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Inspection on 25/09/06 for Cherry Orchard Nursing Home

Also see our care home review for Cherry Orchard Nursing Home for more information

This inspection was carried out on 25th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

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

What the care home does well

Relatives stated that they are made to feel welcome. There are sufficient numbers of staff on duty to meet the needs of the service users. Lunch that was served during the inspection was nutritionally balanced and nicely presented. Both units have good links with the health professionals at Maskells Park and behaviour- monitoring charts have just been introduced for some of the service users on Thames/Ripple unit.

What has improved since the last inspection?

Four of the previous requirements have been met. These requirements were associated with the procedures and administration of medication.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Cherry Orchard Nursing Home Dagenham Avenue Dagenham Essex RM9 6LG Lead Inspector Julie Legg Key Unannounced Inspection 25th September 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000015587.V313932.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. DS0000015587.V313932.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherry Orchard Nursing Home Address Dagenham Avenue Dagenham Essex RM9 6LG 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) 020 8984 0830 0208 596 9127 manager.cherryorchard@careuk.com www.careuk.com Care UK Community Partnerships Limited Care Home 40 Category(ies) of Dementia - over 65 years of age (28), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (12) DS0000015587.V313932.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: Cherry Orchard is a care home with nursing situated in Dagenham. It is someway from public transport, and can be difficult to find. The home is situated in the part of Dagenham Avenue that is next door to the Goresbrook Sports Centre (opposite Eustow Road). Care UK Community Partnership Ltd, a large, private, provider, which has many similar homes across England, manages the home. It is a single storey, purpose built home, which is divided into two units. Castle Green is a 12-place unit for people over the age of 65 who have functional mental health problems. Thames/Ripple is a 28-place unit for people aged over 65 who have dementia. All places at the home are block purchased by Barking and Dagenham Primary Care Trust, with two beds on Thames /Ripple being for respite care. All bedrooms are single and have en-suite toilets and wash hand basins, and all are a good size. Castle Green has a small kitchenette and open plan dining and lounge area, leading onto an enclosed patio and garden. There is also a separate conservatory. Thames/ Ripple comprises of two corridors, connected by a large dining room. Each corridor has 14 bedrooms, and a lounge, bathroom, toilets and shower. One of the lounges leads into a garden. Personal and nursing care is provided on a 24-hour basis, and the nurse in charge of Castle Green is qualified as a psychiatric nurse. The home is visited every two weeks by psychiatrists, who regularly review all service users. The local Community Mental Health Team also continues to work with some of the service users following admission. Where specialist health needs are identified community specialists, such as the tissue viability nurse are involved in the provision of care. All areas of the home have full disabled access. The Statement of Purpose and the Service User Guide are issued to every prospective resident and both of these documents are displayed in the entrance hall of the home. A copy of the most recent inspection report is also available. A resident or relative/representative could ask for his or her own copy, which DS0000015587.V313932.R01.S.doc Version 5.2 Page 5 the manager would make available. DS0000015587.V313932.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over a day. Another inspector Sandra Parnell-Hopkinson accompanied the lead inspector Julie Legg. The evidence for this inspection has been gained by a tour of the home, discussions with the manager the senior nurse in charge and other members of staff. A number of staff and residents’ records were examined and staff were directly and indirectly observed providing care. The inspectors were able to speak to three relatives who were visiting the home at the time of the inspection and another relative was contacted by telephone. General A tour of the whole premises was undertaken and this included the kitchen, laundry and external grounds. The kitchen and laundry areas were clean and very well maintained. However, the external grounds required a great deal of attention. There is a paved area with raised flowerbeds, which was totally devoid of any plants, and the paving was broken in places and there was also a broken wooden gate across the entrance to the paved area. To ensure that the garden areas were secure and safe to use for people living with dementia there is much work to be done. Thames/Ripple Unit (older people with dementia) The inspectors were able to talk to three visiting relatives during the visit. One relative was generally satisfied but felt that there were areas for improvement with regard to social activities and the environment. The other two relatives were quite satisfied with the care being given. Due to the illness and mental capacity of the residents it was difficult for the inspectors to have meaningful discussions with those residents spoken to as to their views of the home and care being received. With regard to the care being provided to service users living with dementia, the inspectors were not satisfied that this was good in particular relation to their health and social care needs. Whilst referrals are being made to health care professionals where necessary, basic care is not always being followed and the care plans must be more specific. For instance if somebody requires a pressure relieving mattress for the prevention of pressure sores, but spends most of the day sitting in an armchair, then pressure relieving equipment must also be provided for the resident during the day. There was no evidence that social care needs are being met. There was very little interaction between service users and staff, and it seems that staff think that a television, with the sound turned down, is an acceptable form of stimulation for people living with dementia. There must be improvements to training for all staff, and senior staff must ensure that such