CARE HOMES FOR OLDER PEOPLE
Bybrook House Nursing Home Middlehill Box Wiltshire SN13 8QP Lead Inspector
Tim Goadby Unannounced Inspection 2nd, 5th & 13th June 2006 09:35 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 Bybrook House Nursing Home DS0000015894.V298372.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. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bybrook House Nursing Home Address Middlehill Box Wiltshire SN13 8QP 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) 01225 743672 01225 744281 pen.b@talk21.com Avon Care Homes Limited Vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability over 65 years of age of places (6), Terminally ill over 65 years of age (2) Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. 6. No more than 30 persons aged 65 years and over may be accommodated at any one time No more than 28 persons aged 65 years and over may be in receipt of nursing care at any one time of which no more than 2 persons may be in receipt of terminal illness care No more than 6 persons with a physical disablement aged 65 and over may be accommodated at any one time. These persons may not also be in receipt of nursing care Rooms 25, 26, 27 & 28 may not be used for nursing care due to unsuitable access The staffing levels set out in the Notice of Staffing Levels issued by Wiltshire Health Authority on 20 March 2000 must be met at all times Only the one, named, female service user referred to in the application dated 31 August 2004 may be aged 64 years and under 30th September 2005 Date of last inspection Brief Description of the Service: Bybrook House provides care and accommodation for up to 30 older people. Most service users have nursing care needs. The home can also take up to six people who have physical disability, and two people for terminal care. The home is privately owned by Avon Care Homes Ltd. The company has another nursing home in Wells, Somerset, where its administrative operations are based. The principal company director is Mrs Maria Cristina Bila, who regularly visits Bybrook House. The home is in a rural area, close to the village of Box. The city of Bath is approximately five miles away. The house is an attractive older building. It has extensive grounds, with pleasant views of surrounding countryside. The majority of service users have single rooms. There are three bedrooms which may be shared, if people wish. These can also be occupied as singles, for a higher fee. There is a passenger lift serving the home’s three floors. Some rooms can only be accessed via small flights of steps. A number of bedrooms have en-suite toilets, and two have baths also. There are five baths for general use, with at least one per floor. There is an adapted bath on the first floor. Fees charged to service users vary, depending whether nursing care is being
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 5 provided by the home. Without such input, the lowest weekly fee is £637. With nursing care, the minimum charge is £791 per week. The highest weekly rate is £1132, or £1600 for a larger room. All of these figures are the rates charged to new service users. Existing residents may be paying less. Information for prospective service users is available on request from the home. It includes a brochure and a service user guide. Various relevant information is also on display in the entrance hallway. This includes contact details for the CSCI, and a copy of the home’s most recent inspection report. CSCI contact details are also contained in service users’ contracts, and in the home’s complaints procedure. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This Key inspection was completed in June 2006. The evidence gathered included pre-inspection information supplied by the service; surveys from service users’ relatives, and staff of the home; and a review of regulatory contact since the previous main inspection in September 2005. This included additional inspection visits in December 2005, and in January and March 2006. These were to follow up on requirements, most of which were to do with staff records and recruitment. Three visits then took place to the home. The first of these, on 2nd June 2006, was unannounced. The second, on 5th June, was by appointment, to complete the inspection process and give initial feedback. A final visit was carried out by the CSCI’s pharmacist inspector on 13th June, to follow up on issues regarding medication which had been identified during the inspection process. The fieldwork section of the inspection included the following: observation of care practices; sampling of records, with case tracking; discussions with service users and management; sampling a meal; and a tour of the premises. There were 18 service users at the time of this key inspection. 18 survey forms were completed and returned by relatives. During the inspection visit the inspector met with most of the service users, and spoke in more depth with three of them. Twelve staff completed surveys. What the service does well:
Bybrook House is providing a service which most service users and their families are generally satisfied with. A range of positive feedback was received over the course of this inspection. Comments included: “I am happy with the way Bybrook is run and thankful [my relative] is well cared for”; “I have been very happy here… I feel well looked after”; “Very friendly and dedicated staff”; “I think it is a very good home and I would recommend it to anybody.” Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 7 There are effective systems for the assessment and admission of new service users. The home is also thorough in re-assessing people who have had a stay in hospital. This means that there is a clear picture of the current needs for each person who enters the home, and that care can be delivered accordingly. People can feel confident that they will receive appropriate and effective nursing care. Health care at Bybrook House has consistently been complimented by service users and families as an area of particular strength. Comments received this time included: “The staff are very kind, especially when people are ill” The home provides a pleasant environment for people, both in individual rooms and communal areas. It is attractively furnished and decorated in many areas, and is kept to a good standard of cleanliness. This enhances quality of life for the home’s residents. Service users’ rights and dignity are respected. People have choices, such as what food to eat. Relevant specialists are consulted in identifying equipment and therapies that will help people to live with particular health needs, and keep some independence for as long as possible. Bybrook House has been through a period of additional regulatory activity, including extra inspection visits during the year between April 2005 and March 2006 to follow up on unmet requirements. Throughout this period, the registered provider has shown a willingness to address any issues of concern. Suitable steps have been taken to resolve deficits. Following this Key inspection visit, some steps have already been taken promptly to respond to the requirements made this time. Service users can be confident that the home takes appropriate action in response to the findings of CSCI inspections. What has improved since the last inspection?
