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Inspection on 05/03/09 for Beech Spinney

Also see our care home review for Beech Spinney for more information

This inspection was carried out on 5th March 2009.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Inspecting for better lives Random inspection report Care homes for adults (18-65 years) Name: Address: Beech Spinney Beech Spinney Ironbridge Telford Shropshire TF8 7NE one star adequate service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Deborah Sharman Date: 0 5 0 3 2 0 0 9 Information about the care home Name of care home: Address: Beech Spinney Beech Spinney Ironbridge Telford Shropshire TF8 7NE 01952432065 01952432209 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Self Unlimited care home 7 Number of places (if applicable): Under 65 Over 65 0 learning disability Conditions of registration: 7 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) 7 The maximum number of service users who can be accommodated is: 7 Date of last inspection Brief description of the care home Beech Spinney is managed by Cottage and Rural Enterprises Ironbridge. The responsible individual is Mr Erik Whitehouse. The Registered Managers post is vacant and is being covered by an acting manager. Beech Spinney is registered with the Commission for Social Care Inspection as a residential Care Home for a maximum of seven adults with learning disabilities and additional complex needs. The registration consists of a five single bedroom permanent Care Homes for Adults (18-65 years) Page 2 of 14 Brief description of the care home home known as Honeysuckle House and an adjoining two-bedroom respite facility. The respite home (Thistle Lodge) has a dedicated staff team and runs independently from Honeysuckle House. All bedrooms have spacious en suite bathrooms and have access (via a tracking hoist if required) to large assisted bathing and showering facilities. Communal space at Honeysuckle House comprises of a large kitchen, dining room and lounge. The gardens are landscaped and easily accessible. Beech Spinney also has use of a resource centre that boasts an indoor pool and a fully equipped sensory room. We did not ask about fees at this random inspection and enquiries about fees should be directed to the service. Care Homes for Adults (18-65 years) Page 3 of 14 What we found: This inspection was a random inspection carried out on 5th March 2009 from 9.30am to 7.30pm. The purpose of a random inspection is to focus on particular aspects of the service, not all key National Minimum Standards as in a key inspection. At the last key inspection in July 2008 we recognised that the service was improving and judged it as providing an adequate service overall. However the service still needed to take steps to improve matters related to how it moved and handled people to reduce risk and the number of injuries. It also needed to continue to improve how it manages medication. To ensure such improvements, the last inspection report outlined two requirements, one for moving and handling and the other for medication. The purpose of this inspection was to assess to what extent these requirements for improvement had been met. We therefore did not plan to assess most of the recommendations made at the last inspection. They have not been carried forward into this report, but progress towards them will be assessed at the next key inspection. Prior to inspection we planned what we were going to do by looking at information we know about the service using previous inspection reports, the services written improvement plan and the Annual Quality Assurance Assessment or AQAA submitted by the service to us prior to inspection in February 2009. The AQAA is a legal self assessment document submitted by the service annually. It outlines what they think they do well, what has improved and what they still need to improve as well as how they are going to make these improvements. On the day of inspection we talked to the registered manager who although on leave when we arrived, came in later. She was able to answer questions, supply documentation and support the inspection process. Four of her senior staff were also involved for varying periods of the inspection and supported the process in the same way by answering questions and providing documentation. We met people who live at Beech Spinney who are not able to answer questions as a consequence of their disabilities. However we could see how they were being cared for by staff. We spoke to two new support staff and also spoke to a further three staff members individually to assess their knowledge of peoples needs relating to moving and handling or medication. In addition we looked at training records, care plans, medication records and accident records. We followed up some recorded accidents by looking at the environment and facilities where these accidents happened. We can see that the number of moving and handling incidents has decreased. Perusal of accident records and talking to managers confirmed that there have not been any moving and handling accidents to either the people living or working at Beech Spinney since we last inspected in July 2008. Since the last inspection, there have been two admissions to Accident and Emergency. One of these, where an injury was sustained was investigated under Safeguarding procedures by multi agency partners as a possible moving and handling injury. The conclusion was that there had not been a moving and handling accident or injury. We talked to a staff member who could describe how the injured person requires moving and handling and the staff member demonstrated a clear knowledge. The Manager Care Homes for Adults (18-65 years) Page 4 of 14 described the advice given by a physiotherapist and community nurse about this persons moving and handling needs and the staff member repeated this accurately. The care plans had not been updated to reflect changes in condition but we could see that information is being passed on to staff effectively. Moving and handling training took a disproportionate time to assess due to failures in recording systems. It is positive that since the last inspection a senior staff member has been trained to provide moving and handling training to staff. This avoids delays in the training programme and a significant amount of practical training and update training has taken place since the last inspection. Moving and handling theory training is being provided separately often on different dates to the practical training but training records do not distinguish between these courses, so it was difficult to assess who had done what. In addition systems are not sufficiently developed to ensure that training records are routinely updated following the provision of training. We asked if staff are provided with certificates and received two different answers. The person who provides the practical moving and handling