training is implemented. Improvements to activities, innovative use of DS0000015587.V313932.R01.S.doc Version 5.2 Page 7 communal spaces, signage and décor and the environment would mean that the service would be more able to meet the assessed needs of residents living with dementia. The internal environment was fairly bare, carpets in many areas were dirty and “sticky” and the bedding in some of the rooms was of a poor standard with some pillows and bedrail bumpers having to be condemned. Some areas of the unit also had an unpleasant odour. Castle Green (Older people with mental health problems) In contrast the health and social care needs of the service users living on this unit were being met. Inspectors observed that there was good interaction between service users and staff and the environment within the unit was clean, bright and pleasant. Care plans were comprehensive and service users appeared well cared for and relaxed. The inspectors were able to feedback to the manager at the end of the inspection and though she has only been in post for seven weeks, she had an understanding of the work that needs to be carried out to ensure that service users are safe and comfortable and that their needs are being met appropriately. What the service does well: What has improved since the last inspection? DS0000015587.V313932.R01.S.doc Version 5.2 Page 8 Four of the previous requirements have been met. These requirements were associated with the procedures and administration of medication. What they could do better: THAMES/ RIPPLE – Dementia Unit The care plans were generally very health focused and detailed. However, these plans should be more comprehensive to include social care needs and life histories. The care plan should aim to enable the residents to be able to take as full a part as possible in their daily living routines and so allow them to maintain as much independence as is possible. The care plans should also include continence programmes, oral care and more details as to the behaviours of some residents and how staff should deal with these. Consideration must be given to the environment to best use the lay out and design to meet the specialist needs of people living with dementia. For example, through the use of décor, visual clues such as colour, signage and the use of familiar things from a person’s previous setting, such as photographs and ornaments. Some people living with dementia like to “walk” and would probably enjoy the freedom of being able to walk/sit in a garden that was accessible and well maintained with plants and flowers. Activities must be tailored to meet the changing needs of people living with dementia. Service users would benefit from a wider programme of activities, more individually focused, for shorter periods, and give more stimulation. Activities should not only be the responsibility of an activities co-ordinator but these are the responsibility of all staff working in the care home. Activities should be very varied and person centred to ensure that they have real meaning for the person living with dementia. The carpet and other floorings must be attended to as a matter of urgency. Carpets were stained and dirty and “sticky” when walked on. The offensive odours must be eliminated and especially that in the assisted shower room. More must also be done to ensure that people living with dementia are enabled to make positive choices, especially with regard to meals. It is pointless asking people living with dementia what they want for dinner the next day, because they will have forgotten by the time the meal is served. The manager must review the current system of menu selection and enable residents to make choices at the time of the meal. DS0000015587.V313932.R01.S.doc Version 5.2 Page 9 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. DS0000015587.V313932.R01.S.doc Version 5.2 Page 10 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 DS0000015587.V313932.R01.S.doc Version 5.2 Page 11 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): 1,2,3,4,5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Prospective service users, or their relatives, have some information needed to enable them to decide if they want to live at Cherry Orchard. An assessment is undertaken but this needs to be more comprehensive to ensure that all of the residents’ needs can be met. The statement of purpose and service user guide is made available to all residents and their relatives and prospective residents are invited to visit the home prior to admission, but in practice it is often the relatives who do so. All residents should have a written contract/statement of terms and conditions so that they are aware of such things as notice periods, details of funding, and what is covered by fees and what services are additional to the fees. DS0000015587.V313932.R01.S.doc Version 5.2 Page 12 EVIDENCE: When case tracking residents’ files it was evident that these did not contain a copy of the statement of terms and conditions. Barking & Dagenham Primary Care Trust funds all of the residents, and services are commissioned at Cherry Orchard under a ‘block contract’. It is essential that the provider ensures that all residents are given clear documentation as to the terms and conditions of placement at Cherry Orchard as required by the Care Home Regulations and National Minimum Standards. THAMES/RIPPLE It was evident from case tracking four residents that a pre-admission assessment is undertaken for all prospective residents and that care plans are drawn up using this assessment. However, more detail needs to be obtained around a person’s existing abilities with regard to ordinary activities of daily life and life histories. This should then be incorporated into the care plans to enable the staff to provide the right level of care, in all aspects, to assist the residents to continue to live as full a life as is possible, and for as long as possible. The service must endeavour to provide information in a format that could be more easily understood by people living with dementia. The inspectors were satisfied that an assessment of need is undertaken prior to residents moving into the home. However, the inspectors were not satisfied that the registered person was able to demonstrate the home’s capacity to meet their needs, and were not satisfied that staff individually and collectively have the skills and experience to deliver the service and care to people living with dementia which the home offers to provide. One relative told the inspectors that she was able to visit the home prior to her mother’s admission and that