Serious deficits had been identified in recruitment practices, placing the protection of service users at risk. These have been addressed. Employees who had been working without the required checks having been completed were removed from their duties until this had been remedied. All staff now working in the home have had the minimum requirement of a check to ensure that their name is not on the national list of those considered unsuitable to work with vulnerable people. All staff now also obtain a full Enhanced Disclosure from the Criminal Records Bureau. To minimise any risk of future problems arising, the company has devised a recruitment pack. This provides a checklist of all the necessary checks to be completed. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 8 Overall, staff records at Bybrook House had been in a poor state, with many required documents missing. The company has made determined efforts over recent months to remedy this. The administrator, who is based at another home in Somerset, has given a lot of input to the task. Regular updates have been provided to the CSCI, and by May 2006 the home had succeeded in having copies of all required records for all employees of Bybrook House. Steps have been taken to improve the security of the room where medication is kept. This helps to ensure that items will not be accessible to anyone who shouldn’t be able to reach them. Service users can be confident that their medication is being stored safely. Appropriate signs are in place for all areas where oxygen cylinders are kept, including those that have been used. This helps to promote safety for everyone in the building. A recommendation relating to the disposal of medication has been met. A suitable contract is in place. Kits are available for the ‘de-naturing’ of any controlled drugs before their disposal. This means they cannot be misused by anyone else. The medication procedure has been updated to include information about these arrangements. There has been an extensive programme of repair and decoration, to improve service users’ environment. Damaged areas of walls and ceilings have been replastered and repainted. Various bedrooms have been redecorated, including replacement of any damaged woodwork. Some new electric cabling has been installed. Sluices have been upgraded. The main issues identified for attention during inspections in 2005 have now all been resolved. Work is to continue on improving the decorative appearance of the home, as resources permit. Progress has been made on National Vocational Qualifications (NVQs) for carers after a long period of difficulties. The home is now above the 50 threshold for care staff with the qualification at Level 2. This means that service users benefit from having more of their support provided by people who have gained relevant knowledge and skills. Hot water has been regulated for baths and showers, so that it can only reach an approved maximum temperature. This means that service users will not be placed at risk of serious injury through immersion in hot water. Arrangements for fire safety have improved, protecting the welfare of all users of the building. All relevant checks, practices and instruction are now being carried out and recorded at the necessary intervals. Recent visits by the fire service have found the arrangements at Bybrook House to be suitable. All service users now have an updated contract of residence, setting out the terms and conditions. It is clear what is covered by the fee paid for care and accommodation, and what will be charged for additionally. This gives
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 9 prospective service users and their representatives necessary information to help their decision about whether to choose this home. What they could do better:
The home has been without a registered manager since the previous one left in September 2005. There has been a delay in putting forward a new applicant for registration, because a matron was appointed, but only stayed for a short time. Mrs Rosemary Goff has now been promoted to matron, and needs to submit an application for registration to the CSCI. It is important for a registered home to have a registered manager, as this is the key person who can be held accountable for the welfare of its service users. The home is supporting some service users with particular additional needs, such as dementia. It is not yet clear how these elements of need are being supported. This must be done effectively, either by the home adjusting its own resources, or by ensuring that the support is provided from elsewhere. Individual service user plans must demonstrate that all needs of each person are being met. A number of issues were identified in relation to medication. These covered recording; the reporting and following up of errors; risk assessment for any service user retaining some of their own medication; and guidelines for the use of drugs prescribed to be given ‘as required’. The home must ensure safe practice in all aspects of medication management, so that service users are not placed at risk. There was a lack of appropriate awareness about the right steps to take if abuse of a service user is alleged or suspected. This included poor knowledge of the local multi-agency procedures for adult protection. Service users could not be confident that the necessary steps would be taken in the event of possible abuse. Recruitment records for a staff member due to start working in the home shortly were not all available. When they were produced, the references were not entirely satisfactory. As a great deal of work has been undertaken to get the home’s recruitment practices and records up to the required standard, it is important not to let this slip again. Service users need to have confidence that they are protected by robust procedures for staff recruitment. The home does not yet have a completed training plan. This needs to provide evidence of what topics are covered, and show that all staff members receive the minimum three days paid training that is required per year. The plan could include any courses which staff are to attend; any topics to be discussed inhouse, perhaps during staff meetings; and also show time allocated to individual employees for study, such as any nurses undertaking courses, or carers working towards NVQ awards.