training however, is not being asked to validate certificates as we would expect. Often the only record there was of these practical sessions was in the trainers diary. Registers of attendance are held but we were told these were not on the premises and were not available for inspection. During a protracted process, we were able to identify that all staff with the exception of the Registered manager, a senior support worker and three bank staff have done either training or retraining in moving and handling. We were able to verify a small part of the newly provided practical training by asking an available staff member who confirmed attendance on one of the dates. The registered manager has not done moving and handling training with this organisation since taking up post. Given her position and the urgent need to improve moving and handling practice since the last inspection, she recognised the implications of this omission and undertook to ensure that she and those other people identified would attend moving and handling training on a specified date in March 2009. The manager confirmed how since the last inspection the provision of moving and handling training to new staff has been prioritised before they are allowed to start supporting people. We could see from talking to two new staff and from looking at records, that for the most part this has been successful. Out of six new staff employed since the last inspection, five had received moving and handling training before working their first shift. One bank staff member who regularly covers staff absences has not been provided with appropriate training. We left the management team to consider what steps they were going to take to rectify this situation to assure the safety of people. We have previously been concerned about the number of falls incurred by some people living at Beech Spinney, by two people in particular in Honeysuckle House. Although, not directly always related to moving and handling, we looked into this as information was available to us when we looked at the accident records. We could see that since the last inspection in July 2008 one person with a history of falls had slid to the floor on 13 occasions and the other person had fallen on 5 Care Homes for Adults (18-65 years) Page 5 of 14 occasions. Each incident was without injury for both people although on one occasion there was some slight grazing incurred. We looked further into three of the recorded falls which were of particular concern. One person had fallen out of bed. We looked at the bed and the bedroom and there were no evident hazards. We were assured by senior staff that this was a one off event and that for now no further action is thought to be necessary. The second person had trapped his foot between the mattress and bed frame during a seizure. We looked at the bed and found it to be an ordinary double wooden framed bed without bedrails or fitments. The mattress fitted tightly into the frame with no excessive gaps or evident hazards. It was difficult to see how a foot could become trapped although it is more understandable considering this happened during seizural activity. On reflection, perhaps one way of avoiding this risk in future would be to have a divan style bed rather than a wooden framed bed but advice should be sought about this. Positively since the last inspection, for the person at most risk of falls, the manager has sought the advice of a falls prevention specialist who has carried out an assessment and written a report. In addition a physiotherapist has carried out a reassessment and updated written guidance for staff is available and is being acted on. Also a number of further actions have been taken to safeguard the person. These include the provision of technical alert aids fitted to the persons mattress and bed. These alert the staff to movement and seizures so the person can have privacy and yet be supervised when moving or experiencing seizures. In addition, the manager explained how a new chair has been provided to prevent him falling sideways. A risk assessment had been completed for the risk of falling sideways with the new chair as a control measure. This included a safe system of using the chair but the risk assessment had not been signed or dated. It was of concern then, given that this person is known to fall sideways, that the risk of falling from the toilet had not been considered and that sufficient action had not been taken when this person slid off the toilet to the left, suffering graising. The matter had not been risk assessed before or after the accident and no action had been taken to prevent this happening again in the six months since the accident. When we looked at the toilet we could see that there is a grab rail on the right but not on the left where he fell. We were told that although he usually slides to the right, he would not be able to use grab rails to support himself and to stop himself falling. We therefore concluded that an urgent referral should be made for an occupational therapy assessment and in the meantime staff would be formally reminded of the need for sufficient preparation and supervision at all times when providing his support. Assessing progress towards meeting the medication requirement was more complicated. The requirement being assessed was that appropriate detailed information relating to medication must be kept, for example, in risk assessments, protocols and care plans to ensure that staff know how to use and monitor all medication including when required and as directed medicines so that all medication is administered safely, correctly and as intended by the prescriber, to meet individual health needs. Information available to us was contradictory and there was confusion about the location and availability of medication protocols. The services action plan for improvement dated 1.9.08 tells us that since inspection all medication protocols were Care Homes for Adults (18-65 years) Page 6 of 14 revised by the required date with only 3 remaining with the relevant professional for signature. At inspection, the registered manager told us that she fully believed all protocols to have been returned, signed and authorised by the two doctors to whom they had been sent. A senior support worker who has monthly liaison meetings with the GP provided us with a list of protocols for each person that had not been received back from the GP, twenty one in total. The services action plan for improvement dated 1.9.08 also tells us that copies of the medical protocols are in peoples daily record files, care plans, emergency folders and medication files. We were advised by a senior staff member that protocols are taken out of peoples files and on this basis, we agreed to initially look at protocols in the place where we were told they were most likely to be, in the medication room. We looked at the availability of medication protocols for all five people