended a death, dying and bereavement course. Staff meetings are being held. What they could do better:
At this inspection, 15 requirements and 21 recommendations were identified. Several of the matters identified are unmet requirements from previous inspections. Requirements that where residents exhibit bruising, that this must always be documented in the residents’ records and the home’s accident book and also that residents need care plans in place to direct staff on how to meet their social care needs, have been identified at previous inspections and have not been addressed by this inspection. Other requirements were identified at previous inspections but have not been addressed in full by this inspection. All residents must have care plans in place to meet all their assessed nursing and care needs. Where frail residents care needs to be monitored by use of frequent care charts, these records must be fully completed on all occasions, to show that they have received the care they need. All residents who are assessed as having complex manual handling care needs must be cared for in a variable height bed, to prevent risk of injury to the resident and staff. An assessment of response times when call bells are used is needed to identify if response times are regularly over 3.5 minutes and an action plan needs to be put in place to ensure that response times are improved. All sanitary items must be clean, free of staining and debris. The Commission must be informed on each occasion when the home is not able to comply with its specified staffing levels and of the actions taken to minimise risk to residents. New requirements were identified at this inspection and related to a range of areas. The service users’ guide must include all matters needed, to fully inform relevant persons of the services provided. There must also be evidence that all relevant persons are issued with the service users’ guide. All residents must have a full nursing and care assessment completed prior to admission for longterm care. All controlled drugs must be properly stored in accordance with legislation, to ensure resident safety. Risk assessments for residents who wish to self-medicate must be regularly reviewed and accurately reflect current practice. Where two medicines containing Paracetamol are prescribed, the medication administration chart must contain clear guidelines for use to ensure that the resident does not receive an over-dose. The home must ensure that all unsafe equipment is secured, repaired or taken out of use. There must be written evidence that the home has been visited on a monthly basis by a representative of the proprietors and a written report of this visit produced. Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 8 Several of the recommendations from previous inspections had not been addressed. The home’s policy on escorting residents to external appointments had not been included in the service user’s guide. The activities coordinator had not attended a course on activities provision. The sugar and carbohydrate content of manufactured foods had not been assessed, to ensure that foods with a high sugar and carbohydrate content are not given to diabetic residents. Some corridor carpets are heavily stained but have not yet been replaced. All baths, apart from one, are low-level but action plans have not been developed to identify how the needs of disabled residents are to be met. The homes policy on staff uniforms has not been reviewed, to ensure that it conforms to current Health Protection Agency guidelines. Some recommendations showed progress, but had not been addressed in full. A review of the intermediate care contract, to ensure that service users have appropriate medical support had not taken place. Precise terminology continued not to be used on all occasions when describing residents’ presenting care needs. Systems to ensure that residents can be taken out of the home on outings had not been fully developed. The staffing levels on the first floor had not been fully reviewed. New recommendations were also identified at this inspection. All nursing and care documentation had not been dated and signed by the person drawing it up. Rooms where intermediate care residents are cared for need to be properly labelled, to prevent confusion to residents, their visitors and staff. Care plans for residents who need turning on a regular basis should specify exactly how often the persons’ position needs to be changed. All residents who are observed to sustain bruises should be assessed for risk and a care plan put in place to direct staff on how to reduce risk of bruising. All persons temporarily who perform laundry should be trained in the importance of returning residents’ personal items to them promptly. All pre-employment information should be dated and signed by the person completing the information. Staff who have not worked in care previously and/or whose first language is not English, should work more than two days on a supernumerary basis, to ensure that they are fully inducted into their roles. All staff training profiles should be fully completed. A matrix for staff supervision and health and safety training should be developed, so that the home can demonstrate that all staff have received regular supervision and mandatory training. 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. Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 The home does not provide prospective residents with all relevant information to make an informed choice. All residents are now issued with a contract. Not all residents had full assessments before coming into the home on a permanent basis. The home works to ensure that residents admitted for intermediate care are helped to maximise their independence, however more support is needed from some external professionals. EVIDENCE: The manager reported that the service users’ guide is generally available in the front entrance but that it had been mislaid recently. She reported that prospective residents and their families are sent a copy of the home’s brochure. This brochure does not include all the matters needed in the service users’ guide, for example it does not include terms and conditions in respect of accommodation or a summary of the most recent inspection report. This means that prospective residents will not be fully informed about the services provided by the home. The home also cannot evidence that all residents have been given a copy of the brochure, for example at times persons admitted for intermediate care become permanent residents and it was not clear if they are given full information about the home either on admission or when they
Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 11 became permanent residents. The brochure does not include reference to the home’s policy on escorting residents to out-patients and other external appointments, as was recommended at the follow-up inspection of 15th September 2005. The owners have now drawn up and agreed a standard contract for residents. Evidence was available to show that all residents had been issued with a copy of this contract and that these were gradually being returned to the home, having been signed by relevant persons. This was a matter which had been outstanding for four inspections. The home uses a standard assessment tool for all prospective admissions. The files relating to two recently admitted persons were reviewed. One had been completed in detail with all the individual’s details. The other one related to a person who had been admitted for intermediate care, but following assessment, had become a permanent resident in the home. This person’s assessment had not been completed to the same standard and some areas had not been assessed, this included a social care assessment, dietary assessment and baseline observations such as blood pressure and weight. The document had also not been dated or signed. Avonmead is registered to care for persons who need intermediate care. All such service users are admitted under the care of one specific team, who arranges for rehabilitation services, such as physiotherapy. All residents have their own room and therapies can take place in their room. Rooms for intermediate care residents and for respite care residents are all labelled “respite”, not the resident’s name. This may be confusing for staff and other professionals, as the two categories of care need different interventions and may make it complex for residents to identify their rooms. At the inspection of 21st July 2005, it was recommended that a review of the intermediate care contract should take place, to ensure that intermediate care service users can have appropriate medical support and that the team performs reviews in a timely manner. A meeting has been held to discuss these issues and more are planned. Staff reported that reviews are taking place on a more timely manner but that the issue of medical support remains unresolved, this means that residents’ rehabilitation programmes may be delayed/cannot be started while the service user is awaiting medical decisions. Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Improvements have been made in the standards of care planning since July 2005, however some residents may be at risk, as they do not have full care plans for all of their nursing and care needs. Frail residents may also be at risk as the home is not able to show that frail persons have had their positions changed or have had fluids given on the frequency needed. The home has clear procedures for the safe handling of medication, however risk assessments must be up to date to protect residents. Residents’ privacy and dignity is generally upheld. EVIDENCE: Avonmead has put much work into improving its approach towards care planning since the previous inspection. All residents have assessments for matters such as manual handling, pressure damage risk and dietary risk. Where residents are assessed as being at risk of pressure damage, care plans are now drawn up to direct staff on how risk is to be reduced. These could benefit from specifying how often a person needs their position changing, to prevent pressure damage, as different residents’ needs in this respect will vary. Records provide evidence of consultations with residents’ GPs and other healthcare professionals. Records relating to wound care are clear and enable assessment of the effectiveness of treatment programmes. Care plans for
Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 13 diabetic residents are now very clear, stating precise blood sugar levels and actions to be taken by staff when these blood sugar levels fall outside these levels. Some residents, due to frailty, are at risk of bruising and they would be supported by completion of assessments for such risk, together with care plans to direct staff on how risk is to be reduced. At the follow-up inspection of 15th September 2005, it was required that all residents must have care plans in place which direct staff on actions to take to meet the resident’s needs and progress was noted at the follow-up inspection of 22nd November 2005. Progress continued to be noted that this inspection, however some omissions continued to be noted. One resident’s daily record and discussions with staff indicated that they were much affected by anxiety and this was affecting their daily lives, however they did not have a care plan in place to direct staff on how to support the resident. Another resident had a urinary catheter in place, there was no clinical indicator documented for use of this catheter and no record of its size, amount of water in the balloon or batch number. One resident had very clear and detailed instructions in their room about the care of an ostomy, it was not signed or dated, so it was not possible to assess if these were the current instructions. As observed at the follow-up inspection of 22nd