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 10 Induction of new staff needs review. In particular, the approach for care staff must be revised so that it ties in with the national standards that have been developed for this workforce. This will address the concerns raised by some staff about practice in this area, and ensure that service users benefit from new staff receiving adequate support. Systems for individual supervision of all staff need to be reinstated, so that their conduct and practice is regularly reviewed and developed. This will help to drive up the overall standard of care in the home, to the benefit of its service users. The manager has already supplied information which indicates that substantial progress should be made on this issue shortly. Not all relatives who completed surveys were aware of the home’s complaints procedure. This information should be publicised again, as it is important for all service users and their relatives to know how they can raise any concerns, and what response they can expect if they need to do so. Quality assurance measures for the home could be enhanced if the groups surveyed also include Bybrook House’s staff. It is clear from their responses to this Key inspection that the home’s team have a range of valid topics for discussion, and they should be enabled to contribute to service review and development. This will ensure the involvement of a key stakeholder group in the quality assurance process. The home has already taken some steps to address this recommendation. There should also be an overall service development plan. At the moment, various actions are identified from the various ways in which service quality is measured, and these do seem to be followed up. A single plan would help to provide clearer evidence of continuous service development, and could show how this is done in line with the wishes and preferences of service users. 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. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 11 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 Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 12 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have individual terms and conditions of residence in the home. Prospective service users have their needs assessed, so that a decision can be agreed about whether or not the home will be able to meet these. The service needs to review its resources and facilities, to demonstrate that it is able to effectively support all the needs of all current service users. Standard 6 is not applicable to this service. EVIDENCE: All service users have up-to-date contracts, which set out the terms and conditions of residence in the home. These include the fee charged to each individual. It is made clear what is covered by this, and what has to be paid for in addition.
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 13 A number of relatives made comments about being charged for special equipment, such as beds, mattresses and chairs. This issue was discussed with the provider during the inspection. The home’s contracts say that “All nursing care (not including nursing products or other special equipment required) … included in the fees.” The home must provide suitable adaptations and equipment for service users who need these, because Care Homes Regulations require this. When the home is admitting someone, it must ensure that it has all the necessary resources to support all of their needs. This needs to be made clear in the service’s Statement of Purpose. Bybrook House does have certain equipment to meet special needs. For instance, because the home can provide terminal care, it has a syringe driver. This is a device for giving medication to relieve pain when someone is in the final stages of life. The home also has a range of equipment to use in moving and lifting people, such as hoists. Problems can arise when a service user’s needs change over time. Then there needs to be individual review and consultation about whether the home can still support them, and what extra resources might be needed. There also has to be a dialogue about how to provide these. The home has purchased or contributed to the cost of some equipment for individual service users. Pre-admission and assessment processes are carried out effectively. The format used by the home covers all required areas. Service users are reassessed following hospital admissions. The home has clear information about which needs it can and cannot meet. These are explained in its Statement of Purpose. Most care needs are being met. Comments from service users and families show satisfaction with how Bybrook House is doing this. For instance, one service user staying for short term care, after periods in hospital, said “It was lovely to come to this haven… I am very grateful to the home for restoring me to life.” The person was now feeling much healthier and happier again, and hoping to be able to return to their own home soon as a result. There needs to be more evidence of how specific additional needs, such as dementia, are planned and cared for. Many service users are likely to have some level of dementia, and for this to develop over time. The home has also recently admitted someone already diagnosed as having “very profound” dementia. Bybrook House does not have the specific registration category which would show that it can provide specialist dementia care. So it needs to show how anyone with such needs has these met properly, within their overall individual care. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 14 The new admission was discussed during the inspection. The service user’s other physical health needs make their placement at Bybrook House appropriate. It also fits in with the wishes of their family. But the home acknowledged that they have not yet got a fully structured programme for the individual. A referral has been made to a consultant for input about the service user’s dementia. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 15 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have their abilities, needs and goals reflected in their individual plans. Service users are supported to address their personal and health care needs effectively. Service users are placed at risk by deficits in the home’s practices for the administration and recording of medicines. The manager has recently made improvements in the area of medication handling. These must be followed by all staff to ensure the service users’ safety. Service users have their privacy and dignity respected. EVIDENCE: Three service user plans were sampled during this inspection. All cover relevant areas and show evidence of review and updating. Concerns are