living in Honeysuckle House and two people who have respite in Thistle Lodge. For the first person we looked at, all seven medication protocols were available in the medication room for medication taken both regularly and as required. Three of the seven had been signed and agreed by medical professionals and four had not. We later also found copies of these written directions on the persons care file and on the office computer. We spoke to a staff member who had a very good understanding of how to administer the medications we asked about, to this person. For the second person whose care we looked at, 3 medication protocols were available on her file in the medication room. These had not been agreed as appropriate by medics. Copies were held on the office computer, but were not available in her care file. We talked to a different staff member about how and when to administer two of these medications and again the staff member was able to demonstrate sufficient knowledge which accorded with the unauthorised written guidance. We asked for medication protocols for a third person. We could see from her medication administration records that she takes ten prescribed medications regularly and two creams or ointments when required. There were no written protocols for this person in the medication room. Two were later provided from the office computer, one of which was dated November 2008 for a medication called cinnarazine that we did not recognise as currently prescribed as it was not on the medication administration record. Protocols to guide staff were also not available for the barrier cream and mouth ulcer gel prescribed to be given as required, meaning these may be applied inconsistently, on the wrong area of the body or not at all. We looked at what written medication guidance was available to staff for a fourth person. We could see from his medication administration records that he is prescribed 3 medications regularly and an additional three to be taken as required. There were no medication protocols available for staff to consult in the medication room for this person either for his regular or as required medications. This was confirmed by two senior staff, one of whom explained that, anything weve not got here on site is with the GP. We were later provided with one unsigned protocol for as required paracetomol for this person which had been located on the computer. This was verbally confirmed to us as the only one available leading us to conclude that a number were missing and had not been developed to meet our requirement. We looked for medication protocols for the fifth person whose medication care we were Care Homes for Adults (18-65 years) Page 7 of 14 assessing. From his medication administration records, we could see that he is prescribed five medications to be taken as required. He is also prescribed eye drops, sodium cromaglicate which on the administration record are directed to be given four times per day. Staff have changed the administration record to direct these to be given as required. We could see from the administration records available starting from 23.2.09, that none had been administered. A senior staff member confirmed the change in direction to have been medically authorised. However no protocols were available in the medication room where we were told we were most likely to find them. When we looked further, we were provided with what we were told was a finite version of available protocols. Printed directly from the computer, we were given five written medication protocols for this person. One of these describes regular oral medications and the other four describe a variety of medications taken as required, including the eye drops referred to earlier. However protocols were not available for two other additional as required medications listed as prescribed on his medication administration record. These were for laratidine syrup and Niconzole. We asked a staff member about how to administer this persons zolmitriptan nasal spray. The staff member had not administered this before and was less sure of the prescribing directions or how to use it. The staff member said it would be necessary to check the guidance. However we are not assured that this would be sufficiently and readily accessible. Records show that medications prescribed as required are rarely being administered in Honeysuckle House. We looked at administration practice by auditing some medication records for three medications belonging to two people. We looked at how short courses of antibiotics had been administered to two people. We did this because with antibiotics, there is a clear start and end date. The number of staff signatures tallied with the number of tablets prescribed. This combined with evidence that these medications had not been returned to the pharmacy, shows us it is likely that the people received the full course of treatments promoting their health and welfare. We then looked at how diazepam prescribed on an ongoing basis to be taken as required had been administered to one person over the course of the previous 12 months. Records over the 12 month period showed 11 tablets to have been administered. As 28 had been prescribed we would have expected 17 tablets to be left. A count showed that 17 were left. It would be possible to conclude therefore that administration had been accountable and safe. However, as the service has still not implemented our recommendation to carry forward remaining stock to the start of a new medication period, they are not able to sufficiently assure us that administration of medication is always accountable, safe and as the prescriber intended. To be assured, in this instance of good practice, records would need to demonstrate that the 28 diazepam received into stock were administered from a stock with a zero balance. Without a carry forward system, the service cannot adequately demonstrate this. We then shifted the focus of the inspection to look at how guidance for the administration of medication to individual people is provided for staff in Thistle Lodge where people receive respite care. It is positive that prior to each persons stay, that information about prescribed medication is sought from each persons GP. For the first person we looked at, it was clear from comparing his most recent care plan to the fax received from the GP prior to admission that there had been medication Care Homes for Adults (18-65 years) Page 8 of 14 changes. Midazolam Buccal liquid and Timodine cream had been added to his prescription. The faxed copy of the prescription tells staff that the midazolam is to be given as 1ml after 5 minutes from the start of seizure, but no other information is available to ensure its safe administration at a time of trauma. Also this same document tells staff to apply Timodine cream twice daily without further information about why, where on the body and how. There was the further potential