she was able to discuss her mother’s care needs with a senior nurse. CASTLE GREEN It was evident from case tracking four residents that a pre-admission assessment is undertaken for all prospective residents, and that care plans and risk assessments are drawn up using this assessment. The inspectors were satisfied that the registered person was able to demonstrate the home’s capacity to meet the needs of older people with mental health problems, and were satisfied that staff individually and DS0000015587.V313932.R01.S.doc Version 5.2 Page 13 collectively have the skills and experience to deliver the service which the home offers to provide. The home does not provide intermediate care. DS0000015587.V313932.R01.S.doc Version 5.2 Page 14 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 and 11 Quality in the outcome area is poor. This judgement has been made using available evidence including a visit to this service. The health and personal care needs for residents on both units are set out in individual care plans but there is limited information, particularly on Thames/Ripple unit, which will impact on the care residents receive. The daily reporting on the care plans needs to be completed at the end of every shift. Both manual and computer systems must be up to date at all times to ensure the safety and well being of the service users. Not all residents have detailed risk assessments, which could impact on the safety of them and others. The home’s policies and procedures for dealing with medicines ensure that Residents are protected , however all medication including creams must be recorded and all medication stored appropriately. Residents are not always treated with respect and their right to privacy is not always upheld. Residents do not have end of life care plans, therefore their wishes in relation to death and dying are not clearly identified. DS0000015587.V313932.R01.S.doc Version 5.2 Page 15 EVIDENCE: THAMES/RIPPLE Some staff were observed to treat residents with respect, but often the arrangements for their personal care did not always ensure that their right to privacy was upheld. One resident who has a habit of spitting out food was seated in the bedroom on a lounge chair, which was surrounded by a dustsheet. The bedroom door was wide open and he had obviously finished eating but the dirty dustsheet was still on the floor. When the manager asked a member of care staff to remove the sheet, her response was “that is not my job but the domestic.” Some half an hour later the sheet was still in the same position as was the resident. It appeared that staff were reluctant to act under instruction from senior staff and this does not promote the dignity of the resident. Some staff were observed to be “leading” residents by the hand without any interaction at all. The Inspectors were satisfied that individual care plans are available for each service user but these were primarily related to the physical health care needs. There was limited information on meeting the dementia care needs of service users. Care plans were being reviewed on a monthly basis and updated to reflect the changing health needs, but they did not include end of life plans. Records also indicated that other health care professionals see service users and some risk assessments are undertaken for all service users. However, detailed risk assessments were not always evident around the use of bedrails or some behavioural problems. It had been recorded that a resident exhibited inappropriate sexual behaviour, but there were no records as to the monitoring of this, or what action should be taken by staff when such action is being exhibited. Body maps are also completed following an accident or incident and accident forms are completed. However, the majority of the records are now being maintained onto a computer system, but some, such as the body maps are on a manual system. Staff are not always ensuring that both records are up to date. For instance one resident’s manual file indicated an allergy to penicillin but the computerised record did not evidence this very important aspect of the assessment. DS0000015587.V313932.R01.S.doc Version 5.2 Page 16 Although recordings into the care plans is carried out twice daily, this is not sufficient since there are three shifts, and recordings should be made at the end of each shift which will provide a comprehensive report of the resident’s day. Care plans must be more detailed, for instance there may be a standard sentence ‘to meet personal hygiene needs’ but then there are no specific details as to what these needs are for the individual and how they will be met. Examples are: It was recorded that a resident was incontinent of either urine or doubly incontinent, but there was no care plan/programme in place. A resident was identified as needing a pressure-relieving mattress after having developed a pressure sore. There was no evidence of proactive intervention. Also this same resident spent most of the day in a chair but there was no evidence that pressure relieving equipment was in place for the daytime. Another resident who had been mobile on admission several years previously, was now immobile and again there was no care plan in place to prevent the development of pressure sores. When the inspectors asked the nurse as to the reason for this resident’s bruised shins, they were told that “she rubbed her slippered feet up and down her shins, and therefore did not wear slippers.” However, it was evident from observation during the time of the inspection that this resident was wearing slippers. Although service users were being weighed on a regular monthly basis and their monthly weights were being recorded there was no evidence that variations in weight were being acted upon. For instance one record showed the weight of a resident on admission as being74kg, the next month as being 55kg, the next month as being 67kg and the next month as being 75kg. There was no evidence that such major weight variations had been questioned, or that a referral had been made to a dietician or a nutritionist, or that the weighing equipment had been checked for any malfunction. Weight variations were evidenced when case tracking other service users and again there were no records to show that any action to be taken had been identified. Appropriate aids such as spectacles or a hearing aid had been mentioned on the initial assessment, but there was no specific care plan to ensure that the aids were cleaned and ready for use each day. Where residents wore dentures these were not always marked, and again no specific mention of oral care for