Inspection on 13/11/07 for Buchanan Court Nursing Home

This inspection was carried out on 13th November 2007.

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

Buchanan Court Nursing Home 01/04/09

Buchanan Court Nursing Home 25/04/08

Buchanan Court Nursing Home 04/06/07

Buchanan Court Nursing Home 12/10/06

Buchanan Court Nursing Home 09/02/06

Buchanan Court Nursing Home 28/06/05

Buchanan Court Nursing Home 18/01/05

Buchanan Court Nursing Home 28/07/04

Buchanan Court Nursing Home 02/02/04

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

CARE HOMES FOR OLDER PEOPLE Buchanan Court Nursing Home Buchanan Court Care Centre Sudbury Hill Harrow Middx HA1 3AR Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 13th November 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000022918.V351704.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. DS0000022918.V351704.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Buchanan Court Nursing Home Address Buchanan Court Care Centre Sudbury Hill Harrow Middx HA1 3AR 020 8423 3311 020 8423 2299 buchanoncourt@schealthcare.co.uk 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) Ashbourne Homes Limited Care Home 85 Category(ies) of Old age, not falling within any other category registration, with number (84), Physical disability (1) of places DS0000022918.V351704.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Temporary variation agreed for individual (BC) who is under the age of 65 years for the duration of her stay. Maximum of 85 persons may be accommodated Temporary variation agreed for individual (CC) who is under the age of 65 years for the duration of his stay. Maximum of 85 persons to be accommodated 4th June 2007 Date of last inspection Brief Description of the Service: Buchanan Court belongs to Ashbourne Plc, which has been taken over by Southern Cross Healthcare, a national provider of care homes mainly for the elderly. The care home is found in Sudbury Hill and is easily accessible by public transport as the area is well served by buses. The closest underground station is Sudbury Hill, which is about 10 minutes walk away. There is an extensive parking area in the grounds of the home and there are maintained lawn/shrubs areas in the front and at the back of the home. There are some shops and amenities in Sudbury but Harrow on the Hill, where more shopping facilities and amenities are available, is about five minutes drive from the home. Buchanan Court is purpose built and consists of three floors. Accommodation is provided in a mixture of single and double bedrooms with en-suite facilities although most of the double bedrooms tend to be used as single bedrooms. As a result even though the home is registered for 85 elderly residents requiring nursing care, only 70 beds and less are in use. The ground and first floors accommodate 25 residents each and the second floor accommodates 20 residents. The home is run by Melanie Boyd, the manager, and her deputy, Kamala Chohun with support from line management from Southern Cross Healthcare. The home charges local authorities £549-£784 for residents placed by them and charges self-funding service users £784-£800 depending on the needs of the service users. On the day of the inspection there were 53 residents in the home. DS0000022918.V351704.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection is the second for the period 2007-2008. The first key inspection took place on the 4th June 2007. This inspection took place on Tuesday 13th November from 10:00-17:00 and on Wednesday 14th Wednesday from 09:45 to 13:45. The aim of this inspection was to check for compliance with the key national minimum standards During the course of this inspection I spoke to some visitors to the home, some residents, a healthcare professional, a social care professional, the manager and some members of staff. I toured some of the premises and I looked at a sample of records. I also looked at the management of medicines on the first and second floor. An Annual Quality Assurance Assessment (AQAA) was provided by the manager. This was used where possible in this inspection. An immediate requirement was imposed on the home on the 14th November to address issues regarding a resident receiving a medicine above the maximum dose as outlined in the British National Formulary for medicines, the lack of recording and investigation in a case where a resident had a bruise on the back of his hand, and the adequacy of the call bell system in the home. I would like to thank all the residents and visitors who spoke to me to share their experience of living in the home, the health and social care professionals, and the manager and all her staff for their support during the inspection. What the service does well: The home provides information about the service to people for them to decide if they want to use the service. The prospective residents are also assessed to make sure that the home would be able to meet their needs. Once residents are admitted to the home care plans are prepared to make sure that the needs of residents would be met. Residents living in the home have the opportunity to choose if they wish to take part in a number of social and recreational activities in the home, which are of a good standard. Residents and their relatives gave positive feedback about the activities that the home provides and about the activities coordinator. The residents also enjoy suitably varied and nutritious meals, which are provided according to their choices and their needs. The physical environment of the home is conducive to the care of older people. It is purpose built, bright, airy and free from odours. The garden and the exterior of the home are maintained to a good standard. The home also enjoys DS0000022918.V351704.R01.S.doc Version 5.2 Page 6 a good location in the local community with regards to access and links to community facilities. The home is managed by Melanie Boyd. She is approachable to residents and their relatives, visitors and staff. She runs the home in an open manner and keeps a presence on the floors to make sure that she knows what is happening in the home. She also holds monthly surgeries and has an open door policy. Visitors and residents said that they would talk to her if they have any concerns. The staff team has been fairly stable to ensure continuity of care. The staffing level is generally adequate for the number of residents who are accommodated in the home. Feedback of residents and visitors about members of staff were on the whole good. One visitor said ‘that she is kept informed of changes in the condition of her relative’. Another visitor said that ‘she had no complaints and that staff are very good’. What has improved since the last inspection? The service users’ guide has been updated and now contains information about the manager and the responsible individual. People using the service therefore have more information to make