Inspection on 30/09/05 for Bybrook House Nursing Home

This inspection was carried out on 30th September 2005.

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

Bybrook House Nursing Home 16/12/08

Bybrook House Nursing Home 25/07/08

Bybrook House Nursing Home 19/09/07

Bybrook House Nursing Home 17/05/07

Bybrook House Nursing Home 02/06/06

Bybrook House Nursing Home 29/04/05

Bybrook House Nursing Home 08/10/04

Bybrook House Nursing Home 02/07/04

Bybrook House Nursing Home 11/02/04

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

CARE HOMES FOR OLDER PEOPLE Bybrook House Nursing Home Middlehill Box Wiltshire SN13 8QP Lead Inspector Tim Goadby Unannounced Inspection 30th September 2005 09:50 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.V255107.R01.S.doc Version 5.0 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.V255107.R01.S.doc Version 5.0 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 Mrs Gillian Penelope Lloyd 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.V255107.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Rooms 25, 26, 27 & 28 may not be used for nursing care due to unsuitable access 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 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 5th May 2005 4. 5. 6. 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. But the home can also take up to 6 people who have physical disability, and 2 people for terminal care. The home is privately owned and operated, by Avon Care Homes Ltd. The company has another nursing home in Wells, Somerset, where its administrative operations are centred. The principal company director is Mrs Maria Cristina Bila, who has regular input into Bybrook House. The home is located in a rural position, close to the village of Box. The city of Bath is approximately 5 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 3 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 3 floors. But some rooms can only be accessed via small flights of steps. A number of bedrooms have en-suite toilets, and 2 have baths also. There are 5 baths for general use, with at least 1 per floor. An adapted bath is situated on the first floor. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in September 2005. The lead inspector was accompanied for part of the day by the pharmacist inspector, who checked medication systems and practice. A total of 8 inspector hours were spent in the home. The following inspection methods have been used in the production of this report: indirect observation; pre-inspection questionnaire, completed by the provider; sampling of records, with case tracking; sampling a meal; sampling activities; discussions with service users, staff and management; survey of service users, relatives and professionals; tour of the premises. After the inspection visit took place, the CSCI contacted the provider to obtain further information on some areas, where it had not been possible to gain a complete picture on the day. What the service does well: There were 19 service users in residence on the day of this inspection. Around half of these met with the inspection team, for varying periods of time. All appeared well, and expressed satisfaction with the care provided by the home. One said that they would recommend Bybrook House to anyone. 14 comment cards were received by the CSCI, 10 from service users, and 4 from relatives. Feedback from these was largely positive. All service users felt well cared for, and all relatives were satisfied with the overall care provided. 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 spell 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. Health care at Bybrook House has consistently been cited by service users and families as an area of particular strength. Comments received this time included “The care my father has been given over the past 3 years … has been excellent”; and “I am very happy with the level of professional help for my mother.” People can feel confident that they will receive appropriate and effective nursing care. The home generally 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. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 6 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 maximise their independence for as long as possible. What has improved since the last inspection? The previous inspection took place in April and May 2005. Since that time, the principal director of the company, Mrs Maria Cristina Bila, has completed the process of registration with the CSCI as the ‘responsible individual’ for Avon Care Homes. In connection with this approval, Mrs Bila was required to give undertakings about the satisfactory fulfilment of her role. These included ensuring that outstanding requirements from previous inspections were resolved, to avoid the necessity of further enforcement action. A number of these issues had now been fully resolved. A new nurse call system has been installed throughout the building. Service users and staff reported that this was working well. The main problem with the previous system – the lack of an effective emergency call facility – had been resolved. Risk assessments have been completed in respect of any remaining uncovered radiators in the building. Some had been removed, where they presented a particular hazard. The fitting of temperature regulators to hot water outlets throughout the building has been carried out. The temperature for two baths checked during the inspection was at an appropriate level. A fuller programme of activities is being provided again, following the appointment of a staff member to lead in this area. A range of sessions are being offered, including both group and individual activities. The activities coordinator described the various ideas that she has implemented. Several service