these, or indeed any of the residents whose files were case tracked. DS0000015587.V313932.R01.S.doc Version 5.2 Page 17 Where fluid charts were in use these were not being accurately completed on a regular basis. There was little evidence on the files to confirm that residents or their relatives had been consulted with regard to end of life matters. It is extremely important that end of life care for all residents is in accordance with their wishes, or that of their relatives. End of life care is not just recording ‘burial’ or ‘cremation’, it should also contain the care the resident would like and where they would like to be cared for at the end of their life and what they do not want to happen. Because the care plans did not always show evidence of a person’s current ability and level of functioning, staff were not always able to ensure that the correct care was being given to residents. The quality of care, which is experienced by a person living with dementia, can be improved by the way staff use and understand care plans. A comprehensive care plan, covering both health and social care needs, can only enhance the care experience of a person living with dementia. Because the label of “dementia” tends to prompt negative responses, care plans tend to be couched in terms of risk, dependency or disability. The assumption that people with dementia cannot do much leads to dependence on care staff to do tasks that they could actually be encouraged to do for themselves. There was some evidence that some background history regarding previous activities enjoyed by service users was recorded, but there was no evidence that such information is used in a meaningful way in the delivery of care. One service user wanted to telephone her husband, but this is not recorded in her care plan. In fact a care worker said that the husband preferred that his wife did not telephone him as he telephones the home daily. However, this relative does visit the home and the inspectors were able to talk with him. He was very clear that he would like his wife to ring him. It would be more beneficial to this resident if she were enabled to telephone her husband as this could reassure her and reduce some of her behavioural problems. Staff should also ensure that aids, such as dentures, spectacles and hearing aids, are marked with the name or initial of the resident. People living with dementia will leave such items in odd places, and the absence of such aids can add to the confusion of the individual who then cannot see or hear properly. The absence of dentures could be a reason for not eating well. There were clear medication policies and procedures for staff to follow, and only the nurses are responsible for giving medication. A review of the medication records showed that the policies and procedures were being followed and the Inspector was satisfied that residents were safeguarded with regard to their medication. However, where the application of creams was prescribed, the actual application was not being recorded onto the MAR DS0000015587.V313932.R01.S.doc Version 5.2 Page 18 (medication administration record) sheets. Nurses must ensure that they apply the creams and complete the MAR sheets or that the care worker applying the creams completes that part of the MAR sheet. Also the storage of insulin in current use was being stored inappropriately. Such insulin should not be stored in the refrigerator. No service users were responsible for administering their own medication. The inspectors spoke to three relatives, one relative said “I have no complaints, the staff are all good”, another relative said “overall my mum has been looked after but I do feel that there should be a member of staff in the lounge at all times”. The unit does appear to have a good liaison with consultants from Maskells Park, and a behaviour-monitoring chart has just been introduced for some of the residents on this unit. CASTLE GREEN The files of four residents were case tracked and the assessments were found to be comprehensive. Where necessary risk assessments were in place and the health care needs were being met with weight and dietary monitoring in place. There is good liaison with health professionals around the mental health needs of the residents on this unit, and a consultant visits on a regular basis. Residents are seen by a GP when necessary, and either see a visiting dentist, optician or chiropodist in the home, or are taken to the necessary surgery or clinic. Residents were well groomed and appeared very relaxed with good interaction between themselves and the care workers. Some residents were reading newspapers, some listening to music and others were chatting. DS0000015587.V313932.R01.S.doc Version 5.2 Page 19 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 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. An activity co-ordinator is currently being recruited and she will take the lead in the delivery of activities. However, activities need to be more tailored to meet the individual needs of residents. The meals are well presented but people living with dementia may benefit from the use of pictorial menus and more flexible mealtimes to maintain independence and exercise choice around food and eating. The dining room does not provide a congenial setting for residents to sit and eat their meal. There needs to be better stock control of food/drinks to ensure that residents are not being given food/drinks that are out of date. Residents are not always also helped to exercise choice and control over their lives, which would enable them to retain as much independence as is possible. Visiting times are flexible and people are made to feel welcome when visiting the home. This ensures that residents are able to maintain contact with their family and friends as they wish. DS0000015587.V313932.R01.S.doc Version 5.2 Page 20 EVIDENCE: THAMES/RIPPLE It was possible to talk with three relatives who were visiting and they were able to confirm that visiting times are flexible and that residents are able to receive visitors in one of the lounges or in their own bedrooms. Generally meals are served in the dining room but some residents eat in their bedrooms or the lounges. Dining tables were not covered with a tablecloth and were not routinely laid to make the eating of meals a pleasant experience. It is acknowledged that once tables have been laid there may be some residents, who then proceed to move things, which makes extra work for staff in relaying the tables. Staff should discuss this to agree on strategies to distract residents rather than act negatively by not laying