a judgement about moving into the home. Residents’ needs are addressed in the care records but not always comprehensively. There has been a slight improvement in the content of care records and there is evidence of continuous efforts from staff to improve the care records. Residents and their relatives can now be expected to be asked about their care and to take part in care planning and in the review of the care plans and risk assessments. Progress has also been noted in completing the assessment of the social and recreational needs of residents. The home accommodates a number of residents with epilepsy. There has been improvement in ensuring that clear care plans and protocols are in place to manage this aspect of the care of residents and to promote their safety. The home has not always enjoyed a consistent approach and investment in the redecoration and maintenance of its physical environment. As a result serious improvement can be made in this area. Improvement noted during the inspection includes a number of bedrooms that have been redecorated, work that has started in converting two large toilets into showers to improve the bathing facility in the home and maintenance of the decorative order of the communal areas. To make sure that staff in the home are able to care for the residents that are accommodated in the home the standard of training has been improved. This was demonstrated by the training plan of the home. For example the home now uses an induction for care workers based on the common induction standards from Skills for Care. Care workers are able to benefit from more DS0000022918.V351704.R01.S.doc Version 5.2 Page 7 regular supervision to make sure that they feel supported in doing their job. The manager has also started to address the appraisal of staff. What they could do better: 29 requirements have been imposed on the home following this inspection. Out of this 12 are repeated and out of the 12 repeated requirements, 6 are repeated twice or more. For people to have confidence in the service and in its commitment to provide a quality service, requirements must be met within the timescales. Failure to meet requirements might result in enforcement action. It was noted that although the service users’ guide has been updated it does not yet contain all the information as required by legislation, as it does not yet contain information about the fees that the home charges. This is particularly important for people who are self-funders to enable them make a decision based on their finances as well as other aspects of the service that Buchanan Court provides. The home admits residents who require nursing care. Some of the residents have high dependency and a number of needs. While the home is able to demonstrate that it can meet the needs of residents with low to medium dependency, it has not been able to show how the needs of highly dependent residents are being met. For example it has not been possible for the home to demonstrate how it was managing the care of people who experience pain or who were at risk of malnutrition. Residents have not always been weighed regularly and pain charts have not been used where required. One resident had an unexplained bruise and there were no records about the bruise or an accident/incident entry. There was also a lack of records to show when residents who were cared for in bed, were having a bath or a shower. There has been a slight improvement in the standard of care plans. However, more improvement is required to make sure that the assessments of the needs of residents are always carried out comprehensively and that these are reviewed as and when required, such as after a period of hospitalisation when residents’ needs may change. More progress must also be made in addressing the needs of residents with regards to dying and sexuality, and incorporating aspects of the cultural, religious and ethnic backgrounds and sexual orientation of residents into the care plans as much as possible. Residents’ rights and safety must be respected as much as possible and they must be given a call bell unless there are appropriate risk assessments in place. The manual handling risk assessments and the associated care plans must be clearer about the equipment to use, number of staff and the actual manual handling manoeuvres required to move residents. Residents must be provided with appropriately ironed clothes and these must be stored tidily in the wardrobes and drawers of residents. DS0000022918.V351704.R01.S.doc Version 5.2 Page 8 Another area where the rights and welfare of residents could be further promoted, involves the time for the serving of breakfast. This must be reviewed to make sure that this suit the needs and wishes of residents and that residents do not go for long periods of time without any meals. Breakfast must be served where residents prefer to have them. If that is the dining room, then residents must be encouraged and supported to use these areas. Staff who administer medicines must make sure that they do not give medicines above the maximum dose that is recommended in the British National Formulary. In cases where the dose to administer is more than what is recommended then they should consult the prescriber and/or the chemist. To demonstrate that the home takes complaints, and allegations and suspicions of abuse seriously, all complaints that are made against the service must be recorded and investigated thoroughly. The valuables that residents bring into the home must be recorded to make sure that there is an audit trail to prevent financial abuse. As stated in the section ‘ what has improved since the last inspection’ there has not always been consistent and sustained investments in the environment of the home. A comprehensive redecoration and refurbishment plan must be prepared to provide a reassurance of the organisation’s and the home’s commitment to continue improving the environment of the home. The home has experienced some subsidence. There must be a plan to address the subsidence problem to make sure that the home continues to be safe for residents. There must be a high standard of hygiene in the home to make sure that appropriate infection control procedures are being adhered to. Bed frames and window frames must be free from dust. The manager has been in post for about 11 months and has not yet been registered. She stated that she was in the process of getting registered. To get feedback about the quality of the service the home must carry out a satisfaction survey. There was no evidence that one has been conducted during the past year. 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. The summary of this inspection report can be made available in other formats on request. DS0000022918.V351704.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000022918.V351704.