for error in medications for the second person who uses Thistle Lodge as a respite facility. The most recent care plan lists the names of 4 medications without stating the dose, frequency or times that each medication should be administered. Following the list it states, this is usually given during breakfast. It is not clear whether this instruction refers to all meds or the latter on the list. Reference to a copy of the prescription provided prior to admission by the GP shows one of the list of medications must be administered at night. Neither the care plan nor the faxed prescription from the GP provides guidance how to administer any of the medications listed. The faxed prescription states Loratidine tablets 10mg 1 or 2 as required, Omeprazole dispersible 10mg 1 to 2 tablets once daily and melatonin 9mg at night. A definition of when required is not provided and staff are not guided to know how to judge whether to administer one or two tablets in either the information provided from the surgery or in the care plan. The maximum dose in a given period is not stated. Therefore our conclusion is that there is inadequate information to ensure that staff know how to administer each medication safely. This puts people at some risk and is concerning given the length of time the service has had since we last inspected. Risk is however minimised by the fact that no controlled drugs are now held or managed on the premises, the number of medication errors has reduced with none reported in the nine month period since the last inspection and an improvement in the provision of medication training to staff. Four different medication training courses remain listed on the training matrix. Since the last inspection in July 2008, we can see from the matrix that 8 staff still employed have done MDS Boots training including 4 bank staff. We can also can see that 15 staff including 4 bank staff have done handling medication training since last inspection July 2008. From the matrix it seems that all staff with the exception of one, have done at least one form of medication training with 18 staff having done at least 2 meds courses. The service in its AQAA, recognises the need to increase the numbers of staff undertaking full medication training. We agree, as we can see that very few staff have done externally assessed distance learning training with those that have having completed this mostly back in 2006 and 2007, with only one person completing this since then. We can see that steps have been taken to ensure staff previously involved in medication errors have received some training although progress with this is unclear for one of these people still. A new system of structured training and assessment is being implemented for new staff. We confirmed this by talking to two new staff and looking at medication records. This limits risks of medication errors by inexperienced people. The provision of what the manager has described as full medication training should now be prioritised. However, as a result of our concerns about compliance, we served a Code B notice under The Police and Criminal Evidence Act to enable us to continue to investigate a possible breach and to seize documentation as evidence of possible none compliance. What the care home does well: Care Homes for Adults (18-65 years) Page 9 of 14 There is no doubt that overall, compared to performance a year ago the service has improved. Staff morale remains good, shifts are directed well, communication is improved within the service and with external agencies and staff are calm, focussed, are aware of their roles and peoples needs as well as how to better meet peoples needs. Incidents and accidents have reduced and new staff are being inducted well before they support people. This improves peoples safety. There have been no moving and handling related incidents since we last inspected. The service is keen to improve and everyone involved worked openly and cooperatively with us, throughout a long and tiring inspection day. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Adults (18-65 years) Page 10 of 14 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These requirements were set at the last inspection. They may not have been looked at during this inspection, as a random inspection is short and focussed. The registered person must take the necessary action to comply with these requirements within the timescales set. No. Standard Regulation Requirement Timescale for action 1 20 13(2) Appropriate detailed 31/07/2008 information relating to medication must be kept, for example, in risk assessments, protocols and care plans to ensure that staff know how to use and monitor all medication including when required and as directed medicines so that all medication is administered safely, correctly and as intended by the prescriber, to meet individual health needs. This requirement was not met at this inspection July 2008. 2 42 13(5) Suitable arrangements to 31/07/2008 provide a safe system for moving and handling service users must be made. This must include providing full moving and handling training to new staff prior to undertaking the moving and handling of service users and refresher training to staff at sufficient intervals. New requirement arising from this inspection July 2008. Care Homes for Adults (18-65 years) Page 11 of 14 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 27 13 A competent person must be 31/05/2009 asked to assess the toilet of the person who sustained a fall from it, to ensure it is suitable and safe for the persons specialist needs. In the meantime steps must be taken to reduce the risk of accident or injury from the toilet This will ensure that the persons independence and dignity is maximised along with safety and the reduction of any further risk and injury which may be incurred from falling from the toilet. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 20 The home should ensure that at the start of each month it has an accurate record of all medications present within the home. Also the home should simplify the system for checking that medication has been administered during the month. Care Homes for Adults (18-65 years) Page 12 of 14 This was a new recommendation July 2008 and has been carried forward at this random inspection. 2 35 It is recommended that steps are taken to clearly differentiate practical and theoretical moving and handling training on the team training matrix. Systems should be employed to ensure all practical moving and handling training provided by the homes train the trainer, is accurately reflected in the training matrix and that systems are sufficiently in place to properly confirm attendance and that participants have achieved the requisite level of competence during training. Care Homes for Adults (18-65 years) Page 13 of 14 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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