tables. The dining room does not currently provide a congenial setting for meals, as it is very bare. The kitchen units in the servery part of the dining room were not very clean and neither was the floor in some areas. The menu that was on display was dated August 2005, this is a year out of date. Nutritional drinks were also being stored in one of the cupboards and some of these drinks were found to be out of date. It is extremely important that staff are aware of expiry dates on food/drink items and that any that are past the expiry date are disposed of. There were sufficient staff on duty during the inspection and some staff were observed to be on hand to assist residents with eating when necessary. Many of the residents needed either supervision by staff or assistance with eating, but there were times when residents were just left with little or no assistance. The meals were well presented but it appeared that it was the staff that decided what somebody would eat. People living with dementia may benefit from the use of, for example pictorial menus, finger foods, small nutritious snacks and more flexible mealtimes to maintain independence and exercise choice around food and eating. This area does need to be developed through the provision of pictorial menus or other methods such as making available to residents before the actual mealtime, small portions of the meals so that they can see, smell or touch the food and thereby make a more informed choice. The kitchen staff were aware of the dietary needs of residents including those who required a pureed diet and special diets due to health needs such as diabetes. Refrigerators, freezers and store cupboards were appropriately stocked and all foods were labelled with the date of when it was opened. DS0000015587.V313932.R01.S.doc Version 5.2 Page 21 Fresh fruit is served twice weekly and the manager should give consideration to ensuring the provision of this on a daily basis. The lack of appropriate signage and décor on this unit restricts the ability of residents to locate their own bedroom, toilets or other rooms thus restricting choice of freedom of movement around the building and could lead to residents entering the rooms of others, by mistake. There had been a general programme of activities for the home, but currently this is on hold because the previous activities person left. However, a new person has now been recruited and it is to be hoped that the provision of activities improves. There must be more consideration given to the specialist needs of people living with dementia. For instance more individual activities, including the use of life histories, and small group activities focusing on the individual’s needs and cognitive functioning, and adapting activities to relate the individual’s likes, dislikes, past and present and concentration span. All staff must recognise the important part that they can play in the encouragement and motivation of residents living with dementia. It is important for residents to be able to access the garden areas of the home, but on the day of the inspection the doors leading to the garden from this unit were locked. However, the garden area requires a great deal of attention to make it suitable and safe for those residents living with dementia. It would also seem that a member of staff is present in the lounge areas at all times. The senior nurse stated that “the purpose of this is for staff to observe residents so that there is a witness if one has a fall”. This is not necessarily a good use of a care workers time. In addition to sitting and observing, perhaps that person could also interact with the residents. In discussions with relatives and from observations however, a member of staff was not always present in the lounge areas. It was also evident from touring the building that the call alarms were not always sited near to where residents could access them if the need arose. In some bedrooms it was noted that these were missing, but there was no corresponding risk assessment in place or an alternative form of communicating that a resident needed help, if they could not use the alarm system. CASTLE GREEN In contrast, on this unit the external doors were open as it was a very pleasant and warm day, and residents had access to the garden area if they wished. Meals on this unit were taken in congenial surroundings with the tables being nicely laid and each had a vase of flowers. Service users can make choices and are encouraged to do so. DS0000015587.V313932.R01.S.doc Version 5.2 Page 22 Again the lack of an activities co-ordinator has meant that residents have been deprived of a programme of general activities. However, residents on this unit are more able and staff do ensure that they are engaged in some daily activities, such as visiting a local shop, reading, music and games. In discussions with the senior nurse suggestions such as themed evenings were explored and he has agreed to discuss this with residents to gain their views. As previously stated the provision of activities should not just be left to an activities co-ordinator. This person may take the lead and organise “whole” home events such as external entertainers or day trips, but care workers must recognise the very important part that they play in the day-to-day life and activities of residents. DS0000015587.V313932.R01.S.doc Version 5.2 Page 23 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s complaints policy and procedure provides residents and their relatives with the appropriate information to ensure that formal complaints are dealt with promptly. However, not all of the residents would be able to use the formal written process and a complaints form in a format accessible for people living with dementia would be beneficial Staff working in the home have received training in Adult Protection/Abuse Awareness. However the manager must ensure that the policies and procedures are adhered to at all times and that any risks identified are dealt with through risk management and not restraint. EVIDENCE: The inspectors were able to speak with relatives who felt confident that they knew who to complain to and that they would be listened to. Residents accommodated on Castle Green were able to complain and felt confident in doing so if the need arose. However, there was no evidence available such as a complaints form in a format accessible for people living with dementia, to indicate how they were enabled to complain. Again care DS0000015587.V313932.R01.S.doc Version 5.2 Page 24 plans should indicate the different methods of communication for each individual such as