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1-4 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People receive information to enable them make an informed decision about using the service. The needs of all prospective residents are assessed prior to admission to make sure that all their needs are clearly identified. The home is not always able to demonstrate how the needs of highly dependent residents are being met. EVIDENCE: The service users’ guide (SUG) has been updated and now contains details of the current manager and of the responsible individual from Southern Cross Healthcare. Copies of the SUG were available in the bedrooms of residents and one visitor said that she would refer to this if she required more information about the service. The service users’ guide has however not been updated with information about the range of fees that is charged by the home and about what is covered by the fees and other information such as the arrangements in place to deal with DS0000022918.V351704.R01.S.doc Version 5.2 Page 11 the registered nursing care contribution. This is required under regulation 5(1)(bb) of the Care Homes Regulations 2001 as amended in 2006. The manager stated that all prospective residents who are referred to the home are assessed prior to them being offered a place to ascertain if the home is able to meet the needs of the prospective residents. This includes residents who are admitted for respite/interim care and for short term care. Preadmission assessments were found in the care records of residents to show that their needs had been assessed. These were on the whole completed comprehensively and they accurately described the needs of residents. Members of staff are on the whole familiar with the needs of less dependent residents who are admitted to the home. Some of these residents and some of their visitors, who were spoken to at the time of the inspection, were in the main satisfied with the standard of care that these residents received. The home however accommodates a number of highly dependent residents with a number of needs. Some of these residents’ condition may not be stable, and they may experience poor mobility, cognitive difficulties, acute illnesses, and pain. The concerns about whether the home is able to meet the needs of highly dependent residents with complex needs were also expressed by two community health and social care professionals, who provided feedback about the general views held within their organisations. Some of the residents living in the home are from minority ethnic groups. Although the care records are at times lacking with regards to addressing the cultural and ethnic needs of residents, staff were familiar with this aspect of care of the residents. There were individuals among the staff team who were able to translate for most residents whose main language was not English. DS0000022918.V351704.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 People who use the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. The assessment of the needs of residents and care plans are not that comprehensive to demonstrate that residents’ needs are being met. Some issues were noted which showed that the healthcare needs of residents are not being comprehensively met. The management of medicines is not always carried out in a safe manner. Care records do not address the end of life care needs of residents in a comprehensive manner to make sure that these needs would be met should the time come. EVIDENCE: The care records of 5 residents were inspected. The assessments of needs of residents were completed to a better standard than they had been during the last inspection, but there were still sections in the assessment of needs, which were not completed. The sections not completed included information on dying, sleeping and sexuality. The likes and dislikes of residents were also not always identified. The assessment of needs did not also address the cultural background, ethnic group and sexual orientation of residents. As a result it is DS0000022918.V351704.R01.S.doc Version 5.2 Page 13 not possible to say that the needs of residents are comprehensively assessed and that the assessments are kept under review. Care records contained a number of risk assessments, which were kept updated. The aim was to make sure that once risks were identified, control measures were put in place to address the risks. Three residents were noted without a call bell. It was not always clear why they were not given a call bell. One of the residents’ care plan mentioned that he should be given a call bell, yet he was not provided with a call bell. In some cases this was perhaps because residents could not use a call bell and therefore the cord could pose a risk to residents. While this is acknowledged, it is important to make sure that these issues are addressed within a risk assessment context in relation to balancing the rights of the individual with his/her safety. Residents had manual handling risk assessments and care plans addressing this aspect of care, which were reviewed as required. However, these did not always accurately describe the manual handling manoeuvres to use, to move residents and the equipment to use. One care plan said to use a ‘full body hoist’ and did not say which size sling to use with the hoist. Plans of care generally contained details of the action to take to meet the needs of residents. Short-term care plans were in place when residents developed acute illnesses. However the care plans were not always kept under review when the needs of residents changed such as after a period of illness or after an accident, which resulted in a change of needs. A resident whose needs changed following a period of illness has not had his care plan updated to reflect this. There was evidence that residents and their relatives were involved in the care planning process. Residents/relatives have signed to show that they have been involved in the reviews of the care plans. Visitors spoken to said that they have seen the care records and that staff kept them informed about the condition of residents. The home is commended for progress achieved in this respect. Residents appeared clean and appropriately dressed. Male residents were shaved appropriately. However, inspection of progress notes for three residents over a period of three weeks showed that it was not clear when they had a bath/shower during that period of time. One of the residents was last bathed when his relatives complained. The standard of laundering was generally good, but the standard of ironing was not so good and the clothes of residents were not put tidily in the cupboard of residents. There has been a complaint about the standard of ironing of the clothes. It was noted that residents were seen by the GP as required and that they were referred to the hospital when advised to do so by the GP. It was however DS0000022918.V351704.R01.S.doc Version 5.2 Page 14 not clear if residents were seen by all care professionals according to their needs. A