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 16 followed up. Individual plans are reviewed when necessary. For instance, one service user who underwent a significant deterioration in health earlier in 2006 had a comprehensively revised plan, to reflect the changes in support required. The care given by staff of the home is based on the needs of each service user. When these increase, additional support can be given. For instance, when one person became very frail and dependent, nursing and care staff were checking on and assisting the person at least once every 15 minutes. There is clear evidence of input from various professionals. People with more complex needs have access to specialist advice. Plans also address emotional and psychological needs, such as supporting people through bereavement, or identifying the activities they may enjoy. Bybrook House has consistently been praised by service users and relatives for the quality of health care it provides. Similar feedback was received on this occasion. Care is delivered in ways that uphold the privacy and dignity of service users. Support given by staff is carried out respectfully. Intimate care tasks are always carried out in private. The needs and preferences of service users are set out in their individual care plans. Arrangements for storage of medication are appropriate. The security of the room where most drugs are kept has been improved, with bars fitted to an external window. Some oxygen is kept in the home. Signs are in place for all rooms where cylinders are stored. This includes ones that have been used and are waiting to be returned. Care homes providing nursing have to have special contracts for the disposal of any unused medication. Bybrook House has suitable arrangements. Kits are available for the ‘de-naturing’ of any controlled drugs before disposal. This means they cannot be misused by anyone else. The medication procedure has been updated to include information about these arrangements. Various deficits were found in practices relating to the management and administration of medication. The home has two folders of medication administration record charts. Looking through one of these, there were several issues leading to requirements. No medication errors or issues picked up by the matron had been notified to the CSCI. This is required under Care Homes Regulations. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 17 Medication charts have boxes for times when drugs are due to be given. Staff must sign these to show that a service user has had the drug, or use a code to explain reasons why not. Sampled charts had occasional boxes with no signature or code, so it wasnt clear if that dose had been administered or not, or any reasons why. A short-term care service user was the only person doing any self medicating. This person was keeping their own Paracetamol. The home were managing all the service user’s other drugs. There was no documented risk assessment in place for the self medication. This hadn’t been done because the person was only staying for a short time. But the proper systems have to be in place whenever relevant. Another service user is prescribed medication ‘as required’, to help the management of agitation, and is given this occasionally. There is no documented guidance about how to take the decision to give this drug. This is necessary to show that the prescription is being followed properly, and that all staff do so consistently. One service user is prescribed a particular drug in the mornings only. But on seven consecutive days this had been signed for at 18:00 as well, until the mistake was noticed. This appears to be poor recording, rather than giving the drug when it shouldn’t have been. But there was no record about the actions being taken once the issue had been spotted. Another service user is prescribed a drug which has to be given just once a week. The next due date had been clearly shown on the medication chart, but the dose which should have been given on 30th May was not administered until 1st June. Again, there was no record of the actions being taken in response to this. Shortly after the inspection visit the manager provided evidence of steps the home is taking about many of these issues. The CSCI’s pharmacist inspector then visited on 13th June, and her report is contained in the paragraph below. Medication and records were inspected and discussions held with the deputy matron. Medication is stored securely and relevant records completed. The home has an appropriate policy and recent efforts have been made by senior staff to ensure nurses comply with it. Evidence was seen of medication not being signed for but this had been corrected and staff reminded of their responsibilities. A self-medication policy is available but there were no residents managing their own medicines at the time of the inspection. Care plans have been completed for medication prescribed on an ‘as required’ basis. A suitable system was in place for the disposal of unwanted medication. Certain medication was frequently recorded as refused or not required by residents. This should be brought to the attention of the GP for review. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 18 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are provided with a range of activities and opportunities. Service users are able to maintain and develop appropriate relationships with family and friends. Service users are supported to exercise choice and control in all aspects of their daily lives. Service users are offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. EVIDENCE: Bybrook House’s activities co-ordinator had been absent for a few weeks before this inspection took place. The home is trying to recruit another parttime employee to assist with this area. In the meantime, nursing and care staff provide sessions when they can. These usually take place in the afternoons. Service users confirmed that sessions are continuing to take place, and commented that they enjoy them.