users spoke about how much they are enjoying different activities. On the day of the inspection, a number of people were seen participating in a music session in the lounge. Various key documentation has been completed to the required level. The home’s Statement of Purpose, and Service User Guide, now incorporate all of the necessary information. Terms and conditions of residence for individual service users have been updated, to the organisation’s current version. Mrs Bila must also meet 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 must address a number of criteria prescribed by regulations, and copied must be supplied to the CSCI. The reports have been completed in appropriate detail over recent Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 7 months, and provide useful evidence of how progress in the home is being monitored and reviewed. What they could do better: Although hot water regulators have been fitted, the problem of delivering water at the required safe temperature had not been fully resolved. The home’s own record of temperature checks, provided shortly after the inspection, indicated that, when last checked, every outlet was delivering hot water up to 10 degrees higher than the safe level. Whilst some fluctuations in temperature are likely, and can be rectified by adjustment, this level suggests a more serious problem, placing service users at risk of harm. Following the inspection, the provider arranged for the company who installed the regulators to return and address the issue. This work took place on 14th October 2005. The company has been engaged to return and conduct further checks in November, and there is a proposal to contract with them to carry out thorough checks and maintenance every 6 months. This would be in addition to the home’s own weekly checks. Some premises issues remain to be addressed. Throughout the building, there are areas of décor in need of renewal. These are chiefly in traffic areas, such as corridors and landings, rather than in individual or communal accommodation. But they detract from the overall quality of the environment, and could indicate underlying structural issues in need of attention. The timescale for addressing these issues, set at the previous inspection, has not yet expired. The provider has indicated that any required works will be completed by that date. There were significant deficits in staff records. On the day of the inspection, it was not possible to establish from the sampled files whether all required recruitment checks had been carried out at the appropriate time. There was also no information available in the home about some recent appointments from overseas, who had been recruited via an agency. So it could not be established that service users were properly protected by safe recruitment practices. Following the inspection, the provider has supplied updated information, indicating that all of the identified deficits have been or are being addressed. Training records were also deficient. There was no overall training and development plan, to provide evidence of what areas are covered, and demonstrate that all staff members receive the minimum 3 days paid training that is required per year. Individual training records were not clearly maintained either. The home must be able to show that service users benefit from being supported by appropriately trained staff. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 8 Some oxygen is used in the home. Appropriate signage was in place in most cases. But used cylinders awaiting collection had been placed in the office. Therefore this door also needed a sign. This is because there may still be a residue present, and emergency services would need to be aware of the issue. Action was taken to address this requirement on the day of the inspection. Some deficits in fire safety practice placed service users at risk. The monthly check of fire fighting equipment had not been recorded for August and September; and the means of escape check had also been missed in September. 2 false alarms on the fire system had been recorded as practices, although guidance specifically states that this may not be done. Recommended replacement of smoke strips on some doors had not yet taken place. Checks were therefore being recorded with a note that these are not up to the relevant fire safety standards. Medication is stored securely. However, due to the increased requirement to store medication for disposal, security of the window in the clinic room must be given consideration. This will enhance protection for staff and service users. A new system is in operation for the disposal of medication, in line with current legislation. The relevant procedure needs updating to reflect this. It is also recommended that any written additions or alterations to the medication administration record should be signed, dated and checked by two members of staff. These changes will improve overall practice, to the benefit of service users. The home was without a registered manager at the time of this inspection. The previous postholder had left shortly beforehand. There were appropriate temporary arrangements in place, and a new matron had just been recruited. This person will need to apply to the CSCI for registration when they take up their post. 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.V255107.R01.S.doc Version 5.0 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 Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Prospective service users have the necessary information to make a choice about the home. Prospective service users have their needs assessed. Service users have their needs and aspirations met by the home. Service users have individual terms and conditions of residence in the home. EVIDENCE: The home’s Statement of Purpose, and Service User Guide, have been reviewed and completed since the previous inspection. They now contain all the required information, in line with the criteria of regulations and standards. 