November 2005, some records show imprecise language, for example one record described the resident as showing “aggressive” behaviours, without specifying what these behaviours were, another stated that the resident had been “checked” and “repositioned”, without documenting how the resident was repositioned or the type of checking. Avonmead has had an ongoing issue in relation to full completion of frequent care records, which was identified at the previous inspection and the three follow-up inspections. Frequent care records are needed for frail residents, so that managers can ensure that such frail persons are repositioned at the frequency indicated by their condition and offered fluids regularly, to prevent risk of dehydration. Improvements in the standards of completion of these records has been noted, during the course of two of the follow-up inspections. An additional member of staff now works on the first floor every morning and a review of records showed that all records had been fully completed every morning. Completion of these records was more variable in the afternoons, evenings and night times, so the home continues not be able to demonstrate that such frail residents receive the care that they need on the frequency indicated by their condition. The fact that the situation in the morning has improved, now that there is an additional member of staff on duty may indicate that more staff are also needed at other times of day (see Standard 27). The home has notified the Commission of two incidents of maladministration of medicines since the inspection of 21st July 2005. Both were investigated by the home and related to specific member of staff’s failure to follow procedure. The home report that all persons involved have been re-trained. Some new drug storage has been acquired by the home but at the time of the inspection
Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 14 there was insufficient controlled drug cupboard space for all the controlled drugs held in the home. A procedure for the handling of medicines in the home is available along with a homely remedy list agreed with the doctors. Medication administration records are printed and all appropriate records are maintained. Photographs are used to aid identification. Some residents selfmedicate some, or all, of their medication. This process is risk assessed, but after discussions with one resident it was apparent that the assessment did not accurately reflect what occurred in practice. One medication chart contained Paracetamol and Co-Codamol for the same resident with no indication for use. Staff were observed to knock on doors and await a reply before entering rooms. Staff were also observed to be friendly and helpful towards residents, calling them by their own preferred name. Residents spoke favourably about the laundress, saying how well she laundered their clothes and that she was prompt in returning them. They also reported that the service was not so good when she was away and three residents reported that they had been waiting for the laundress to return from annual leave so that they could get her to look for personal items, which has gone to the laundry and had not yet been returned. Any person who performs laundry duties when the laundress is away should be trained in the importance of returning residents’ own laundry to them in a prompt manner. Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The home cannot evidence that they are providing activities to meet individual resident’s needs. Visiting is encouraged and residents can go out of the home. Residents are supported in choosing how they spend their days. A range of meals are provided and residents can choose where they eat. EVIDENCE: The activities coordinator was not on duty on the day of the inspection. Many of the residents are very frail and not able to inform the Inspector of how they spent their time. Four residents were observed in the sitting room, chatting quietly to each other, watching television. Four Seasons Health Care use a standard social care assessment document, to assess residents’ social care needs. Of the files examined, only one had a completed social care assessment, others were blank or were reported to have been sent to relatives to complete and had not been returned. None of the residents had a social care plan, this has been required since the follow-up inspection of 15th September 2005. Residents have records of activities involved in but these were completed infrequently, so do not provide evidence of what social activities residents have been involved in. Key workers also complete a record but these were also variably completed, so it was not possible to ascertain to what extent carers are able to support residents’ social care needs. At the inspection of 21st July 2005, it was recommended that the activities
Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 16 coordinator attend a activities coordinator course, this has not yet been actioned. Three relatives spoken with said that they felt welcomed into the home and were able to come at any time. They also commented on how good staff were at keeping in touch with them about matters which affected their relative. The home are beginning to develop systems to support those residents who are able to go out of the home, as was recommended at the inspection of 21st July 2005, as the improved weather arrives, this should be further developed. Residents said that it was up to them when they got up and went to bed. They also said that they could choose where to eat their meals. Several residents have been supported in bringing some items of their own into the home and some of the rooms were very personal, reflecting the resident’s likes and preferences. On the day of the inspection, the residents had a choice of mince or pasties with cooked frozen peas or beans and two types of potato for lunch. The chef reported that generally they have at least one, and