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 19 When a new activities co-ordinator has been appointed the home hopes to develop its approach further. The current programme meets the needs of some of the service user group, but could be reviewed to include others. Service users have regular contact with family and friends. Visitors can be seen coming and going regularly. Most service users tend to receive guests in their own rooms. A number also have their own phone lines. Service users who are able to do so continue to do things outside the home. Often they may go out with their families. The home also arranges trips and outings occasionally. A number of service users attend events in the local village, such as concerts at the church. Service users can choose where to spend their time, and what they would like to do during the day. They commented that staff are good at responding to their needs and wishes. Individual reviews are an opportunity for service users and their relatives to have input into decisions about overall care. The service is also hoping to develop consultation with its users on the running of the home. The possibility of setting up a residents’ committee is being considered. Service users commented that the food at Bybrook House is good. The home’s chef was absent at the time of this key inspection, so agency cooks were being used. The home is also in the process of trying to recruit a weekend chef, and more kitchen assistants for afternoons and weekends. Menus are drawn up in advance. Each service user is then asked, during the morning, which options they would like for lunch and tea. Service users confirmed that this happens every day, and that you can choose something different if you want to. The main midday meal on the first day of this inspection visit was sampled, in the company of service users. It was of good quality, and fresh ingredients had been used. Portion sizes were appropriate. Any service users who needed staff support with eating had the same person sitting with them throughout the mealtime. Support was given appropriately, at a pace suitable to the service user. People can have meals in their own rooms if they prefer. Some service users said that they like to do this. Service users also confirmed that drinks and snacks can be requested at any time. One person was particularly grateful that they can get staff to bring them a drink during the night, if they are unable to sleep.
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 20 Bybrook House can support people with special dietary needs. At the time of this inspection, this included people with diabetes, and several who needed to have their meals pureed. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 21 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are protected by procedures for the investigation of complaints. Service users are placed at risk by a lack of awareness at management level of appropriate abuse protection procedures. EVIDENCE: The home’s complaints procedure is displayed in the main entrance hall, and included in the Service User Guide. Contact details for the CSCI are shown. There is a suitable recording format to show actions taken in response to issues raised. No complaints have been received since the previous inspection. A survey of the relatives of all current service users did not identify any complaints that people wished to raise. However, some people commented that they were not aware of the complaints procedure. One relative commented that the home’s senior staff are “understanding and professional”, and “willing to listen to concerns.” There is a lack of awareness of abuse and protection procedures, now that the previous registered manager has left. At previous inspections evidence has been seen of the service’s own procedures, along with information about the
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 22 multi-agency adult protection process in Wiltshire. But these documents could not be found this time. The manager was not fully confident about what would be the correct steps to take if possible abuse was reported to her. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 23 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: The home provides a pleasant environment for people, both in individual rooms and communal areas. It is attractively furnished and decorated in these parts. A range of work has been carried out over recent months. This has improved the overall quality of the environment. Other areas remain for attention when resources permit, but no urgent priorities were noted at this inspection. Service users who met the inspector during this visit commented on how much they like their rooms. People can bring in their own items, such as furniture and pictures, to make their own room feel homely. Some people like to spend
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 24 a lot of time in their own rooms, commenting that they feel so comfortable there. But service users also confirmed that they do enjoy spending time in communal areas, such as the lounge and dining room. Various people were observed using the lounge over the course of the day. Twelve service users had their midday meal in the dining room. Bybrook House also has grounds and gardens available for service users to relax in. Comments from service users showed how much they enjoy the opportunity to use these for short walks. People also like simply having nice views from their windows. Not all bedrooms are accessible to all service users, because some can only be accessed via small flights of stairs. This is reflected in the home’s conditions of registration. When existing residents become more frail, it is occasionally possible that they may need to move to a different room. This is done by agreement with the individual or their family. A new nurse call system was installed throughout the building in 2005. This resolved the main problem with the previous system, which was the lack of an effective emergency call facility. The new call points are also easier for people to operate. Service users said that the system works well. However, some relatives commented that response times from staff can be slow. The manager agreed