Inspection on 19/06/06 for Avonmead Nursing Home

This inspection was carried out on 19th June 2006.

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

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

Other inspections for this house

Avonmead Nursing Home 24/03/09

Avonmead Nursing Home 14/05/07

Avonmead Nursing Home 16/01/06

Avonmead Nursing Home 21/07/05

Avonmead Nursing Home 02/02/05

Avonmead Nursing Home 19/08/04

Avonmead Nursing Home 04/02/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Avonmead Nursing Home 11 Canal Way Devizes Wiltshire SN10 2UB Lead Inspector Susie Stratton Key Unannounced Inspection 19th June 2006 9:30 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.V297212.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 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.V297212.R01.S.doc Version 5.2 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. 16th January 2006 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 a deputy manager and a senior sister. 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.V297212.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit of Avonmead took place on Monday 19th June between 9:30am and 4:15pm, in the presence of Mrs S Cottrell, registered manager and her deputy. The area manager for the home was present during the afternoon of the inspection. Two inspectors and a regulation manager undertook the inspection. The home has presented a range of issues since the last inspection on 16th January 2006 and a follow-up inspection took place on 23rd March 2006 and a random inspection on 24th March 2006. Following this, a meeting was held with the proprietors and it was decided that the managers should be informed of when the inspection was to take place and they were given five days notice of this site visit. During the inspection, the inspectors met with nearly all the service users and observed care for service users who were not able to communicate. Inspectors also received comments from service users, some of their relatives, GPs and social workers. During the inspection, the inspectors reviewed care relating to eight service users in detail, including a review of their records. They also performed a tour of the building and met with staff, including nursing and care staff and the activities coordinator, a domestic, the chef, the laundress and the administrator. Medicines records and storage systems were reviewed. The inspectors reviewed employment records relating to four members of staff and training records. A second site visit was performed on 14th July 2006, between 10:00 and 12:00, to discuss areas outlined on the site visit and to receive managers’ verbal action plans and progress reports. The judgements contained in this report have been made from evidence gathered during the inspection, which included visits to the service and takes into account the views and experiences of people using the service. What the service does well: Avonmead is a purpose-built home, built on its own site, in the midst of a residential area in the market town of Devizes. As part of the site backs on to the Kennet and Avon canal and the rest is off a small residential street, the site is a quiet and peaceful area for service users to enjoy. As there is ample parking on site, it is easy for visitors to come to the home. Some of the staff have worked in the home for several years and know the homes systems and each other well. Service users commented on the staff, one described the activities coordinator as “marvellous”, one person described the deputy manager as “very good”, and another said “she’s lovely”. One service user described staff as “excellent” Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 6 and said “I can have a good laugh with them”, another service user said that “You couldn’t meet a nicer person” about the staff member who had cared for them that morning. One person said that it was “very nice here” about the home. What has improved since the last inspection? What they could do better: At this inspection, 19 requirements and 22 good practice recommendations were identified. The home needs to continue to develop their approach to care planning, especially in relation to management of continence, consistency between different care plans and assessments and care plans for service users who spend most of their time in bed. All care plans must be regularly evaluated and up-dated when needed. Service users dignity must be protected by ensuring that they are in a clean state at all times and wearing appropriate Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 7 clothing. Service users’ needs for privacy should be considered when notifying staff of outbreaks of infections. The home needs to evidence how choice is offered to service users. Medicines administration records must always be completed at the time of administration. There must be full records where a service user is regularly administered medication by injection. Systems must be in place to ensure that limited life medication is not used after it should be disposed of. Medicines records should be further developed with records for signatures and signing of instructions and records of actual amounts of medication administered. Activities programmes need to be developed for service users who do not leave their rooms. The activities coordinator should be supported in attending a course to develop her understanding of her role. Information about systems for taking service users out of the home should be made more available. A survey of service users opinions about meals needs to be progressed, following responses about meals to the Commission. The home needs to ensure that all service users who are assessed as requiring a particular diet in relation to a medical need receive this diet. Stained jugs in the kitchen should be replaced and the programme for deep cleaning of the kitchen should be reviewed. The home’s response to verbal complaints continues to need to be developed. Where a restraint is in place for a service user, there must be regular assessments of the need for this restraint. Al staff who have service user contact need to be trained in awareness of abuse. The Commission must be informed of when the assisted bath on the first floor will be available for use again. Old and thin bed linen need to be replaced. All service users must be left with access to their call bells at all times. An audit of bed safety rails and protectors is needed to ensure that the correct protectors are in place on safety rails. The corridor and communal area carpets should be replaced. Cleaning schedules must be further developed to ensure standards of cleanliness in all areas of the home. The home should consider the provision of disabled showers for service users. The home must be able to evidence that all staff have received statutory and other training to meet service users’ needs. As Avonmead is a nursing home, systems for clinical supervision are needed. The home should ensure that all required records relating to service users are in place. Garden areas should be made more secure to ensure the safety of service users. Persons responsible for maintenance should receive training in health and safety so that they are aware of risks to service users from the home environment. 