relative requested for a resident to be seen by the dentist, there were no records to show that this was actioned. Care plans of residents who were diabetic continued to lack with regards to clarifying what were low and high levels of blood sugar, for action to be taken to manage the care of these residents as this varied from residents to residents. One care plan mentioned that the GP should be informed when the blood sugar is ‘unstable’ but did not clarify what was ‘unstable’. Residents who were epileptic had clear care plans/protocols to manage the care of these residents when they have fits. The home has a chair scale to weight residents and a hoist scale to weight residents who are less mobile. It was noted that as residents become more frail and less mobile, they tended to be weighed with the hoist scale. However the hoist scale has been out of order for some time and therefore a number of residents have not been recently weighed. For example a resident has not been weighed since May 2007. Another resident who lost about 8-9 weight between August and September was not weighed in October to check if he lost more weight. He has also not had his care plan updated/evaluated regarding the lost of weight and there was no evidence that he has been referred to the GP or the dietician for advice. Residents with pressure ulcers generally had care plans in place addressing the management of the ulcers and the dressings to use. There were photos and wound progress notes in place. Care plans however did not address pressure area care in a comprehensive manner. For example residents with pressure ulcers or at high risk of developing pressure ulcers did not have a repositioning regime in place with regards to turning and changing position in bed, the period of time to sit out of bed and the management of pressure area care while seated. One resident’s care plan said that ‘ensure regular change of position’ but did not clarify what was regular. It is important for care plan to be clear to ensure consistency, continuity of care and provides a form of guarantee that residents’ needs would be met. The pressure equipment in place was not always recorded to enable a person reading the records determine if the pressure equipment in place was adequate and appropriate to the needs of the resident. The home uses a pain chart format to assess residents’ level of pain to ensure appropriate management of the pain. It was noted the pain charts were not always completed even if this was mentioned in the care plan for pain. For example a resident had a care plan about pain, but he did not have any analgesia written on the medicines chart and it was not clear whether the management of the resident’s pain had been discussed with the GP. His pain DS0000022918.V351704.R01.S.doc Version 5.2 Page 15 was assessed once a few months ago when he had moderate level of pain and there have not been other assessments. Another resident who was on a combination of painkillers did not have an up to date pain assessment chart. At least four residents were noted in bed during the morning and I was informed that they were normally cared for in bed. This was apparently because they could not sit in a ‘normal’ armchair as a result of their poor mobility and physical condition. It was not clear what had been done with regards to assessing the residents and identifying appropriate seating arrangements for them to sit out and to use the communal areas, if they wished to do that. The manager stated that one of the residents, who has not been out of bed for a number of months was going to be referred for an assessment of his seating needs. Every attempt must be made to make sure that all residents who cannot use a normal armchair, because of their poor posture, be assessed for their seating needs. There has been a repeated requirement with regards to the home having appropriate standard solutions for the internal quality control of glucose meters to make sure that these meters are giving the right reading. This is a guidance from the Medicines and Healthcare Products Regulatory Agency (see “Blood Glucose Meters”. Advice for Healthcare Professionals. (2005). MHRA. Pg 2 and 4, www.mhra.gov.uk ). The operating manuals for a number of meters also reiterate the importance of having an internal quality control system by checking these meters with solutions of known concentration of sugar to check if the meters are giving the right readings. For example the manual for AccuChek, one of the widely used glucose meters, gives information about ‘running a quality control test’ www.accu-chek.co.uk . Care records of residents contain information about the resuscitation status of residents, but there was little information about the end of life care of residents and the arrangements and wishes of residents with regards to managing death and funerals. I was informed that at times this subject was not easily addressed by members of staff with residents and their relatives. The provision of training in end of life care is one way of improving staff approach and knowledge about this area of care. The management of medicines was inspected on the 1st and 2nd floors. Most medicines were signed when administered and recorded when received in the home. Instructions about the administration of medicines were generally clear, except for a few medicines. A resident was written up for silver nitrate. It was not clear how, when and where should this medicine be applied. Another resident was on loperamide and it was not clear when and how often should the medicine be used. It was noted that one medicine had not been administered for about a week but this was probably linked to the supply from the manufacturers of the DS0000022918.V351704.R01.S.doc Version 5.2 Page 16 medicine. There was a homely remedy list, which had been approved by the GP. It was noted that one resident was receiving a medicine above the maximum dose of the medicine as defined in the British National Formulary (BNF). The particular medicine was administered on its own but was also a component in another medicine (a compound analgesic preparation), which was being administered. As a result the resident was getting the same medicine from two sources, which resulted in her getting the medicine above the maximum dose as identified in the BNF. There was no evidence that this had been noted and that this had been checked with the GP and the chemist. DS0000022918.V351704.