4 service user files were checked for evidence of updated terms and conditions. All had recent versions, although there was an inconsistency, as one person had different documentation to the others. This did not cover all of the same points. It was unclear whether there was any specific reason for Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 11 this. Following the inspection, the provider responded that this appeared to have been an oversight, which has now been rectified. As at previous inspections, sampled records showed that pre-admission and assessment processes are carried out effectively. The format used by the home covers all required areas. Service users are re-assessed following hospital admissions. The home has clear criteria about which needs it can and cannot meet. These are explained in the Statement of Purpose. An example was also seen of a letter regarding an individual service user, in hospital at the time, which clearly set out the factors that would govern a decision about whether or not the person could return to Bybrook House. Feedback from service users and visitors indicated that they are satisfied with the care provided by the home, and feel that it meets people’s needs well. Staff on duty displayed a good knowledge of their service users, and an insight into the relevant factors affecting their quality of life. The home has made substantial progress in resolving areas that were detracting from this, including food and activities. Improving these elements has built on the service’s consistent strength in the delivery of effective health care. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8&9 Service users are supported to address their health care needs effectively. The home follows safe handling procedures with regard to medication. But the security of storage could be improved, to enhance the protection for service users. EVIDENCE: 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. All 10 service users who completed comment cards felt well cared for. All 4 relatives who did so were satisfied with the care given to their family member. They also felt that they were kept appropriately informed and consulted about this. A medication policy and procedure is available to all staff administering medicines in the home. A new system is in operation for the disposal of medication, in line with current legislation. The procedure needs updating to reflect this. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 13 All appropriate records are kept. But it is recommended that all written additions or alterations to the medication administration record should be signed, dated and checked by two members of staff. Oxygen is kept in the home. Appropriate signage was in place in most cases. But used cylinders awaiting collection had been placed in the office. Therefore this door also needed a sign. This is because there may still be a residue present, and emergency services would need to be aware of the issue. Action was taken to address this requirement on the day of the inspection. Photographs of residents are available with the medication administration records. Clear notes are kept of doctors’ visits and changes to medication. Medication is stored securely. However, due to the increased requirement to store medication for disposal, security of the window in the clinic room must be given consideration. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 14 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 & 15 Service users’ expectations and preferences in social and recreational needs are being met. Service users are offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. EVIDENCE: A fuller programme of activities is being provided again, following the appointment of a staff member to lead in this area. This person works 4 half days each week, usually in the afternoons. A range of sessions are being offered, including both group and individual activities. The activities co-ordinator described the various ideas that she has implemented. By offering a range of options, she hopes to encourage as many people as possible to participate, at least some of the time. The focus is not just on group sessions. Activities are initiated which people can then continue independently. For instance, some people were knitting blankets to be supplied to a local premature baby unit. Existing interests of service users are also taken as opportunities to promote engagement for them. The home’s oldest resident, who rarely leaves their room, is a keen bridge player. As other service users also enjoy the game, the aim is to start a group who will play Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 15 together. These sessions can easily take place in someone’s own room, if they prefer it. On the day of the inspection, a number of people were seen participating in a music session in the lounge. A visiting pianist was playing tunes on request, some of which people sang along to. The programme on display for the week incorporated quizzes, card games, bingo, jigsaws, art, and individual sessions. Several service users spoke about how much they are enjoying different activities. They pointed out examples of artwork which has been produced, and is now being displayed. Before the inspection, comment cards from service users showed that 6 people were satisfied with the activities provided, whereas another 4 felt they needed some improvement. Comment cards from service users also showed that 9 out of the 10 respondents were pleased with the food provided. This represents a substantial improvement in an area where the home has been