facial expressions, different words and their meanings for the individual. Staff will have gained this knowledge through the delivery of care to that resident. Complaints are recorded together with the actions taken as was evidenced from viewing the complaints log, and in discussions with the manager she viewed complaints in a positive way. Staff that spoken to during the inspection were aware of the action to be taken if there were concerns about the welfare and safety of residents, and they had received training in adult protection. There had been an allegation of physical abuse that was appropriately reported and thoroughly investigated under the Protection of Vulnerable Adults, the police were involved but no action was taken. The resident concerned has been transferred to another home as Cherry Orchard felt they could no longer meet the person’s needs. The rights of all residents must be protected at all times. The use of restraints must be through a risk management process and when restraints are used this must be recorded and the reasons why. During the inspection it was observed that a child safety gate was in place across the bedroom doorway of one resident. It would seem that the relative had requested that this be put in place as he was concerned as to the safety of his relative when he was not visiting. Although there was a signed consent letter from the relative for the use of the gate, there was no evidence as to the reason for this. However, in discussions with the relative he was concerned that other residents went into the bedroom and took items such as spectacles. It is not acceptable for this form of restraint to be used, without clear evidence as to the reasons and the decision making process. Staff who are supervising and observing other residents should be managing any risk appropriately. If there is not sufficient staff on duty to do this, then the manager must review the staffing levels. In the absence of visiting relatives, the resident should be encouraged to spend some of their time sitting in the lounge areas, as this would also add to the stimulation for this person. The use of such a gate is also detrimental in the event of a fire, or if the gate is closed but the door is open another resident could climb over and this could lead to a possible accident. Whilst it is important to work closely with relatives, this must always be in the best interests of the resident, and unless there are clearly recorded reasons any form of restraint must be avoided and all environments should be supportive and enabling. The introduction of the Mental Capacity Act 2005 in April, 2007 will have implications for providing services for people living with dementia, and DS0000015587.V313932.R01.S.doc Version 5.2 Page 25 managers will need to familiarise themselves with its contents. Key points include that: Every adult has the right to make his or her own decisions and must be assumed to have capacity unless it is proved otherwise… No one can be deemed incapable as a result of a particular medical condition or diagnosis… DS0000015587.V313932.R01.S.doc Version 5.2 Page 26 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,23,24,25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Generally the environment within the home is not of a good standard and this was further compromised by the offensive underlying odour in Thames/Ripple unit. This has the potential for putting the safety of residents, relatives and staff at risk. EVIDENCE: GENERAL A visit was made to both the kitchen and laundry, which were both maintained to a good standard. DS0000015587.V313932.R01.S.doc Version 5.2 Page 27 The laundry staff were aware of when to use protective equipment and hazardous substances were being appropriately stored. A new maintenance person has been recruited and he was busy repainting the lobby area between the two units. THAMES/ RIPPLE The standard of the décor, furnishings and fittings on this unit were not to an acceptable standard. Some carpets smelt offensively and were heavily stained, dirty and “sticky” when being walked on. Flooring in some of the bedrooms was poor and without carpet, it was evident that this was because of either incontinence or other problems such as spitting. The manager is required to review this practice since it is a form of ‘labelling’ and there are carpet like materials, which are stain resistant and this together with modern cleaning products should alleviate any offensive odours. Generally, with proper continence management and behaviour management programmes, accidents can be avoided. One resident had no curtains at their bedroom windows, the inspectors asked why this was and the manager stated “ This action had been taken by the previous manager, as the resident keeps pulling the curtains down”. There is some plastic coating on the windows but this does not afford the resident totally privacy and during the summer months the light nights could disturb their sleep. Some bedrooms showed little evidence that they had been personalised. On entering one bedroom it was evident that some of the pillow covering had rotted. This was discussed immediately with the senior nurse who then ensured that all such pillows in other bedrooms were removed. Bedrail bumpers were also seen to be dirty and coverings had also rotted in some places. Relatives should be encouraged to bring in items that are familiar to the person living with dementia, as this will make their environment more personal and meaningful. Bathrooms and toilets had no appropriate signage and other forms of identification as recommended in all practice guidance. Assisted bathrooms were also used as storage rooms for wheelchairs and hoists, and one assisted shower room was evidently not used frequently because the offensive odour of “drains” was overpowering when the inspectors opened the door. As the ability of people living with dementia to communicate with words decreases, the use of non-verbal cues and the environment are important in enabling them to cope better with daily life and aids to orientation. DS0000015587.V313932.R01.S.doc Version 5.2 Page 28 Consideration must be given to utilising the existing design and layout of this unit to meet the specialist needs of people living with dementia. For example, through the use of visual cues such as colour and signage. Containers with suitable materials could be located around the unit so that those residents who can walk can touch and feel things. The use of calming equipment such as lighting or a small aquarium could be used. On the day of the inspection the majority of residents were sat