that this issue has been raised in some care review meetings as well. As a result, the home is arranging to carry out an audit to identify any patterns, such as times of day when response times may be slower. Suitable actions can then be taken to improve things. The home appeared clean and hygienic in all areas seen during the inspection. Bybrook House employs domestic staff who carry out a range of tasks, including cleaning and laundry. Service users commented that the home is always clean and tidy. Feedback from relatives also mentioned this. Flat linen, such as bedding and tablecloths, is sent to be washed by an outside contractor. All other laundry is done at Bybrook House. There are appropriate arrangements for collecting items for washing, and dividing them into loads. Infection control risks are minimised by the approach used. For instance, heavily soiled items are placed in special bags, which can then go straight into the washing machine. This reduces the need to handle the laundry. The washing machine has a suitable programme to get such items clean and disinfected. Some feedback from relatives commented that there have been problems with the laundry, with clothes ruined by being washed incorrectly. The home are aware of the issues, and have reimbursed people who had items damaged. A Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 25 working party was set up to address the issues, and these now seem to have been resolved. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 26 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported by suitable numbers of staff. The home is unable to evidence that appropriate recruitment processes are in place, to ensure the protection of service users. There is insufficient evidence that staff receive relevant training to assist them in meeting service users’ needs effectively. EVIDENCE: Bybrook House was registered under previous care and nursing home legislation. This means it has to maintain staffing at the same level set before April 2002. Staff numbers may vary, depending upon how many service users are in residence. At the occupancy level at the time of this inspection, the home was running on five staff in the mornings; three for afternoons and evenings; and three waking staff overnight. Because the home is registered to provide nursing care, a qualified nurse is on duty at all times. Sometimes there are two nurses on the same shift,
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 27 depending on the particular skill mix. Nursing staff are supported by a team of carers. Bybrook House also employs its own staff for other key tasks, such as catering, cleaning, and maintenance. The home had almost all the nursing and care staff it needs. One vacant night time post for a qualified nurse was about to be filled, once all recruitment checks were completed. It is also hoped to recruit one more part time qualified nurse for night duty work. Surveys from staff and relatives contained some comments about pressure on staff, leading to delays in attending to service users’ needs. But no serious concerns were raised, and the general message from all feedback is that good quality care is provided. Recruitment practices at Bybrook House have been checked extensively over recent months. Serious deficits had been identified, which the home has worked hard to sort out. All staff now working in the home have had the minimum requirement of a POVA First check. This ensures that their name is not on the national list of those considered unsuitable to work with vulnerable people. This check forms part of a full Enhanced Disclosure from the Criminal Records Bureau, which is also now carried out for all staff. Employees from overseas, who had been working without these checks having been completed, were removed from their duties in January 2006, until this had been remedied. By May 2006 the home succeeded in having copies of all required records for all employees of Bybrook House. To minimise any risk of future problems arising, the company has devised a recruitment pack. This provides a checklist of all the necessary checks to be completed. However, at this inspection visit there were still difficulties in finding the evidence of all recruitment checks for one recently appointed person. This staff member had not begun working at the home, as the result of their POVA First check hadn’t been received yet. But the person’s application form, and copies of their references, couldn’t be produced at inspection. The references were found shortly afterwards, and copies sent to the CSCI. Two of these dated from 2000 and 2001, representing general testimonials about the person’s qualifications and character at that time. A more recent reference was from the person’s last employment in care, as required. However, it had not been requested directly by Bybrook House, but was a copy of a reference supplied to the Nursing and Midwifery Council to support the
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 28 person’s application to be registered to practice as a nurse in the United Kingdom. Having done a lot of work to sort out recruitment practices and records, the home now needs to ensure that these continue to meet all the requirements. Comments from staff indicate the need for more focus on training. In particular, staff recruited from overseas have fewer opportunities to access courses, because funding isn’t available for them. The manager agreed on the need to make progress with training. One of the nursing team has been put in charge of this area. Some courses have been attended by various staff, and others are planned for coming months. The home is also aiming to develop in-house training sessions. These can take advantage of the knowledge within the staff team, and can focus on topics relevant to the care of service users. A programme for the period June to November 2006 has now been drawn up. This includes topics such as pressure ulcers, dementia care and Parkinson’s disease. There will also be case studies on particular service users, to be decided by discussion with the care staff. There is no overall training and development plan, to provide evidence of what areas are covered, and demonstrate that all staff