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.V297212.R01.S.doc Version 5.2 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 Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 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): 1 & 3: 6 - the intermediate care contract is being ceased by the purchaser. Processes are being developed to inform service users and their representatives about the services offered by the home. All service users have a pre-admission assessment performed. Quality on this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: The home now provide a copy of the service users’ guide in the entrance hall, the lounges and a copy has been given to each service user. The guide is in the process of being up-dated, to include a copy of the most recent inspection report. Two of the relatives who contacted the Commission stated that they had looked at the Guide, including the inspection report in the entrance hall. Only two of the six service users who responded to the questionnaire reported that they had been given enough information about the service prior to admission, however this is likely to relate to the previous situation, before the home distributed the Guide more widely. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 10 Four Seasons Healthcare has a standard admission assessment tool, which a representative of the home uses when they assess a prospective service users’ needs. These assessments continue to improve. For example one service user’s dietary preferences were clearly documented. It is anticipated that assessments will further improve in the future, now that the manager has returned from a period of sick leave, freeing up registered nurses to perform such assessments. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 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, 9 & 10 The home has a system in place, which aims to meet the nursing and care needs of service users. Improvements have been made in these systems in some areas but there needs to be continuing emphasis on consistency in planning and development of care plans, especially in the management of continence and service users who are cared for mainly in bed. Medicines are safely stored, but action is needed in certain areas of documentation, to ensure that the home can evidence that safe systems are in place. Service users’ dignity needs would be supported by an improved emphasis on meeting their individual personal needs, particularly in relation to hygiene. Quality on this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: The home has put much work into improving care planning during the past year, through monitoring by managers, providing training for staff and piloting and introducing changed documentation. The inspectors met with a range of service users during the inspection, some of whom had complex needs and others of whom were more able and could comment on the care provided to them. Responses were also sought from service users’ relatives and GPs. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 12 Some care plans were very clear and reflected in full what service users and staff told the inspector. Where service users are assessed as being at risk of pressure damage, there are care plans in place to direct staff on how risk is to be reduced. Service users with manual handling needs have assessments and care plans in place to direct staff on how needs are to be met. One service user had two clear care plans relating to management of their diabetic condition. Where service users have wounds, there are clear care plans and monitoring systems for management of their wounds. The home uses an approach of generating a wide range of care plans. For example one service user had two care plans relating to one particular need and reference to this need was also made in a night care plan. Staff report that they find this approach useful in ensuring that all care needs are met. Where staff are using this approach, they need to ensure that full crossreferencing takes place. In the example quoted above, the night care plan did not reflect what was documented in one of the other care plans and a review of the individual’s daily record indicated that the night staff had not followed the specific directions in one of the care plans. Another service user had a care plan relating to their lack of appetite, there were details of what they liked to eat in their admissions assessment, however no reference had been made to this in their care plan, to support the service user in taking in an improved diet. While care plans are improving, the home needs to continue to develop precision when documenting care needs. One service user had a care plan relating to their bowels but they did not have any statement about their normal bowel habit, which is needed as people may vary greatly in this respect. Another care plan documented that a service user’s blood pressure needed to be maintained at normal levels, without stating what their GP considered to be normal for that individual. Another said that complications of their condition needed to be prevented, without documenting what the complications were. Following the setting of requirements at previous inspections, the home has introduced continence assessments for service users, however many service users who are assessed as having continence needs continue not to have care plans in place. Where care plans were in place, they did not reflect what was documented in their assessments. As issues relating to continence can be common in the elderly, development of improved responses towards the management of continence issues continue to need to be addressed. Following the setting of requirements, some care plans had been regularly evaluated and up-dated when indicated, however some continue not to be evaluated regularly, for example one service user’s medical condition, as documented in their care plan, was clearly changing, however their care plan had not been up-dated since May to reflect this. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 13 Both inspectors noted that several service users spent all or most of their time in bed. At lunch-time, ten service users ate or were given their meals in bed. One service user said that they did not wish to do this and did not know why they stayed in bed all the time. Service users care records also did not indicate why they remained in bed. The managers reported that they were aware of the situation and had it under review. For some of the service users, they were awaiting delivery of specialist chairs, so that they can be assisted to get up when they wanted to. At the follow-up site visit of 14th July 2006, this matter was discussed again and the managers reported that they had reviewed the needs of several service users who stayed in bed and were developing action plans to support some service users in getting out of bed. The managers reported that not all service users who stayed in bed had been reviewed as yet, as this needed to be done individually. The home have a past issue relating to ensuring that service users who are frail have their positions changed regularly and fluids provided to them. A new frequent care chart has been introduced and was commenced on the day of the inspection. All charts had been completed in full, however as past records could not be reviewed, compliance in this area will need to be reviewed in the future. All care was given behind closed doors and staff were observed to knock on bedroom doors prior to entry. As noted in the previous two inspections, not all service users were noted to be in a clean state, several had dirty fingernails and needed attention to their footcare. One service user had odorous feet with flaky skin, another had swollen ankles with flaking skin. Some of this may relate to the fact that one of the baths was reported not to be usable and that no service users had been given a bath for a period of time, although it was reported that they were all given a general wash every day. One service user had a continence pad in place with no underwear to maintain it in position, so it would be easily dislodged. This was discussed at the follow-up site visit and alternative systems for managing service users needs with specific needs was discussed. They were also advised that such matters should be documented. Another service user reported that they were not routinely offered the toilet and had been advised to use their pad for toileting. On one floor of the home, there were notices on some bedroom doors and areas advising on the use of protective aids, despite an outbreak of infection being resolved several weeks previously. One service user was cold to touch when visited and had their window open. The inspector found a carer who closed the window and got another blanket. This was despite this service users condition being monitored by a frequent care chart. Records indicated that they had been given care regularly during the morning. A GP was visiting on the day of the inspection, having been called in urgently to review one service user. Another service user’s records provided evidence of regularly communications with their GP. Three GPs who responded to the Commission stated that they considered that the home managed the care of Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 14 their patients well. One relative commented on how the home called in a GP to their relative when needed, however another said that they had to remind the home about healthcare appointments. Records provided evidence of regular contacts with the local tissue viability nurse. The home have changed their pharmacy supplier recently and some areas are under discussion with the new pharmacist. These relate to certain drugs which are needed in emergency, which were held in the home’s refrigerator but were not on the service user’s MAR chart and an unsafe system for storage of drugs to be sent for disposal. Some medication administration records had not been completed, this is required because if such records are not completed the home cannot evidence that drugs have been given to service users. To prevent risk to service users from the over-use of the same injection site, where service users are prescribed drugs which need regular administration of a medication by injection, a record of the site rotation needs to be maintained. On one floor of the home, limited life medication was not dated when it was opened, as is required to prevent use of the medication after its expiry. More consistency is needed in approach when a service user is prescribed one or two of a medication. On four MAR sheets, the amount given was documented, but not on two other sheets. Where additional handwritten instructions on the administration of medication have been added to a MAR sheet, they should always be signed and countersigned. On five occasions out of twelve, this had not taken place. The folder for medicines charts did not include a sample signature sheet for all persons who give out medicines, this had been addressed by the second site visit. The folder also did not include the home’s policy on actions to take in the event of a maladministration of medicines, this had also been addressed by the second site visit. All medicines were safely and securely stored. The temperature of the medicines fridge was regularly monitored. A new controlled drugs cupboard had been installed and all controlled drugs were correctly stored and documented. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 The home aims to provide activities for service users. Areas relating to provision of activities to people who do not or are unable to leave their rooms needs to be further developed. Documentation to evidence activities provision needs further development. Service users are able to maintain contact with family and friends. Service users are able to exercise choice in some areas of their daily lives. There was a range of opinions expressed about the meals, varying from good to poor. Service users with medical conditions could be put at risk by the chef not being informed of their documented dietary needs. Quality on this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: The home employs an activities coordinator, she is positive about her role. Of the six service users who responded to the questionnaire, three said they always and three, usually found there were activities arranged by the home that they could take part in. One service user did comment that the member of staff in charge of activities has to work as a carer. Some activities were observed taking place in the communal lounge in the afternoon. During the morning, the activities coordinator gives out the morning coffees and chats to service users in their rooms while doing this. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 16 There was evidence that service users who are unable or unwilling to leave their rooms have a 1:1 with the activities coordinator only about one a month. This is unlikely to be sufficient to meet their needs. By the second site visit, the activities coordinator’s role and duties had been reviewed to start developing systems to meet the needs of such service users. Documentation to support these changes were yet to be developed. All service users have activities care plans in place, several of these had not been reviewed recently. The activities coordinator reported that these had recently been delegated to her. She may need more support in understanding how to review and draw up revised care plans. The activities coordinator is to receive training in her role during the Autumn, this has been advised for the past two inspections. Service users reported that their visitors could come when they wanted. Relatives who contacted the Commission supported this and one said how good the staff in the home were in contacting them about matters affecting their relative. One service user said that they went out regularly with their family. One service user said in their comment card that they would like to be taken out of the home into the town. At the second site visit, the manager outlined the systems that are in place to support service users in going out of the home. It was advised that a range of options, such as an activities newsletter and information in the service users’ guide be used to inform service users and their relatives of how the home supported service users in going out of the home. Service users gave a wide range of opinions about their ability to choose how they spent their days. One service user said that they liked to get up early every morning and that the night staff helped them to do so. Other service users said that they preferred not to go to the sitting room and that this was respected by staff. Service users said they could choose their meals. Other service users were not so positive. One service user said they had to wait to get up until 12 noon. One relative said that their relative had to wait until dinner-time to get up. Another, as noted in standard 2 above, said that they would like to get up but that they had to stay in bed and they did not know why this was. Service users on the first floor reported that they had not been given the option of having a bath on the ground floor, while the first floor assisted bath was out of use. There was also a wide range of opinion stated by service users and their representatives about the meals provided in the home. Comments varied from “very good”, “pretty good”, through to “emphasis here on quantity rather than quality”, “not brilliant”, “not something I’d enthuse about” to “Mostly the meals are very poor” and “I do not like the food”. One diabetic service user reported that family members bring in snacks for them to eat, to assist them in managing their diabetic care as these were not provided by the kitchen. Meals can be taken in one of two dining rooms on each floor of the home. In practice Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 17 most service users tend to eat on their own in their rooms on trays. A choice of fluids is offered to service users at mealtimes. Issues relating to attitudes towards the meals provided were discussed at the second follow-up visit and a range of methods of seeking views and presenting of information to service users was discussed. These are to be put forward by the managers of the home. The chef reported that she had food handling qualifications but no other formal cooking qualifications and has learnt her role by experience. She reported she had all the equipment needed to perform her role. Some of the plastic jugs used for gravy and custard showed considerable staining, which the chef said could not be removed, despite frequent cleaning. These will need to be replaced. The providers have a set menu for the chef to cook to, although she can vary this, depending on service users likes and her own experience of what service users will eat. The chef was aware of the needs of diabetic service users and service users who needed a soft or liquidised diet. The names of such service users are listed on a board in the kitchen, so that all her staff are aware. She reported that she is to be provided with a new blender, so that she can improve the quality of such meals. Two of the service users met with were documented as needing a low fat, low salt diet to meet a medical need. The chef did not know about these service users and their names were not listed as needing such diets on the information board in the kitchen. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home is continuing to extend and develop its approach to complaints and needs to improve awareness of apparently small but to service users, significant matters. Senior staff showed an awareness of working within local vulnerable adults procedures. Not all staff who have service user contact have received training in abuse awareness. Service users who have lap belts in place should have regular evaluations of their need for this form of restraint. Quality on this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: The home has developed its approach to complaints since the last unannounced inspection. A complaints monitoring book has been set up and for recent complaints, outcomes from complaint investigations have been documented, so the home is continuing to develop their approach in this area. One relative informed the Commission that in the past they had written a letter of complaint about a matter, that they had received an acknowledgement, but no further response from the home about any investigation. This may relate to the previous situation. Several service users raised concerns about the food in questionnaires and responses, such as that “the tea is always cold” or that the “meat is tough”. Four concerns relating to responses to the call bell and five comments about lack of staff were also raised. The number of such issues raised was fewer than at previous inspections, however the home needs to continue to develop its approach in this area, to ensure that managers are informed of such concerns raised by service users and their representatives. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 19 The deputy manager, who was acting up for the manager during a period of sick leave, has worked closely with different local vulnerable adults authorities during the past few months. She has been supported by senior managers from the parent company. While it is clear that some staff have been trained in vulnerable adults procedures, it is also clear from the home’s records that not all staff have been trained. The chef has contact with service users but neither she, nor her staff, have been trained in vulnerable adults procedures. All staff with service user contact need to be trained in abuse awareness so as to protect vulnerable persons they have contact with. This was discussed at the second site visit and the managers agreed to progress systems for ensuring that all staff are trained and developed in abuse awareness on a regular basis. Two service users were observed to have lap belts in place when they were sitting in their chairs. Lap belts are regarded as a form of restraint, as they can prevent a person from moving when they want to. They must only be used if their use is needed to ensure a person’s safety. One service user said that they did not know why they had their belt on and that they could not take it off themselves. Both service users notes showed that they had had a past history of falling, and their lap belt was documented in their records. For one service user this documentation related to February 06 and had not been reviewed since. The other service user had not had their need for a lap belt reviewed since their admission. Neither service users records showed that they had fallen in the past few months. The need for these types of restraint therefore needs urgent review. All service users who had safety rails in place had risk assessments in their care plans relating to this. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22 & 26 Parts of the environment of the home are well maintained, although the home would benefit from new carpeting in some communal areas. A range of communal areas are available to service users. Due to temporary difficulties experienced by the home, for a period there was in effect, only one usable bath for service users. Equipment is provided or on order for service users assessed as needing it, however some attention needs to be paid to its use or function in certain areas. Some service users could be put at risk by not being left with access to their call bell. The home has systems to prevent spread of infection. Issues relating to appropriate cleaning may reduce the effect of these systems. Quality on this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: Areas of Avonmead were being maintained at the time of the inspection and external contractors were re-painting the windows on the outside of the building. The dining room on the ground floor showed signs of recent reAvonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 21 painting and parts of the carpet had drops of paint visible on it. The corridor and communal carpets are all old and many are stained, which much detracts from the atmosphere in the building. At the second site visit, it was reported that new carpets had been chosen and were on order. There is a garden area at the back of the building, with a small covered patio, which the activities coordinator reported that service users sit out in nice weather. One service user said that they had sat out several times during the hot weather and had enjoyed it. There is a paved path running from the paved area, round the back of both sides of the building. Avonmead has a sitting and dining room on the ground floor and a sitting/dining room on the first floor. A quiet lounge is also provided on the first floor. All rooms are ensuite and there is a communal wc close to the sitting room on the ground floor. There are two baths on each floor, however in practice, only one of these is used, as one of the baths on each floor is low and it is complex to bath frail, physically disabled persons in such baths. The managers report that they have put in an order for a wet room for one of these bathrooms. There is a Parker bath on the ground floor. The mercury in the bath thermometer in this room was broken, so the temperature of the bath water could not be properly assessed. This bath was dry and had not been used on the morning of the inspection. By the second site visit, the thermometer had been replaced. A new bath had been installed in the first floor bathroom, however as noted in standard 2 above, there had been problems with its installation and the home were awaiting contractors to rectify the situation. This meant that at the time of the first site visit, no service users on the first floor had had a bath for some period of time and that there was in effect only one usable bath in the building. This had been addressed by the second site visit and alternative arrangements made for bathing some of the service users on the first floor. The home have been supplying more equipment to meet the needs of service users. An assessment of need for variable height beds and recliner chairs has taken place. Some equipment has been delivered and the home are awaiting delivery of other equipment. A range of pressure relieving equipment is provided to service users assessed as being at risk of pressure damage. In parts of the home, the bed sheets were observed to be very thin and needing replacement. By the second site visit, there was evidence that an audit of bed sheets had taken place and an order was to be placed for new bed linen. Some bed safety rail protectors were not the correct size for the safety rails, some were too long and some were too short for the rail. Safety rail protectors need to be the correct type and size for the rail, to ensure service users, staff and visitors’ safety. The home needs to perform an audit safety rails and protectors to ensure that the correct equipment is in place. By the second site visit, the manager reported that they had swapped some protectors with others and that further protectors were on order. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 22 The home has one washer disinfector on the first floor of the home. This washer disinfector is new. There are three other sluice rooms in the home. All four sluice rooms have all equipment, such as disposable gloves and aprons provided. All clinical waste was disposed of in foot pedal operated bins. A recent outbreak of an infectious condition was dealt with within local guidelines. The home showed an awareness of current infection control guidelines and were also aware of the new guidelines from the Department of Health, which were issued in June 2006 and the parent company are reviewing areas relating to this to ensure compliance. A range of service users and their representatives reported that they found that staff did not respond promptly when they used their call bell. A new monitoring system for response times when the staff call system has been recently installed. A review of print-outs documenting time of response when the call bell is used, indicate that staff are responding promptly when call bells are used. It was observed during the inspection that six persons had not been left with their call bell within reach. One service user’s representative reported that they had had to talk to staff about the need for this. All six service users said that they could use their call bell if it was within reach but could not reach it themselves if it was not close by. This is of concern, as frail persons who are not able to assist themselves always need to have their call bell within reach, to ensure that they can call staff when needed. Of the six service users who responded to the questionnaire, two said the home was always clean, three, usually and two, sometimes. One service user said that staff always came and cleaned their commode chair every evening. Several service users and their relatives commented that the home could at times show an odour. Odour has been reported during previous inspections. One relative described the odour as “dreadful”, particularly upstairs. One said that they thought the corridor carpets should be shampooed more often. Another said that if wet bed sheets were left in trolleys in the corridor for periods of time, that this made the area odorous. Several of these comments related to the weekends. Discussions with the domestic indicated that there was a lower domestic cover at the weekend. It was also reported that where service users remained in bed that their carpets were not cleaned and some of these carpets clearly needed cleaning. One room showed visible debris under both service users’ beds. All commodes, raised toilet seats and safety rails were clean. There did not appear to be a system for cleaning wheelchairs and some of them were not clean. Some of the hoist slings were also not clean and several were odorous. Such items need to be regularly cleaned and laundered, to prevent risk of cross infection. This matter was discussed on the second site visit and evidence was available to show that an audit system to ensure that all wheelchairs and slings were regularly cleaned, had been put in place. Systems for reviewing of cleaning roles and performance was discussed and the managers agreed to develop this area to improve systems for ensuring cleanliness in the home and to review with service users and their relatives areas of concern relating to cleanliness. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Avonmead is staffing the home in accordance with a Notice set out by the Commission. The managers of the home state that they are appropriately staffed, this view is not supported by all service users. Training is reported to be supported, however as the records of training need development, as this is not be supported by records. Service users are protected by a safe recruitment system for new staff. Quality on this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. 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 compliance with this Notice had improved since the last inspection. On the day of the inspection, one of the registered nurses was off sick, but the home had managed to cover for this absence. The registered nurse on the ground floor had newly started working in the home and was being supported by the deputy manager. Responses from service users and their representatives indicated that they felt that there were not enough staff on duty at all times. Comments such as “not enough staff” or “not enough people on the floor” were made. One person felt that there was a high turnover in staff. This perception from service users and their representatives has been raised with managers during the course of more than one meeting and the managers have responded that according to their Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 24 assessments, there are enough staff on duty to meet the needs of service users. The pre-inspection information indicated that only four care staff have been trained to NVQ 2 or equivalent, however there was also evidence that some staff additionally have a range of qualifications from their own countries. If these people are taken into account, 44 care staff are trained to NVQ2 or equivalent. All staff have individual training records, however it was reported that these are not currently up to date as the deputy manager has been acting into the manager’s role during a period when she was off sick. It was recommended during the inspection of July 2005 that action be taken to develop staff training records. As several issues relating to care have been observed, the company must now begin to show progress in this area. It was reported that the deputy manager is to take on responsibility for this area, to develop the home’s approach to supporting staff through both statutory training and training to meet service users’ needs. At the second site meeting, it was reported that the home supports training and of the systems that are planned to evidence the training. The files of a range of newly employed staff were reviewed during the inspection. All included an application form/cv, proof of identity, two references and health status questionnaire. Pova and CRB checks are in place. One newly employed registered nurse reported that they felt supported and were gradually being introduced into their role. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 The manager has only just returned, following an extended period of sick leave, so the standard cannot be fully assessed. Systems for assessments of quality are in place, however they are being further developed by the Commission and so cannot be fully assessed. Service users’ financial interests are protected. As Avomead is a nursing home, systems for clinical supervision need to be developed. There are systems in place to ensure health and safety, however appropriate training for staff cannot be evidenced and some practice indicates that developments are needed, to ensure the safety of service users. Quality on this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: The manager only returned to duty in the home only three days prior to the inspection, following an extended period of sick leave, therefore it is complex Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 26 to fully assess this standard. During her absence one of the senior sisters acted into the role. She has now been appointed as the manager’s deputy. Avonmead is visited regularly by a representative of the company and a report made. A copy of this report is submitted to the Commission. The managers report that the company has its own methods of assessing quality. The Commission is due to require all providers to perform certain quality audits and will be issuing them during the Autumn of 2006, so full assessment of this standard will take place after this has occurred. The home employs an administrator, who knows her role and is organised. As part of her role, she takes care of service users’ personal moneys and has effective systems in place. These are audited by the regional administrator regularly. Supervision records were not reviewed, as the home manager has been away on sick leave and she will need time on her return to review the situation. As this home is a nursing home, clinical supervision is also an issue. During the inspection, it was observed that the registered nurse on one floor worked in the office for most of the time. At least six service users on this floor had high dependency needs but it was not clear from observation as to how the registered nurse was directing and supervising care staff on care provision to these service users. As documented in standard 10 above signs relating to an outbreak of an infectious disease were still on display, despite the outbreak being resolved a period ago. It would be expected that the registered nurse would have instructed staff to remove such signs, once the situation was resolved. On the other floor a new registered nurse was being supervised by a senior registered nurse and was observed to spend much of their time managing and supervising the care of an unwell service user. This was discussed at the follow-up site visit and the deputy manager reported on the steps she had already taken to address this matter. The home will need to develop evidence to show how clinical supervision for all staff is planned and managed. The home maintains a range of records as required by regulation such as a record of visitors to the home, staff rosters and staff recruitment records. As part of the information required during the key inspection, information about service users was requested, but the home were not able to supply all information required for all service users, including for some service users, the address of their next of kin, the address of their GP and address and telephone number of their social worker. At the follow-up site visit, it was agreed that such information held by the home will be reviewed and that they will ensure that all required information is in place. As noted in standard 29 above, while the home does keep individual records of staff training, these records are reported not to be up-to-date, so management cannot review who has been trained in statutory areas, such as manual Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 27 handling and infection control. A lack of systems to evidence that staff have been trained in such statutory areas was identified during the inspection of July 2005. It was reported that the deputy manager is to develop this area, to ensure that all staff have been trained regularly as required. The home has recently been inspected by the fire officer, who has reported that enforcement Notices issued during the previous year have now been complied with. It was stated that the company have systems in place to ensure that all parts of the home and equipment such as hoists, are regularly maintained. The chef was not aware of the last date of a deep clean for the kitchen areas and it is much to the credit of catering staff, that all used areas of the kitchen were clean, although some staining was beginning to be visible on the upper part of the walls and ceiling. At the second site visit, it was reported that there were systems in place and that performing of such duties will be reviewed as part of the review of systems for cleaning detailed in Standard 26 above. As noted in standard 20 above, the garden has paths running behind the building. Both paths end in a gate, both of which have easy to open latches and one of which had been left open by the painting contractors on the first site visit. As the home have at times cared for service users with dual physical and mental health care needs, who would be unaware of the risks of wandering unsupported outside the building, they should ensure that more secure latches are provided on external gates and that they must ensure they are never left open. There is an open shed by one of the exit gates and on the first site visit, this showed several pots of paint, at least three of which had been left open. Next to this is a shed with a door which can be locked, but the paint had not been left securely in the shed. These could also present a risk to frail service users and any such hazardous substances must always be stored securely. By the second site visit, this had been addressed. However at this visit, it was noted at 10:00am that a pile of old mattresses had been left at the side of the building, partially obscuring a fire exit. These had been removed by 12:00. This indicates that staff responsible for maintenance may need training in their responsibilities for ensuring the safety of service users within the home environment. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 2 2 x x x 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 2 2 2 Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 29 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 OP8 Regulation 12(1a) Requirement 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. Records must be completed accurately and contemporaneously. (Identified in inspections since 21/7/05. Compliance with this requirement could not be confirmed as met at this inspection, due to introduction of new documentation.) 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, reviewed during following inspections. Shows progress at this inspection. Not yet met IN FULL.) Where a service user is at risk of incontinence, an assessment must be carried out in every case and a care plan drawn up. There must be evidence to show DS0000015890.V297212.R01.S.doc Timescale for action 15/07/06 2. OP7 15(1,2) 15/07/06 3. OP8 14(1a) 15(1) 15/07/06 Avonmead Nursing Home Version 5.2 Page 30 4. OP7 5. OP10 6. OP7 7. OP7 8. 9. OP9 OP9 10. 