in the lounges with the television on but the sound turned off. Residents were not watching the television but care workers were totally oblivious to this fact. It appeared to the inspectors that staff felt that if the television was on residents were being entertained. It would have been more beneficial for residents for the television to be turned off, and for appropriate music to be played, or for staff to be interacting with them. Lack of a stimulating environment can have a direct impact on a resident’s behaviour. This was mentioned to the manager who then arranged for the television to be turned off and for appropriate music to be played. Later in the day and in discussions with a visiting relative, it was evident that this was appreciated, as one resident who was very poorly was observed to be “tapping” her feet to the music. The very large dining room appeared unwelcoming and bare. The servery part of this room requires urgent attention, as some of the cupboards were damp and stained. Also staff must be reminded that the storage of rubbish under the worktops is not an appropriate place, and that rubbish should be taken straight out to the refuse bins. As stated above some pillows were condemned during the inspection, and staff had put these into black bags, which were then stored under the servery worktops. Even when the manager asked a member of staff to remove these to the refuse bins, they were then left in the reception area until finally the senior nurse removed them to the bins. There were no appropriate pictures in the lounges or dining room. The manager must give consideration to ensuring that there are items of interest for residents throughout the home. Pictures of parts of London, that would have been familiar to residents in their younger days, can be obtained from local libraries and other such outlets. These can also be used as points of discussion with people living with dementia. In good weather more thought should be given to the use of the external areas of the unit. Currently a great deal of work needs to be undertaken as the gate is broken, paving is uneven and broken in parts and there are absolutely no shrubs or plants. The physical environment has an enormous impact on how the strengths and skills of people living with dementia are supported or not. Changes mentioned above if implemented can help to support people living with dementia, and help to maximise independence and minimise confusion. Therefore, since the service is registered for the provision of care to people living with dementia, DS0000015587.V313932.R01.S.doc Version 5.2 Page 29 and this is viewed as a specialist service, the organisation must consider improvements to the environment as follows: To ensure that the floor areas are covered with appropriate flooring which is kept clean and odour free Using changes in colour in different areas to help with orientation Having toilet seats that are a different colour to the rest of the room to help with identification, and this includes the en -suites. Using pictorial signs as well as written signs and ensuring these are at the right height to help with identifying different rooms and areas Providing freedom to walk about in areas that are interesting and that have pictures and sitting areas, together with a route into the garden that is safe and is planted with plants and flowers that have colour and smells. CASTLE GREEN Again by contrast this unit was nicely furnished with appropriate pictures. Bedrooms had been personalised and there were no unpleasant odours. The lounge and dining areas were nicely decorated and furnished and the atmosphere was very homely and calm. DS0000015587.V313932.R01.S.doc Version 5.2 Page 30 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are currently satisfactory and there were sufficient staff on duty to meet the needs of the residents. Generally staff have received training to ensure that they are equipped with skills necessary to ensure the safety of residents, but some care workers still require training in dementia awareness. The home has a clear recruitment policy and procedure and appropriate checks are undertaken, which ensure the protection of residents. EVIDENCE: GENERAL The personnel files of recently employed staff were viewed and it was evident that the organisation’s recruitment processes are robust. Evidence was found that references are taken up and that criminal records bureau disclosures are obtained and that an initial check is made against the Protection of Vulnerable Adults list. In addition to qualified nurses and care staff, the home employs an activity coordinator, catering, laundry, domestic, maintenance and administrative staff. DS0000015587.V313932.R01.S.doc Version 5.2 Page 31 At the time of the inspection there were sufficient staff on duty to meet the needs of all of the residents and staff rotas that were examined correlated with the number of staff on duty. However, the manager must ensure that all staff are aware of their responsibilities and of the management structure. As during the inspection staff were seen not to respond to instructions from senior staff. Training is available for all staff and recent areas covered are; manual handling, fire safety, first aid, health & safety, dementia awareness, service user involvement, care planning and personal development. 50 of the care workers have obtained their NVQ2. Thames/Ripple The senior nurse will be undertaking a training course in the care of people living with dementia, but some care staff have already received this training. However, it was not evident during the inspection because of observed poor practice methods. If the organisation is providing appropriate training, then the manager and senior staff must ensure that such training is put into effect for the benefit of people living with dementia. Care staff must be supported and enabled to develop the skills, knowledge and abilities required to successfully enable residents to continue to exercise choice in their daily lives and reach their full potential for as long as is possible. DS0000015587.V313932.R01.S.doc Version 5.2 Page 32 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. A new manager has recently been appointed who is aware of the improvements that need to take place to ensure that the home is run in the best interests of the residents. The welfare of staff and residents is not always promoted by the home’s policies and procedures. Residents’ best interests are not always safeguarded by the home’s record keeping. Monitoring visits by the responsible individual are undertaken on a regular