often two meals which have been cooked up from raw ingredients. Many of the residents need assistance eat and staff were available to support residents, sitting with them and assisting them. Residents gave a variable response to meals, some saying that they liked them very much, others being less enthusiastic. One resident said the food was “generally very nice”, another “all right”, another “so so”, another that the home should “emphasise quality, not quantity” and another described the meals as “a bit boring”. The home is again advised that the sugar and carbohydrate content of foods should be considered when preparing meals for diabetic residents. It was noted that the dried soups used at suppertime contained sugar, additionally there did not appear to be a system to ensure that diabetic residents did not have potato, pasty and peas at lunch, all of which contain carbohydrate. The desserts are made with sugar-free preparations. More emphasis needs to be placed on diets for diabetic residents. Avonmead Nursing Home DS0000015890.V275590.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): 16 The home has a complaints procedure, which is effective in practice. EVIDENCE: The home has a complaints procedure, to which all residents have access. The home manager has put much work into improving systems for reporting and documenting of complaints and concerns. Records seen were clear and provided evidence that a range of concerns were raised by residents or their relatives, such as might be anticipated in a home of this size. The records indicated that staff were consistently reviewing issues raised and responding to resolve the situation. The home manager reported that she is now working on developing an audit system for complaints and concerns, to identify any trends. Residents spoken with knew how to raise issues, one said they spoke to the “supervisor” if they had concerns and another said “I only have to talk to one of the sisters and they will listen.” Avonmead Nursing Home DS0000015890.V275590.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, 20, 21, 22, 23, 24 & 26 Residents at Avonmead have access to a range of communal spaces, as well as their own bedrooms. Some residents may be put at risk by a lack of appropriate equipment and response times when call bells are used. Systems for prevention of infection have improved, but some areas still need to be addressed, to ensure that residents are not put at risk. EVIDENCE: Most of Avonmead is well maintained. At the time of the inspection, builders were working on the reception desk. More grab rails have been provided in en-suite bathrooms. The first floor corridor carpet continues to be very stained and detracts from the atmosphere. The manager reported that she has requested for it to be changed. Sitting and dining rooms are provided on each floor and there is a pleasant patio outside to the rear of the building. A range of wcs and baths are available. There is only one variable height bath in the home, all of the other baths are low and may present a risk to residents and staff. There are no disabled showers in the home. One of the baths has been scraped by the bath
Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 19 hoist and the enamel is no longer intact, the manager reported that it is due to be replaced by a new bath during the next few weeks after the inspection. Most of the residents are cared for in single rooms with en-suite facilities. Where rooms are shared, screening is available. At the previous inspection, the manager was required to carry out an audit of residents with complex manual handling care needs and develop an action plan to provide such residents with variable height beds. This has taken place and the number of variable height beds has much increased. However it was noted that two intermediate care residents had complex manual handling needs but continued to be cared for in divan beds, this could put the residents and staff at risk. Residents had generally been left with access to their call bell, however one resident was observed to be in an uncomfortable position during the late morning. The Inspector rang the resident’s call bell but had no response after 3.5 minutes and as the resident was beginning to appear distressed, the Inspector asked a catering assistant to stay with the resident and went to look for a member of staff. All members of staff were busy at the time, however one person was able to stop what they were doing temporarily, to ensure the resident’s safety. Avonmead is a nursing home and as persons with acute medical needs need attention within at least 3.5minutes, to ensure that their medical condition can be stabilised, an extended time to answer a call bell is unacceptable. As at the inspection of 21st July 2005, residents spoken with commented that there was a variable response when they used their call bell, depending on how busy staff were. Two residents commented on how “helpful” staff were when they came. A recommendation was made at the inspection of 21st July 2005 that the situation should be monitored. The manager reported that following this, she has requested a monitoring system for call bells so that she can fully assess response times. The observation made during this inspection and comments made by residents at this and previous inspections may relate to staff availability at certain times of the day (see Standard 27). Avonmead has had issues in relation to adequate systems for prevention of spread of infection during recent inspections. Most of these have now been resolved. New commode chairs have been provided, sterile gloves are now available for aseptic procedure and a new washer disinfector for bed pans is to be installed shortly. All clinical waste is placed in appropriate waste bins. The laundry is clean, including behind the washing machines. The home has two washing machines, both of which have a sluice wash programme. A full system for separation of clean and potentially infected laundry has been put in place. At the unannounced inspection of 21st July 2005, it was observed that a range of raised toilet seats were not clean on their undersides, this was not noted to have improved by the follow-up inspection of 8th August 2005 and immediate
Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 20 requirement certificate was issued. Cleanliness of such items was noted to be improving by the follow-up inspection of 15th September 2005 but had not been fully addressed and the issue was not fully resolved until the follow-up inspection of 22nd November 2005. Standards have declined since this followup inspection and at this inspection, again the majority of such aids had not been properly cleaned on their undersides, showing yellow and brown debris, although this was not as ingrained as at previous inspections. Slipper bed pans are used where indicated and these show considerable staining, with brown and yellow debris in the enclosed section, such pans need to be properly cleaned after use, to prevent build-up of such materials. The home has also not reviewed its policy on cleansing of staff uniforms, to ensure that it conforms to Health Protection Agency guidelines, as recommended at the inspection of 21st July 2005. Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 21 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, 29 & 30 The numbers and skill mix of staff have improved. Problems experienced by the home with complying with all aspects of minimum staffing levels and actions taken were not reported to the Commission. Residents are protected by the home’s recruitment and training procedures. EVIDENCE: Avonmead are required to staff their home in accordance with a Staffing Notice issued by their previous registering authority. A review of rosters showed that they had not complied with this Notice, in that the sister(s) in charge had not worked 37 hours in addition to the registered nurses, during a period of two weeks absence by the manager. The manager reported that this failure to comply with the Staffing Notice had been unplanned and was over the New Year period, so had been difficult to address. She was advised that failure to comply with the home’s Staffing Notice had been identified at the inspection of 21st July 2005 in relation to the same matter and an immediate requirement certificate was issued. At is appreciated that staffing a home at short notice over a holiday period is complex, but if this is the case, the home must always inform the Commission and actions taken to ensure resident safety. This is a matter which the home had already been previously notified about, so it is of concern that appropriate action was not taken. Since the follow-up inspection of 15th September 2005, when the home were found not to be complying with their minimum staffing levels, which led to the issuing of an immediate requirement certificate, the home have been regularly
Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 22 informing the Commission of occasions when they have not been able to meet their minimum staffing levels, apart from the matter detailed above. The number of such notifications has reduced recently. The manager reported that this is because the home have been successful in their recent recruitment campaign. At the follow-up inspection of 22nd November 2005, it was advised that the home should review staffing levels and as noted above, this has taken place and additional member of staff now works on the first floor in the mornings. However evidence from issues relating to provision of care to frail residents and response times to call bells indicates that there may still not be enough staff on duty at all times to meet the complex care needs of a dependant population and this matter needs continued review. The files of three recently employed staff were reviewed. All contained all relevant information, apart from one, which only included one reference, this person had left employment before completing their induction period. Two of the staff were employed from abroad, they had completed information to support their application by hand, these were not dated or signed by the person. The agency interviewing these staff on behalf of Four Seasons Health Care Ltd. had completed an interview assessment questionnaire, but also had not dated or signed the questionnaire. All other relevant proofs of identity, health checks, CRB and pova clearance had been obtained. The home has a standard induction programme, which as been produced by the owners. It is currently being up-dated to conform to Skills for Care guidelines. At present newly employed staff work only two days supernumerary before being included as permanent staff on the rosters. Four of the recently employed staff had not had experience of working as a carer previously and did not have English as their first language, so two days appears to be a low number of supernumerary days for such persons. Many other providers have a flexible approach to induction, allowing for more supernumerary experience for persons without previous caring experience and/or whose first language is not English. All staff have individual profiles, on which details of their training is meant to be documented. These documents are variably completed, some are detailed, others are more or less blank although there is evidence in other documents that some of these staff members have received training. The manager was advised that many homes review past training and future needs during supervision, to ensure that all records are fully up to date. Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 23 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): 33, 36 & 38 The owners of the home have a quality audit system. The home was not visited regularly by a representative of the company, to review the home’s systems during a period when a range of issues had been raised about practice in the home. The home have a system for staff supervision to protect residents. Some systems are in place to ensure health and safety, however residents could be put at risk by some potential unsafe equipment and a lack of documentation and investigation of bruising to residents. EVIDENCE: The home manager reported that the owners have a system for regularly reviewing quality of service provision. Two of the reports inspected were for 2005. The second report included detail to evidence findings and a clear action plan was appended at the end of the report. The owners are meant to ensure that the home is visited monthly by a representative and a report drawn up. A review of the home’s file shows that such visits were documented for June, September and November 2005 only. The unannounced follow-up inspection
Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 24 of 22nd November 2005 was performed by the CSCI Inspector and the Care Services Director from Four Seasons Health Care Ltd. As the home has had several issues relating to provision of care and health and safety documented in inspections reports, it is of concern that increased visiting, rather than reduced visiting by a representative of the company has been taking place. At the inspection of 2nd February 2005, it was required that staff receive formal supervision at least six times a year. The home now has a system for supervising of staff. Records seen were clear, however the manager does not maintain a overall summary or matrix, so it is not possible to evidence if all staff have received supervision in accordance with the standard. As noted in Standard 30 above, although there is evidence that staff are receiving mandatory training in areas such as fire safety and manual handling, records are not clear enough to evidence that all staff have received such mandatory training. Evidence was available of servicing and electrical testing of equipment. All cleaning materials have been fully secured. Two raised toilet seats had lost one of their feet, they therefore were not steady and a frail, unsteady person might topple over if they put their weight in the wrong place. This needs addressing promptly. One resident was prescribed oxygen, the cylinder was not secured. Oxygen cylinders are heavy and can overbalance easily, therefore to protect residents and staff, all cylinders must be secured. At the follow-up inspection of 22nd November 2005, it was noted that a resident had sustained a bruise but that no record had been made in the home’s accident book or the resident’s record. The resident had been able to inform the Inspector of how the bruise had occurred. At this inspection, two residents were noted to have sustained bruises; both residents were able to inform the Inspector of how these had occurred. No records had been made of either of the bruises in the home’s accident records or the resident’s records. Both occurrences of bruising should have been considered and a review of care plans and staff practice initiated if indicated. It is of concern that appropriate actions have not been taken by the home to ensure resident safety. Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 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 1 3 3 x x 2 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 3 3 2 3 3 x 2 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x 3 x 2 Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 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. Standard OP1 Regulation 5(1)(a f)(2) Requirement The service users’ guide must include all matters detailed in regulation. There must be evidence that all service users are issued with the full service users’ guide. All service users must have a full assessment completed prior to admission for long term care, by a person qualified to do so. All service users must have care plans in place which direct staff on actions to take to meet the service user’s needs. (Identified at the follow-up inspection of 15/9/05; it shows much progress but is not yet complete.) Where frail service users care needs to be monitored by use of a frequent care chart and/or food chart, these records must be fully completed on all occasions. (Identified at the inspection of 21/7/05. Requirement shows some progress, but is not addressed in full.) All controlled drugs must be
DS0000015890.V275590.R01.S.doc Timescale for action 31/03/06 2. OP3 14(1) 28/02/06 3. OP7 15(1)(2) 31/03/06 3. OP8 12(1)(a) 28/02/06 4. OP9 13(2) 31/01/06
Page 27 Avonmead Nursing Home Version 5.1 5. OP9 13(2) 6. OP9 13(2) 7. OP12 15(1)(2) 8. OP22 13(4)(c) 23(2)(n) 9. OP22 12(1)(a) 13(4)(c) stored in cupboards meeting the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973. Sufficient cupboards must be available to cover the needs of the home. Risk assessments for selfmedication must be regularly reviewed and accurately reflect current practice. Where two medicines containing Paracetamol are prescribed, the medication administration chart must contain clear guidelines for use to ensure that the resident does not receive an over-dose. All service users must have care plans in place which direct staff on actions to take to meet their social care needs. Senior staff must ensure that staff comply with care plans. (Identified at the follow-up inspection of 15/9/05. It has not been addressed and is therefore UN MET.) All service users who are assessed as having complex manual handling care needs must be cared for in a variable height bed. (A similar requirement was identified at the inspection of 21/7/06; it has been addressed in part, but not in full.) A regular audit of response times when call bells are used must take place and written evidence of this audit be available at inspection. If response times of over 3.5 minutes are identified, an action plan must be put in place to identify how response times are to be improved. (Identified as a recommendation at the inspection of 21/7/05.