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides social and recreational activities to suit the needs of the residents. Residents receive a nutritious and varied diet to meet their needs, although the timing for the serving of breakfast was not always according to residents’ wishes and habits. EVIDENCE: The care records contained a section on the assessment of the social and recreational needs of residents and a section on the life history. The section on the social and recreational needs of residents was on the whole completed, but the life history section was not always completed. Care plans were in place to address the social and recreational needs of residents. Records were also made about the actual activities that residents took part in. The home employs a full time activities coordinator. Residents and visitors to the home were complimentary about the activities coordinator. On the first day of the inspection, there was a visit by a representative from a local church and in the afternoon there was a quiz session. Residents stated that even if they do not go to the lounges they enjoy attending the activities sessions. A DS0000022918.V351704.R01.S.doc Version 5.2 Page 18 programme of activities was in place in the home and residents and staff confirmed that most of the activities planned, do take place. Activities, which are organised, also include outside entertainers who visit the home on a regular basis. The activities coordinator stated that there are weekly visits to the home by representatives of the local churches and that residents are able to go to the churches with their relatives and would be assisted by staff where required. Residents who are from ethnic minorities mostly rely on their relatives to meet their religious needs with assistance from staff in the home. The activities coordinator mentioned that she arranges trips and outings for residents. The home has a mini bus that is used for this purpose. For example residents recently had the opportunity to go to the Ruislip Lido and shopping centres. The mini bus can take about four residents at a time and there was therefore a lot of interest from residents to go out. One resident said that the trips provide the opportunity to go to places where they did not think they would go again. According to the activities plan, more trips are planned in the near future. Visitors were observed in the home and all those who spoke to the inspector said that they are made to feel welcome in the home and that they can visit at any time during the day. They said that staff greet them and speak to them about their relatives/friends. The manager has also ensured that free drinks are available in the reception area for visitors to the home. Lunch was observed on the first day of the inspection on the first and second floors. The dining rooms were prepared appropriately to make these areas inviting and congenial. Lunch consisted of minestrone soup, braised liver, Cornish pasties, potatoes and cauliflower. There were also omelettes and salads for those who wanted these options. Deserts consisted of tapioca pudding with jam. I was informed that residents from ethnic minorities at times received meals, which were according to their cultural needs. Feedback from residents and relatives showed that they were satisfied with the range and quality of the meals served in the home. I observed that residents were assisted with their meals in a discreet and appropriate manner. On the first day of the inspection it was noted that some residents were still having breakfast at about 10:45. One resident said that breakfast was late as he was woken up and assisted with washing and dressing late and that lunch would soon be served. I was informed that on the first floor, breakfast used to be served in the dining room and that it is now not possible to serve the breakfast in the dining room as staff are busy getting residents up. The breakfast tray in a residents’ room was left unattended and there was no one feeding the resident, although it was evident that someone had been feeding the resident. A member of staff later said that she did not get around to finish feeding the resident, as she got involved in another task. DS0000022918.V351704.R01.S.doc Version 5.2 Page 19 DS0000022918.V351704.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints and allegations and suspicions of abuse are in the main taken seriously and investigated as appropriate to make sure that residents were safe. EVIDENCE: The complaints register was inspected. There have been 4 complaints since the last inspection in June. The nature of the complaints was mostly to do with the standard of care that is provided in the home and the monitoring of the condition of residents by staff. The complaints were investigated and responded to as appropriate by the manager. The complaints procedure is available in the service users’ guide and in the foyer of the home. The manager holds an open day surgery once a month but is also available on a daily basis to talk to residents/visitors about their concerns, if they have any. Visitors reported that they knew who the manager was and that they would talk to her if they had any concerns about the care of the people who live in the home. On reading the care records of a resident, I noted in the progress notes that the daughter of the resident ‘had complained about the laundry’. I also found that this was not recorded in the complaints register. Since the word ‘complaint’ was used, it was unclear why this issue was not treated as a complaint and the complaint procedure followed. DS0000022918.V351704.R01.S.doc Version 5.2 Page 21 There has not been any allegation or suspicion of abuse since the last inspection. In the past, allegations of abuse have been referred to the local authority as appropriate and action has been taken where necessary to protect residents. There was also evidence that members of staff have received training on abuse and on safeguarding adults. Staff, who spoke to me, said that they would report to the person in charge if they suspected abuse of a resident. However I noted a bruise on the left hand of a resident on the first day of the inspection (see section under healthcare). There were no documentation or report about when and how the bruise occurred. The person in charge of the floor was aware of the bruise on the second day of the inspection and it seemed that no one reported the bruising or recorded it. As a result there were some doubts as to whether this matter was taken seriously and investigated as required to make sure that residents were safe. DS0000022918.V351704.