members receive the minimum three days paid training that is required per year. Groundwork has been put into this task, as seen at additional inspection visits earlier in 2006. Files have been provided to maintain an individual training record for each staff member. Employees have been asked to provide copies of any relevant certificates they have gained. Overall summary sheets have been devised for three groups of employees – qualified nurses; carers; and ancillary staff. These will give a clear visual record of what training each person has completed, what they need to do, and when any updates are due. Comments from staff also highlighted that induction for new starters is not always effective. Some people felt that they did not know enough about the needs of service users before they had to start working with them. The home needs to review its induction process. For carers, it is important to ensure that this is linked to the relevant national standards for the social care workforce, which serve as a pathway into National Vocational Qualification training (NVQs). Records need to be maintained to provide evidence of each employee’s induction. The summary training record should also be amended, to include a note of when induction has been completed. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 29 Progress has been made on NVQs for carers after a long period of difficulties. The home is now above the 50 threshold for care staff with the qualification at Level 2. Some of these staff are now due to go on to study for the Level 3 award. Other care staff will also be starting NVQ Level 2. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 30 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35, 36 & 38 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Standard 31 was not applicable at this inspection. Quality assurance measures underpin service developments, and include actions based on the views of service users. Staff are not supported and supervised effectively, which hinders their delivery of a service to meet its users’ needs. Service users are protected by the home’s approach to upholding health and safety. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 31 EVIDENCE: The home’s previous registered manager left Bybrook House in September 2005. A new manager was then recruited, and started in November 2005. But they then left, after only a short time in post. Mrs Rosemary Goff, one of the home’s existing nursing staff, has now been appointed as the new matron. She is due to apply for registration with the CSCI. Mrs Goff has not yet completed her registration application, and needs to attend to this without further delay. Other senior nursing colleagues at the home also remain in post, and are providing assistance to the manager. There is a deputy matron. Other staff are also being delegated specific areas of responsibility. Mrs Goff and another senior nurse are due to start NVQ Level 4 management training. Comments received by the CSCI from staff raised a number of concerns. As well as the training and induction issues already mentioned, the lack of individual supervision meetings was raised by several people. The manager confirmed that the system used previously in the home has lapsed, and needs to be reinstated. The home is aware of some of the issues and concerns which staff have. It needs to ensure proper consultation and supervision systems, to enable these to be explored and addressed more fully. Meetings have been held for qualified nursing staff recently. The manager also intends to set up meetings for other groups of staff, and to consider holding more general sessions across the whole team. Detailed information was supplied shortly after the inspection visit to show the planned approach for individual supervision and appraisal of all staff. Policies and procedures are being put in place. There is information for staff about the purpose of supervision meetings, and how they will be carried out. Senior staff have been allocated groups of people who they will act as supervisors for. Supervision contracts will be agreed, and records will be kept of each meeting. Appraisal forms have also been devised for the various different jobs in the home. This includes nursing, care, kitchen and domestic staff. There was also positive feedback from staff. People commented that they feel good care is provided at Bybrook House. There were also references to a “very friendly and warm atmosphere.” Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 32 The principal director of Avon Care Homes, Mrs Maria Cristina Bila, acts as the ‘responsible individual’ for the company. Mrs Bila meets the statutory requirement of completing monthly reports on the conduct of the home, based on her visits to Bybrook House, and meetings with service users, visitors and staff. These reports address a number of criteria prescribed by regulations. Copies are supplied to the CSCI. They provide useful evidence of how progress in the home is being monitored and reviewed. Arrangements are in place for consultation with service users and their families. Surveys are conducted at least annually. The results of these are published and displayed in the home. The most recent took place in August 2005. The topics covered included the environment, activities, care, food, and the response to queries or complaints. Various actions have been taken in response to points arising from the survey. The next survey is planned to take place in the near future. An updated action plan can then be drawn up. It would be sensible to survey staff for their views at the same time. The manager has now provided evidence that a format has been drawn up to do this. The home does not get involved in the management of service users’ money. If people are no longer able to manage it themselves, they need to have a relative or someone else who will help them. All service users have lockable storage in their own rooms, so that there is somewhere safe to keep any money and valuables. Key health and safety concerns raised at recent inspections have now been resolved. Risk assessments seen during the inspection visit dated from several years ago. More recent ones were found and copied to the CSCI shortly