DS0000015890.V275590.R01.S.doc 28/02/06 28/02/06 31/10/05 31/03/06 31/03/06 Avonmead Nursing Home Version 5.1 Page 28 10. OP26 13(3) 23(2)(d) 11. OP27 37(1)(e) 12. OP33 26(2)(3) (4)(5) 13. 14. 15. OP38 OP38 OP37 13(4)(a) (c) 13(4)(a) (c) 17(1)sch (3)(j) Direct evidence of concerns were identified at this inspection, so the matter has become a requirement.) Safe systems, which conform to principals of prevention of spread of infection, must be in place for all sanitary items, to ensure that they are clean, free of staining and debris. (Identified at the inspection of 21/7/05. It was not addressed until the third follow-up inspection of 22/11/05. It has again been identified as a requirement at this inspection.) The Commission must be informed on each and every occasion when the home is not able to comply with its minimum staffing levels as set out in their Staffing Notice, together with actions taken to minimise risk. (Identified at the follow-up inspection of 15/9/05. It had been met by the follow-up inspection of 22/11/05, but has again been identified at this inspection.) There must be written evidence that the home has been visited on a monthly basis by a representative of the proprietors and a written report of this visit produced. The home must ensure that unsafe toilet rails are taken out of use or promptly repaired. Oxygen cylinders must be fully secured at all times. Where service users exhibit bruising, this must always be documented in the service user’s records and the home’s accident book. (This requirement was identified at the follow-up
DS0000015890.V275590.R01.S.doc 28/02/06 31/01/06 31/03/06 31/01/06 31/01/06 30/11/05 Avonmead Nursing Home Version 5.1 Page 29 inspection of 22/11/05. It has not been addressed and is therefore UN MET.) 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 OP1 Good Practice Recommendations The home’s policy on escorting service users to outpatients appointments and other external appointments should be included in the service user’s guide. (Identified at the follow-up inspection of 15/9/05; it has not been addressed.) All admissions documents should be dated and signed by the person completing the assessment. Rooms where intermediate care residents are cared for should be distinguished from respite care rooms, or labelled with the individual’s name to prevent confusion to service users, their visitors and staff. A review of the intermediate care contract should take place, to ensure that service users have appropriate medical support. (Identified at the inspection of 21/7/05. Addressed in part.) Care plans for service users who need turning on a regular basis should specify exactly how often the service user’s position needs to be changed. All service users who are observed to sustain bruises should be assessed for risk and a care plan put in place to reduce risk of bruising. All care instructions placed in service users’ rooms should be dated and signed. Precise terminology should always be used when describing service users presenting care needs. (Identified at the follow-up inspection of 22/11/06. Some progress noted.) All persons who perform laundry when the laundress is absent, should be trained in the importance of returning residents’ personal items to them promptly. The activities coordinator should attend a course on activities provision.
DS0000015890.V275590.R01.S.doc Version 5.1 Page 30 2. 3. OP3 OP6 4. OP6 5. 6. 7. 8. OP8 OP8 OP8 OP8 9. 10. OP10 OP12 Avonmead Nursing Home 11. OP13 12. OP15 13. 14. OP19 OP21 15. OP26 16. 17. 18. OP27 OP29 OP30 19. 20. 21. OP30 OP36 OP38 (Identified at the inspection of 21/7/05. Not yet addressed.) The owners of the home should develop systems to ensure that service users can be taken out of the home on outings. (Identified at the inspection of 21/7/05. Some progress noted, but not addressed in full.) The sugar and carbohydrate content of manufactured foods should be assessed, to ensure that foods with a high sugar and carbohydrate content are not given to diabetic service users. (Identified at the inspection of 21/7/05. Not addressed.) The corridor carpets should be replaced. (Identified at the inspection of 21/7/05. Not addressed. Reported to be being considered.) The suitability of current bathing facilities for disabled service users should be considered and action plans put in place to meet the needs of such service users. (Identified at the inspection of 21/7/05. Not addressed. Reported to be being considered). The homes policy on staff uniforms should be reviewed, to ensure that it conforms to current Health Protection Agency guidelines. (Identified at the inspection of 21/7/05. Not addressed.) The staffing levels on the first floor should be reviewed. (Identified at the follow-up inspection of 22/11/05. Addressed in part.) All pre-employment information should be dated and signed by the person completing the information. Staff who have not worked in care previously and/or whose first language is not English, should work more than two days on a supernumerary basis, to ensure that they are fully inducted into their roles. All staff training profiles should be fully completed. A matrix for staff supervision should be developed, so that the home can demonstrate that all staff have received regular supervision. A matrix for statutory training should be developed so that the home can demonstrate that all staff have been regularly trained in all matters relating to health and safety. Avonmead Nursing Home DS0000015890.V275590.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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