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22, 24 and 26 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. There has been some improvement in the quality of the environment, but further progress is required to make sure that the environment continue to be suitable for residents. EVIDENCE: The parking areas and the grounds in front of the home and on the sides were maintained. The reception area was warm and welcoming. The manager has tried to enhance the atmosphere of the home by providing hot drinks in the reception area. The home is situated in an area, which is prone to subsidence and there has been some subsidence, which has affected part of the building. The manager stated that the organisation is addressing this issue to make sure that the building continues to be safe for all people who use it. A requirement was DS0000022918.V351704.R01.S.doc Version 5.2 Page 23 imposed on the home during the last inspection with regards to having a plan in place to address this matter. This has not yet been produced. It was noted that a number of sockets/panels of the call bell system had come off from the wall or were held/secured loosely. One was held in place by tape. Therefore there were times when residents could not use their call bells. Furthermore the call bell system works with bleepers as there is no ringing tone on the displays to alert staff that a resident require assistance. On the second floor there was one bleeper the four members of staff on duty during a day shift. There was an immediate requirement dated 17th October 2006, which mentioned the poor condition of the call bell system. This had been repaired at the time, but the condition of the system remains poor. There has been quotes for the system but there is no concrete plan as to a timescale to overhaul the system. There is one bathroom on each floor and all bedrooms are en-suite. Most of the en-suites contain a bath, which is against the wall, and a few contain a shower. The bath is not accessible to the use of a hoist and does not allow staff to attend to residents on either side of the bath. As a result, few if any of these baths are in use and most residents have their bath in the main bathroom on the floors. At the time of this inspection, two toilets were being transformed into shower rooms to improve the bathing facilities in the home. There was evidence of ongoing maintenance and decoration. The lounges, dining areas and corridors were on the whole in a good state of decoration. The curtains have been changed in the ground and second floor lounges and there were plans to change the curtains on the first floor lounge. Furniture in the communal areas was also appropriate, although as mentioned previously residents who have a poor posture might benefit from special seating to make sure that they can continue to use the communal areas. A number of bedrooms have been re-painted and one was in the process of being redecorated at the time of the inspection. There were a number of bedrooms that still require redecoration. It is hoped that these will be soon addressed as per the redecoration plan of the home. Some of the bedrooms have been personalised to a good standard but a few remain bare and impersonal. The manager stated that she plans to address this by supporting residents to personalise their rooms and if necessary by providing items of decoration for these rooms, according to the individual resident’s taste and choices. The bedrooms of residents do not have locks to provide residents with the options of locking their rooms for privacy, as per a risk assessment. The manager stated that the home has purchased new armchairs for residents. Some of these were seen during the inspection. However armchairs in a few bedrooms continue to be inappropriate, as the cushions did not always fit the frames of the chairs. The manager said that she would order additional DS0000022918.V351704.R01.S.doc Version 5.2 Page 24 armchairs to make sure that the seating provided to residents was comfortable and appropriate for them. A number of pressure overlays/mattresses were placed on divan beds, which were too small for these. As a result the overlays/mattresses spilled over on the sides and therefore raising the question as to whether these items of equipment were providing the appropriate pressure relief for residents to prevent the development of pressure ulcers. The flooring in some en-suites was coming off and needed to be re-glued or replaced. It is important to address this to prevent water seeping through and for infection control purposes. The home was on the whole clean but there were some areas, which would benefit from dusting: the bed frames and the frames of the windows. There were no odours in the home. DS0000022918.V351704.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides an adequate staffing level to make sure that the needs of residents are met, but the deployment of staff could have been better organised to make sure that meeting the needs of residents’ needs takes precedence above all other tasks. Recruitment procedures are adhered to, to make sure that residents are safe. The provision of training is suitable to make sure that staff are trained to care for residents that are accommodated in the home. EVIDENCE: There are one trained nurse and three carers for each of the floors. At night there are one trained nurse overseeing the first and the second floors with two carers on each floor and one trained nurse and two carers for the ground floor. The number of staff provided to care for the number of residents in the home at the time of the inspection was appropriate. Most of the members of staff have worked in the home for a number of years and were familiar with the needs of the residents. As mentioned in the section ‘Daily life and activities’ it was noted that some residents on the first floor were served breakfast at about 10:30. Considering that they have lunch at about 12:30-13:00 and supper at about 17:30-18:00, they go for about 16 hours without food, if they do not take a snack. Furthermore at least one resident stated that they wanted to have their breakfast earlier and one resident was left with his breakfast on a tray while DS0000022918.V351704.R01.S.doc Version 5.2 Page 26 the nurse attended to other duties. While the staffing on the unit was similar to that in care homes providing similar services, it seemed that the serving of residents’ breakfast was not prioritised and that perhaps other duties were given priority. Three personnel files were inspected. Most of the records as required by legislation were in place for each of the three members of staff including two references and CRB checks. One of the members of staff did not have a CRB check but had a PoVA first in place. Application forms were appropriately completed and there were no gaps in the employment history. There was evidence that new members of staff were getting a general induction about the service and that carers were getting in addition an induction based on the commons induction standards as per Skills for Care. The manager stated that the home now uses the Southern Cross induction package, which is based on the common induction standards from Skills for Care. Members of staff stated that they receive supervision and the manager showed me a plan, which has been arranged for the supervision of staff. She reported that she has also started to address the appraisal of staff. A copy of the training matrix for the home was kindly provided to the inspector. It was noted that out of 38 care staff, 19 have at least a NVQ level 2 qualification in care. There are also a number of carers who are trained nurses in other countries who have yet to complete an adaptation course