afterwards. The manager has also reviewed and updated these at the same time. There are risk assessments and management plans for the few remaining uncovered radiators. Some are not considered by the home to present a high risk, such as those in the dining room. They are being retained, because their style is in keeping with the overall appearance of the room. Some other radiators, in service users’ bedrooms, have now been identified as needing to be covered. Another safety topic the home has identified as needing attention is to secure a number of wardrobes in service users’ bedrooms to the wall. This will remove the danger that they could cause serious injury by falling on to someone. The fitting of temperature regulators to hot water outlets throughout the building has been carried out. Water temperatures are regularly checked and Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 33 recorded. The temperature for two baths, checked by hand during the inspection, was at an appropriate level. Hazardous substances, such as cleaning materials, are stored in locked cupboards when not in use. The home has obtained product data sheets, which are information from the manufacturers about the possible dangers from each substance, and what to do if there is a problem. The home’s fire log book was seen. All required checks, instruction and practices relating to fire safety are recorded as being carried out and up to date. Recommended replacement of smoke strips on some doors has not yet taken place. Checks are therefore being recorded with a note that these are not up to the relevant fire safety standards. There have been four recent call outs of the fire brigade to the home, when the alarm system was activated. One of these was a fault. The others were caused by burning food, and by fumes from a heater in part of the building which is used only for staff accommodation. These events were not notified to the CSCI when they occurred, which is required by Care Homes Regulations. On each call out, a fire officer completes a short report. The recent reports, in March, April and May 2006, all indicate that the fire safety arrangements at the home are considered to be appropriate. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 34 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score N/A 3 3 X 3 2 X 2 Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 35 Are there any outstanding requirements from the last inspection? No 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 OP4 Regulation 12-1 14 Requirement The persons registered must demonstrate that the home can meet all assessed needs of service users, by an initial review of care plans, leading to an action plan with suitable timescales. Errors relating to the management and administration of medication must be notified to the CSCI without delay. A record must also be kept of any actions taken by the home in response. COMMENT: The manager has already supplied information about how this requirement will be addressed. 3 OP9 13-2 17-1a Sch3-3m There must be suitable risk assessments and management plans to support service users retaining any of their own medication. COMMENT: The manager has already supplied information about how this requirement will
Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 36 Timescale for action 28/07/06 2 OP9 13-2 37-1e 13/06/06 13/06/06 be addressed. 4 OP9 13-2 17-1a Sch3-3m There must be clear guidance on the criteria for administration of medication prescribed on an ‘as required’ basis. COMMENT: This requirement has already been addressed for the example raised during the inspection. 5 OP9 12-1a Service users’ GPs must be informed of any consistent refusal to take medication, or where medication appears to be no longer necessary. There must be suitable procedures for protection of service users from abuse, including information about the local multi-agency process, available in the home; and these must be followed appropriately. Staff records must contain evidence that all required recruitment checks are carried out. Statutorily required records must be available for inspection in the home at all times. This part of Regulations also applies to the above Requirement. There must be a staff training and development plan which ensures that all staff receive training to meet the aims of the home and the needs of service users. This must include a minimum of three paid days training per year for all staff. All staff must receive suitable induction training, in line with national targets for the social
DS0000015894.V298372.R01.S.doc 13/06/06 13/06/06 6 OP18 13-6 28/07/06 7 OP29 7;9;19 Sch2 14/07/06 7 OP29 17-2,3b Sch4-6 17-2 Sch4-6g 18-1c 14/07/06 8 OP30 28/07/06 9 OP30 17-2 Sch4-6g 18-1c 30/09/06 Bybrook House Nursing Home Version 5.2 Page 37 care workforce. 10 OP31 8-1 The person appointed to manage the home must apply to the CSCI for registration as manager. From this point forward, all staff must have regular, recorded supervision meetings at least 6 times a year. COMMENT: The manager has already supplied information about how this requirement will be addressed. 12 OP38 37-1e Any activation of the home’s fire alarm system which leads to attendance by the fire service must be notified to the CSCI without delay. 13/06/06 28/07/06 11 OP36 18-2a 13/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP16 OP32 Good Practice Recommendations All service users and their relatives should be reminded of the home’s complaints procedure. Staff should be given more opportunities to contribute to the conduct and development of the home, through staff meetings, and by being included in quality assurance surveys. COMMENT: The manager has already supplied information about how this recommendation will be addressed. 3 OP33 Actions identified from quality assurance audits and surveys should result in the production of an annual
DS0000015894.V298372.R01.S.doc Version 5.2 Page 38 Bybrook House Nursing Home development plan for the home. 4 OP38 Actions identified in the home’s recently updated risk assessments should be taken without delay. Bybrook House Nursing Home DS0000015894.V298372.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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