basis, but these are not adequately identifying areas of deficiency. DS0000015587.V313932.R01.S.doc Version 5.2 Page 33 EVIDENCE: General The manager is newly appointed to the home and has applied for registration with the Commission. She has previous experience in providing and managing care services. She has an understanding of the needs of the residents and the areas in which the home needs to improve and further develop. All maintenance records, including fire safety, lift maintenance and water temperature checks, were viewed and found to be up to date and in good order. Staff have undertaken manual handling training, which is updated on a regular basis. Risk assessments need to be more detailed and reviewed on a regular basis or when a change in need is identified. Some of the home’s records need to be more robust in particular the daily recordings on residents’ care plans. These should be completed at the end of every shift, in order to provide a comprehensive record of events over a 24hour period. Policies and procedures are reviewed on an annual basis and these are available for staff to view. Monthly visits are carried out by the registered individual under the requirements of Regulation 26 of the Care Home Regulations and reports of these visits are being submitted to the Commission. The Regulation 26 visit that was undertaken on 8th August 2006 states under section 3 ‘general internal appearance of the home reflects the strain on domestic staff’. These reports need to be more specific and identify the deficiencies within the home. The Inspectors were satisfied that the financial interests of service users are safeguarded by the robust financial policies and procedures. The manager and the administrator audit residents’ accounts. All staff are receiving supervision but it was evident that this must be more meaningful in both 1:1 sessions and through direct observation to ensure that good working practices are being employed, and that residents remain the priority for the service in meeting their assessed needs. There appeared to be an apparent lack of respect from care workers towards the manager and senior nurse on Thames/Ripple unit. Instructions given to care staff by the manager and the senior nurse were ignored until the second and sometimes third time of asking. This was evident in the instructions given to remove the dustsheet in one bedroom and the condemned pillows. This should be addressed with staff during supervision sessions and via the provider’s monthly monitoring. DS0000015587.V313932.R01.S.doc Version 5.2 Page 34 DS0000015587.V313932.R01.S.doc Version 5.2 Page 35 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 2 2 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 1 X 2 2 2 2 1 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 2 2 2 DS0000015587.V313932.R01.S.doc Version 5.2 Page 36 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5 Requirement The registered persons must ensure that each resident is provided with a written contract/ statement of terms and conditions within the home. The registered persons must ensure that the pre-admission assessment is more comprehensive. The registered persons must be able to demonstrate the home’s capacity to meet the assessed (including specialist) needs of people admitted to the home. Care plans must be more detailed and more information on people’s dementia needs. All records within the home must be kept up to date. The registered persons must ensure that nutritional screening for all residents is undertaken and records maintained of nutrition, including weight gain or loss, and appropriate action taken. The registered persons must ensure that all medication including creams is clearly DS0000015587.V313932.R01.S.doc Timescale for action 31/01/07 2 OP3 3 31/12/06 3 OP4 12 31/01/07 4 5 6 OP7 OP8 OP8 15(2) 17(3) 13(1) 31/01/07 31/12/06 31/01/07 7 OP9 13(2) 31/10/06 Version 5.2 Page 37 8 OP10 12(4) 9 OP11 12 & 15 10 OP12 16(2) (n) 11 OP14 16 12 OP15 16 13 14 OP16 OP18 22 13(6) 15 16 OP19 OP20 OP22 OP25 23 23 17 OP24 OP23 23 recorded and that all medication is stored appropriately. The registered persons must ensure that all residents are treated with respect and their right to privacy upheld. The registered persons must ensure that the care plan for each resident is comprehensive and includes end of life wishes. The registered persons must ensure that the routines of daily living and activities are flexible and varied to suit the expectations, preferences and capacities of all residents. Previous timescale 31/03/06 not met. The registered persons must maximise residents’ capacity to exercise personal autonomy and choice. The registered persons must ensure that residents receive a diet that is suited to individual needs and meals are taken in a congenial setting and at flexible times. The complaints format must be accessible to people who are living with dementia. The registered persons must ensure that all residents are safeguarded from all forms of abuse and that behaviour and risk management are introduced. The manager must ensure that the home is safe, accessible and well maintained at all times. The environment must be suitable and safe to meet the needs of people living with dementia. Resident’s bedrooms must be furnished and equipped to assure comfort and privacy and meet their assessed needs. DS0000015587.V313932.R01.S.doc 31/10/06 31/01/07 31/01/07 31/01/07 31/12/06 31/12/06 31/01/07 31/03/07 31/03/07 31/03/07 Version 5.2 Page 38 18 19 20 21 OP26 OP30 OP36 OP32 16(2) 18(1) 18(2) 12(5) 22 OP33 26 23 OP37 17(1) 24 OP38 24A The premises must be kept clean, hygienic and free from any offensive odour. The manager must ensure that all staff receive dementia awareness training Supervision of care workers must include direct observation of their care practices. The registered persons must ensure that they communicate a clear sense of direction and leadership, which staff and residents understand. The registered persons must ensure that Regulation 26 reports adequately identify all areas of deficiency. The registered persons must ensure that all records are maintained, accurate and up to date. The registered persons shall produce an improvement plan setting out the methods by which, and the timetable to which, they intend to improve the services provided in the care home. 30/11/06 31/01/07 31/01/07 30/11/06 31/03/07 31/12/06 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000015587.V313932.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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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