to be a registered nurse in the UK. The manager kindly provided a training matrix. This was used to evaluate the standard of training in the home. The training matrix also showed that most members of staff were up to date with regards to statutory training, such as fire training, food hygiene, health and safety and abuse. The manager said that the deputy manager has also completed a trainer’s course for the provision of dementia care training. It was noted that some care and nursing staff have already had that training. It is therefore possible to conclude that the home provides adequate training to staff to make sure that they are able to care for the residents who are accommodated in the home. Areas for future training should include the management of pain and the end of life care as identified in section 2 of this report. DS0000022918.V351704.R01.S.doc Version 5.2 Page 27 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager runs the home in an open and transparent manner and is in the process of being registered. The home uses the quality management system of Southern Cross but has not yet conducted a satisfaction survey as part of this process. The management of residents’ money is of a good standard but records of the valuables of residents are not comprehensive enough to make sure that residents are protected from financial abuse as much as possible. Health and safety issues are attended to as required to make sure that residents are safe. EVIDENCE: The manager has now been in post for about 11 months. She is a trained nurse and has worked in a senior position in other care homes prior to this job. She has the registered managers’ award and is in the process of studying for DS0000022918.V351704.R01.S.doc Version 5.2 Page 28 additional qualification in management. She is not yet registered as required under Section 11 of the Care Standards Act 2000. She stated that she was in the process of putting her application through to be the registered manager. It was noted that she is supported by the deputy manager and the line management of Southern Cross in running the home. Comments from staff, residents and visitors shows that the manager runs the home in an open manner and all residents, visitors and staff said that she is approachable. She has prepared a schedule for staff meetings and these are arranged according to the schedule. She stated that she had made arrangement for a residents’ and relatives’ meeting which was unfortunately not attended, and that she would continue to arrange these to make sure that relatives and residents continue to have an opportunity to contribute to the management of the home and to discuss important issues. The quality folder contained monthly audits, which have been carried out by the manager. There were also two monthly validation audits, which were carried out by the operations manager. Action plans were in place in cases where issues were identified which needed addressing. Reports following monthly visits as per regulation 26 are regularly sent to the local CSCI office. The manager stated that the home has not yet carried out a satisfaction survey of residents and relatives. She has sent comment cards to stakeholders of the service but there has been a poor response. The management of personal money of residents was inspected. The accounts of 2 residents were chosen at random. It was noted that good records were kept. Money was checked by two persons when received or removed from the home. Receipts were kept for all expenditures and the balance of resident’s money was up to date. There was also evidence that the manager was checking the management of residents’ money monthly. There was evidence that the home has addressed the issue with regards to residents who were no longer in the home but had money in the residents’ accounts. The head office of Southern Cross has made attempts to track the next of kin of these residents to refund the money. While touring the home, I noted a resident with 3 yellow bracelets on one arm. There were no records of the bracelets on the current property form on file. As a result there was danger that this may not be accounted for. The home had evidence that equipment in the home was being maintained as required. Certificates were in place to show that the hoists had been thoroughly checked according to the required intervals (LOLER checks). This was however not in place for the passenger lifts. Safety certificates were in place. The PAT testing certificate, chlorination certificate and the Gas safety certificate were in place. The electrical wiring DS0000022918.V351704.R01.S.doc Version 5.2 Page 29 certificate mentioned that some ‘code 1’ work was required to make the system safe. There was evidence of quotes having been received. The manager stated that the ‘code 1’ work has been carried out, but there was no records that this has been conducted. The manager stated that the home has acquired equipment for the provision of first aid and it was noted from the training records that there were members of staff who have been trained in first aid. Other in house checks, such as weekly fire detector tests, monthly water temperature checks were carried out according to the required schedule and action was being taken to address issues, which were identified during the checks. It was noted that a number of thermostatic valves have failed. The manager said that quotes have been received and that these were in the process of being renewed. DS0000022918.V351704.R01.S.doc Version 5.2 Page 30 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 3 3 2 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 3 2 X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 DS0000022918.V351704.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5(1)(b) Requirement The service users’ guide must contain information about the range of fees charged by the home in respect to various types of placement and funding. (Previous requirementtimescale 31/12/06 and 31/08/07 not met). The registered person must ensure that only residents, whose needs can be met in the home, are admitted to make sure that their needs would be met. Care plans must be clear about the action to take to meet the individual needs of residents while taking the cultural and ethnic aspects of the needs of residents (Previous requirement-timescale 31/07/07 not met). The needs’ assessment of residents must be carried out comprehensively and must be kept under review (Previous requirement-timescale 31/12/06 and 31/08/07 not met). DS0000022918.V351704.R01.S.doc Timescale for action 31/01/08 2 OP4 14(1,2) 31/12/07 3 OP7 15(1,2) 10/02/08 4 OP7 14(1,2) 10/02/08 Version 5.2 Page 32 5 OP7 12(1) 6 OP7 13(5) 7 OP8 12(1) 8 OP8 12(1) 9 OP8 12(1) The care plans of residents who have diabetes must be clear about what is ‘low’ and ‘high’ level of blood sugar as this can vary from individual to individual (Previous requirementtimescale 31/07/07 not