11. OP9 OP10 that the service users’ needs, as detailed in the care plan are being met. (Requirement identified at the inspection of 21/03/06 some progress noted but Not addressed IN FULL.) 15(2bc) All care plans, including activities care plans, must be regularly evaluated and up-dated when the service users’ condition changes. (Requirement addressed not yet met IN FULL.) 12(1a)13( All service users must be in a 3) clean state. (A similar requirement was identified at the past two inspections. Has not yet been addressed IN FULL.) 15(1,2) Where a service user has more than one care plan or assessment relating to a similar care need, there must either be full cross-referencing between the two plans or a single care plan must be drawn up, to direct staff. 14(2ab)15 The home must review why (1) certain identified service users are cared for in bed most of the time, with full assessments as to why this is needed for the service user. Where indicated, care plans must be put in place to assist such service users to increase their time out of bed. 13(2) All MAR records must be fully completed at the time the drug is administered. 13(2) Where a drug needs to be given regularly by injection, there must be written evidence of rotation of the injection site. 13(2) All limited life medicines must be dated when they are commenced. 12(4,a) Service users using continence DS0000015890.V297212.R01.S.doc 15/07/06 15/07/06 31/08/06 31/08/06 31/07/06 31/07/06 31/07/06 31/07/06 Page 31 Avonmead Nursing Home Version 5.2 12. OP12 12(2m) 13. OP15 12(2i) 14. 15. OP18 OP18 13(6) 13(7,8) 16. OP21 23(2j) 17. 18. 19. OP22 OP22 OP22 16(2c) 13(4a,c) 13(4,a,b,c ) 20. OP26 13(3)23(2 d) aids must always be provided with appropriate underwear, to ensure their dignity or document in their care plan why this is. Activities programmes must be developed for service users who are unable or unwilling to leave their rooms and full records maintained. The all relevant staff, including catering staff must be informed of all special diets assessed as being needed for service users and ensure that they receive this diet, in accordance with advice from relevant professionals. All staff who have service user contact must be trained regularly in abuse awareness. Where a restraint is used for a service user, the need for use of this restraint must be regularly evaluated and its use discontinued as soon as it is no longer indicated. The provider must inform the Commission of when the disabled bath on the first floor will be available for service user use. Old and thin items of bed linen must be disposed of and replaced. All service users must be left with access to their call bells at all times. An audit of bed safety rails and protectors must take place and the home must ensure that protectors, which fit with safety rails, are in used. Cleaning systems and working practice in the home must be reviewed, to ensure that concerns relating to reports of odour are addressed and that the carpets of service users who remain in bed or do not leave DS0000015890.V297212.R01.S.doc 31/08/06 31/07/06 31/12/06 31/07/06 31/07/06 30/09/06 31/07/06 31/07/06 31/08/06 Avonmead Nursing Home Version 5.2 Page 32 21. OP30 18(1c(i) 22. OP36 18(2) their rooms, are cleaned regularly. The home must be able to fully evidence that all staff are trained and competent to perform their roles and receive statutory training at the frequency required. The home must develop a system to ensure that clinical supervision is taking place, to ensure that staff caring for service users with nursing needs are fully supervised in their roles at all times. 31/12/06 31/08/06 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 OP12 Good Practice Recommendations The activities coordinator should attend a course on activities provision and be supported in developing her understanding of her role. (First identified at the inspection of 21/7/05. In progress.) The corridor, sitting and dining room carpets should be replaced. (Identified at the inspection of 21/7/05. In progress.) A matrix for staff supervision should be developed, so that the home can demonstrate that all staff have received regular supervision. (Not reviewed at this inspection). The home should ensure that all care plans use precise, measurable wording. (This matter has been identified for the past three inspections.) Systems within the home for taking service users out on the home should be included in the service users’ guide. All hand-written changes to medicines administration DS0000015890.V297212.R01.S.doc Version 5.2 Page 33 2. OP19 3. OP36 4. OP7 5. 6. OP1 OP9 Avonmead Nursing Home 7. 8. 9. 10. 11. 12. 13. OP9 OP10 OP14 OP15 OP15 OP16 OP21 14. OP26 15. 16. 17. 18. 19. OP28 OP37 OP38 OP38 OP38 instructions should be signed and countersigned on every occasion. Where service users are prescribed a variable dose of medication, the actual amount administered should be documented on every occasion. The home should review its procedure for notifying staff of infection, to ensure that service users’ privacy is maintained. The home should be able to evidence how choice is given to service users. The home should perform a review of service users & their representatives’ opinions about the food, to identify issues and develop action plans where indicated. The old, stained plastic jugs in the kitchen used for gravy and custard should be replaced. The system for reporting of verbal concerns must continue to be developed. Consideration should be given to the provision of showers to meet the needs of disabled persons, in the two smaller bathrooms. (Recommended at previous inspections, in progress.) The home should perform a review of service users & their representatives’ opinions about cleanliness and odour in the home, to identify issues and develop action plans where indicated. Care staff should be supported and encouraged to undertake NVQ training. The home should survey records to ensure that all records relating to service users’ next of kin, GPs and social workers are in place. Arrangements should be made for the regular deep cleaning of the kitchen, before stained areas begin to deteriorate. More secure latching systems should be provided to the two garden gates to the home, to prevent frail persons from exiting by them. All staff responsible for maintenance should be trained in ensuring that the principals of health and safety are in place across all the home environment. Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 34 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 © 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 Avonmead Nursing Home DS0000015890.V297212.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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