the subject of criticism in the past. A new chef had been appointed around the time of the previous inspection, in April/May 2005. This person remained in post, and the changes which he had implemented had proved popular. A second chef had now also been appointed, so that the home was able to cover the whole week without recourse to agency cooks. The main midday meal on the day of this visit was sampled, in the company of service users, and was of good quality. Choices were seen to be available, in line with individual preferences. Special dietary needs were catered for appropriately. For instance, people needing food to be pureed had this done separately for each item, and care had been given to appropriate presentation of the meal. Any service users who needed staff support with eating had the same person sitting with them throughout the mealtime. Support was given appropriately, and at a pace suitable to the person. Menus are drawn up in advance. Each service user is then asked, during the morning, which option they would like that day. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 16 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 Service users are safeguarded by the home’s policies and procedures for complaints and protection. 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 had been received since the previous inspection. All 4 relatives who completed comment cards indicated that they were aware of the home’s complaints procedure. One person had made use of this. 9 out of the 10 service users who completed comment cards were aware of who to speak to if they were unhappy with their care. All 10 indicated that they felt safe in the home. The home’s own survey of service users and families, in August 2005, found that 12 out of 14 respondents felt the approach of the home in this area was either ‘Excellent’ or ‘Very good’. Bybrook House also has a policy on adult protection, which was drawn up by its previous registered manager, and most recently reviewed in June 2004. Information is also available about local multi-agency procedures. Nursing staff were able to demonstrate appropriate awareness of these arrangements, Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 17 and how to access them if necessary. Concerns have been reported via this route in the past, when it was appropriate to do so. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 25 & 26 Individual and communal accommodation is homely and comfortable. But some improvements are needed to the quality of the environment. Service users have suitable adaptations and equipment to promote their independence and quality of life. Service users are not fully protected from the risk of harm by the home’s existing arrangements for the regulation of hot water temperature. There are appropriate arrangements to maintain required standards of cleanliness and hygiene. EVIDENCE: The home generally provides a pleasant environment for people, both in individual rooms and communal areas. It is attractively furnished and decorated in these parts. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 19 Some areas for repair and decoration, itemised in earlier inspection reports, remain to be addressed. These are chiefly in traffic areas, such as corridors and landings. There is evidence of water damage to various parts of walls and ceilings. For instance, a ceiling around a skylight on the second floor is bulging and cracking in places, and showing signs of coming away. This had deteriorated since the previous inspection. Some interior and exterior woodwork is also in need of renewal. Stair carpets continue to show signs of wear on edges. Some have been taped. But none have yet been replaced, as recommended. The deadline for the relevant requirement had not expired at the time that this visit took place. The provider was therefore asked to produce evidence of a suitable action plan, identifying works to be undertaken, the order of priority, and a suitable timescale for completion. In response, the Commission has been assured that all required works will be completed by the date set. Bybrook House also has grounds and gardens available for service users to relax in. 4 respondents to the home’s most recent survey felt that these areas were below standard. In response, the provider has purchased some new garden furniture and equipment. Further improvements are planned. Not all bedrooms are accessible to all service users. 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 has been installed throughout the building. Service users and staff reported that this is working well. The main problem with the previous system – the lack of an effective emergency call facility – has been resolved. The new call points are also easier for people to operate. Risk assessments have been completed in respect of any remaining uncovered radiators in the building. Some have been removed, where they presented a particular hazard. The fitting of temperature regulators to hot water outlets throughout the building has been carried out. The temperature for two baths, checked by hand during the inspection, was at an appropriate level. But the problem of delivering water at the required safe temperature has not been fully resolved. The home’s most recent record of temperature checks could not be located on the day. But it was provided shortly after the inspection, and indicated that, when last checked, every outlet was delivering hot water up to 10 degrees higher than the safe level. Whilst some fluctuations in temperature are likely, and can be rectified by adjustment, this level suggests a more serious problem. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 20 The provider was arranging for the company who installed the regulators to return and address the issue. A letter sent following the inspection, and in advance of the draft report, required evidence of satisfactory completion of this work to be provided not later than 21st October 2005. In response, the Commission was informed that the necessary work took place on 14th October 2005. The company has also been engaged to return and conduct further checks in November, and there is a proposal to contract with them to carry out thorough checks and maintenance every 6 months. This would be in addition to the home’s own weekly checks. A range of adaptations and equipment are available to meet the needs of service users. For one individual with progressively deteriorating mobility, due to a degenerative condition, steps have been taken to maximise the person’s continuing independence. Specialist nurses and other professionals have carried out assessments. Relevant equipment has been obtained, and more is being pursued. The home appeared clean and hygienic in all areas seen during the inspection. Responses to the home’s own quality audit survey, in August 2005, indicated some dissatisfaction with the laundry service provided. As a result, the home has allocated more responsibility in this area to a named staff member. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 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. As such, it must maintain staffing levels in accordance with those which were imposed prior to April 2002. These 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 6 staff in the mornings; 4 for afternoons and evenings; and 3 waking staff overnight. Because the home is registered to provide nursing care, a qualified nurse is on duty at all times. Sometimes there are 2 nurses on the same shift, 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. 2 of the 4 relatives who completed comment cards indicated that they were concerned about whether there are always sufficient staff on duty. There was Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 22 particular anxiety at the fact that the home’s previous matron had been seconded to work in another home for much of the week, over a period of 3 months. However, any concerns were qualified by the observation that “This has never reflected in the care given”. The home had suitable numbers of nursing staff at the time of this inspection. But there was a shortage of carers, and there were ongoing efforts to recruit to these vacancies. Some staff had recently been appointed from overseas, having been supplied via an agency. But the people had poor English language skills, and had not been deployed as carers. It was reported shortly after the inspection that it had been decided not to continue with their employment. Until vacant carer posts can be filled, the home relies on the use of agency carers to maintain rota cover. Efforts are made to use the same workers where possible, to give greater continuity of care for service users. Recruitment records available in the home on the day of the inspection did not provide complete evidence of appropriate practice. There were no records at all in respect of the carers appointed from overseas. 3 other employees’ files were sampled. All had deficits in their required content. A requirement from the previous inspection concerned the importance of no person commencing employment, until a satisfactory result has been received from a POVA First check. This establishes whether or not their name appears on the national list of people deemed unsuitable to work with vulnerable adults. Where files existed, there was evidence that such checks had been conducted. But there was no clear information regarding starting dates, so it could not be established if these were after completion of the check. The provider subsequently provided information indicating that POVA First checks are completed before new employees commence working. From the 3 files checked, various omissions were identified: • • • • Only one had proof of identity, including a recent photograph; Only one had 2 written references; One file had no evidence relating to application for a CRB Disclosure; A nurse’s file had no documentary evidence of relevant qualifications and training. Following the inspection visit, the provider reported that the company’s administrator was to visit Bybrook House, and ensure that all recruitment records were in place. A letter sent following the inspection, and in advance of the draft report, required evidence of appropriate recruitment checks for all individuals identified during the inspection to be provided, not later than 21st October 2005. In response, the Commission was supplied with information indicating that all of the identified deficits have been or are being addressed. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 23 Staff training records are also deficient. 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 3 days paid training that is required per year. Individual training records are not clearly maintained either. Staff reported that there have been fewer in-house training opportunities over recent months, due to other pressures. A session on moving and handling took place during September 2005. Various staff members are also undertaking training on infection control, or food hygiene, via workbooks supplied by a local college. Update training on first aid is due to be provided in the next couple of months. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 37 & 38 Quality assurance measures underpin service developments, and include actions based on the views of service users. Service users’ best interests are not safeguarded by the home’s record keeping systems. Fire safety measures need attention, to ensure that the welfare of service users is promoted and protected. EVIDENCE: The home’s registered manager left Bybrook House shortly before this inspection took place. Suitable temporary management arrangements have been put in place, with other members of the nursing team providing acting cover. A new matron has been appointed, and is due to take up post in Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 25 November 2005. The new manager will then need to apply without delay to the CSCI to become registered. Since the previous inspection, the principal director of the company, Mrs Maria Cristina Bila, has completed the process of registration with the CSCI as the ‘responsible individual’ for Avon Care Homes. Mrs Bila must meet 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 must address a number of criteria prescribed by regulations, and copied must be supplied to the CSCI. The reports have been completed in appropriate detail over recent months, and 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 such exercise took place in August 2005. A range of topics were covered, including the environment, activities, care, food, and the response to queries or complaints. There were 14 respondents, and their feedback indicated general satisfaction in most areas. Activities were identified as the main issue of concern; but the survey took place before the appointment of a new staff member to lead on this. Records showed that various actions have already been taken in response to points arising from the survey, and others are planned. As set out previously, there are significant deficits in staff records, relating particularly to recruitment and training. The provider has been working to address the former since the inspection date. The home’s fire log book was viewed. Most of the required checks and instruction were recorded as taking place at the appropriate frequencies. But there was no documented check of fire fighting equipment since 4th July 2005; and no recorded check of means of escape during September. These deficits in records were remedied shortly after the inspection. 2 false alarms on the fire system had been recorded as practices, although guidance specifically states that this may not be done. 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. Any accidents occurring in the home are recorded appropriately. An analysis of all such incidents over the previous year, conducted by the previous manager, identified no particular patterns influencing their likelihood. Any service users known to be at increased risk have individual prevention programmes in place. Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 26 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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X X 2 3 STAFFING Standard No Score 27 3 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score N/A X 3 X X X 2 2 Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 27 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 2 Standard YA9 YA9 Regulation 13(2) 23(4)(a) Requirement The clinic room must be secure at all times, to ensure no unauthorised access. Appropriate warning signs must be used wherever oxygen cylinders are located. COMMENT: This requirement was addressed on the day of the inspection, as soon as it had been made known. Repair and decoration must be carried out in areas where there is evident damage. (Timescale from 11/10/04 not met) Timescale for action 30/11/05 30/09/05 3 YA19 23(2)(b) & (d) 30/11/05 4 YA25 13(4) COMMENT: The extended timescale for this requirement had not expired at the time of this inspection. The provider has indicated the intention to comply by that date. Hot water at outlets for service 21/10/05 users must be delivered at temperatures close to 43°C. (Timescale from 11/10/04 not met) COMMENT: Regulators had now Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 28 5 YA29 7,9;19; Sched2 been fitted to all outlets, but needed further attention to ensure they were working effectively. Further checks have taken place since the inspection date. The persons registered must provide evidence that all required recruitment checks are carried out for new employees. COMMENT: This could not be satisfactorily established from records present during the inspection. Additional information has been provided subsequently. There must be a staff training and development plan, which meets national training targets, and is suitable to the needs of service users. Individual records of all training undertaken must be maintained for each employee. Staff records must be maintained as specified in Regulations; and must be available for inspection in the home at all times. The persons registered must ensure that all appropriate steps are taken to promote fire safety; including provision of suitable equipment; review of relevant systems at suitable intervals; and the carrying out of fire drills and practices. 21/10/05 6 YA30 18(1)(a) & (c) 30/11/05 7 8 YA30 YA37 17(2), Sched 4(6)(g) 17(2)& (3)Sched 4(6) 23(4)(a) (c)(v)&(e) 30/11/05 30/11/05 9 YA38 30/11/05 Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA2 Good Practice Recommendations Terms and conditions of residence for service users should be reviewed, to remove any inconsistencies between individuals. COMMENT: The provider has indicated that the example noted during the inspection has been addressed. All written additions or alterations to the medication administration record should be signed, dated and checked by two members of staff. The new arrangements for the disposal of medication should be incorporated into the medication procedure. Stair carpets which are becoming worn should be replaced. COMMENT: This issue will become the subject of a requirement, if not addressed before the situation worsens. 2 3 4 YA9 YA9 YA38 Bybrook House Nursing Home DS0000015894.V255107.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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