met). The manual handling care plan and risk assessment of residents must be clear with regard to how to carry out the various manual handling manoeuvres. The type of hoist and the type and size of the sling as well as the number of staff required for the manual handling manoeuvres must be clearly identified. Once a particular plan has been agreed staff must comply with the plan to ensure the safety of residents. (Previous requirementtimescale 31/07/07 not met). The registered person must ensure that residents are bathed/showered according to the residents preferences and that records with regards to this aspect of care be kept as required The registered person must ensure that all residents are weighed at least monthly or according to an individual care plan and that referrals are made as required to the GP or the dietician in cases when residents are loosing weight. In cases when residents cannot be weighed, the home must consider another method of monitoring the nutritional status of residents. The registered person must ensure either by training or otherwise that staff in the home have the necessary knowledge to DS0000022918.V351704.R01.S.doc 31/01/08 31/01/08 31/12/07 31/12/07 31/01/08 Version 5.2 Page 33 10 OP8 12(1) 11 OP8 OP18 12(1) 12 OP8 OP22 14(2) 13 OP9 13(2,4) 14 OP9 13(2) manage the pain of residents to make sure that residents are as free from pain as possible. The equipment in place for the management of pressure ulcers must be recorded and these must be used according to the manufacturer’s instructions (Repeated requirementtimescale 31/07/07 not met). The care plan of residents regarding tissue viability and prevention of pressure ulcers must address the repositioning regime, the turning of residents and the time for residents to sit out. That all residents’ bruises/incidents are appropriately recorded and looked into with a view to prevention and elimination of the possibility of abuse. That residents who cannot use the normal armchairs because of their poor physical condition, be assessed for appropriate seating to make sure that their independence can be maximised and that they can continue to socialise and join other residents. Calibration/standard solutions must be available and must be used at the intervals recommended by the manufacturers to calibrate glucometers as part of the internal quality control procedures to make sure that the meter is working appropriately (Repeated requirement-previous timescale 15/07/06, 31/12/06 and 31/07/07 not met). The instructions for the administration of medicines must DS0000022918.V351704.R01.S.doc 31/12/07 31/12/07 31/01/08 31/01/08 31/12/07 Page 34 Version 5.2 15 OP9 13(2) 16 OP10 12(4) 17 OP10 12(4) 18 OP11 15(1,2) be clear with regards to how to administer the medicine to prevent any errors from happening. The registered person must ensure that the administration of medicines is carried out safely and that people who administer medicines have a good knowledge of the medicines they administer. In case of uncertainty staff must refer to the medicines reference book such as a BNF or must refer to the GP or the chemist. All residents must be offered a call bell to make sure that they can call for help, unless risk assessments are in place. A plan to monitor residents must be in place when they are not given their call bells. Ironing of residents’ clothes must be carried out to a high standard to make sure that residents’ wear appropriately ironed clothes to maintain their self-respect and dignity. The clothes must also be kept appropriately and tidily in the wardrobes and drawers of residents. The instructions and wishes of residents and of their relatives with regard to end of life care and death must be addressed in the care records while taking into consideration the cultural and the religious backgrounds of the residents (Previous requirement-timescale 31/12/06 and 31/08/07 not met). The time that meals are served must be reviewed to make sure that this is according to residents’ wishes and needs and DS0000022918.V351704.R01.S.doc 31/12/07 31/12/07 31/12/07 28/02/08 19 OP15 16(2)(i) 31/12/07 Version 5.2 Page 35 20 OP16 22(3) 21 OP19 23(1)(2) (b) 22 OP19 23(1)(a) that residents do not go for long periods without meals (between supper and breakfast). All complaints which are made about the service to staff in the home must be recorded and investigated appropriately to give people the confidence that the homes takes complaints seriously. The registered person must provide the commission with a comprehensive plan with timescales addressing the redecoration of the bedrooms and of the home, and the replacement of fixtures and fittings. (Previous requirement-timescale 23/10/06 and 31/08/07 not met). The home must provide a report and action plan to address the cracks in the wall/subsidence, if this is the case (Previous requirement-timescale 31/08/07 not met). The provision of armchairs in the home must be suitable for the needs of the residents (Previous requirementtimescale 30/09/07 partly met). 31/12/07 31/01/08 31/01/08 23 OP19 16(2)(c) 31/03/08 24 OP19 23(2)(n) 25 OP24 23(2)(b) To make sure that residents can 31/01/08 summon help appropriately the call bell system must be made good or replaced with appropriate timescales for action. The bedrooms of residents must 31/03/08 be fit for purpose. They must be decorated to a high standard and must be personalised according to the wishes and choices of the residents (Previous requirement-timescale DS0000022918.V351704.R01.S.doc Version 5.2 Page 36 31/01/07 and 30/09/07 partly met). 26 OP26 13(4) The home must be clean and hygienic and must include ensuring that bed frames and window frames are free from dust as much as possible. The flooring in the en-suites must be glued back/replaced in areas where this is coming off to make sure that water and dirt are not accumulating under the flooring. The home must carry out a satisfaction survey as part of its quality control system. 31/01/08 27 OP33 24 31/03/08 28 OP35 17(2,3) 29 OP38 13(4) As part of the processes to 31/01/08 prevent financial abuse, the registered person must ensure as far as possible that there is an up to date record of residents’ valuables, to provide an audit trail. That the LOLER certificates for 31/01/08 the passenger lift be made available for inspection and kept up to date according to a pre determined schedule. 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. 2 Refer to Standard OP24 OP38 Good Practice Recommendations The registered person should provide locks for the bedrooms of residents. The manager must keep evidence that all the ‘code 1’ work as detailed in the electrical wiring certificate, have been conducted to make the system safe. DS0000022918.V351704.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000022918.V351704.R01.S.doc Version 5.2 Page 38 - 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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