Inspection on 31/03/08 for Cooksditch House Nursing and Residential Home

This inspection was carried out on 31st March 2008.

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

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

Cooksditch House Nursing and... 17/09/08

Cooksditch House Nursing and... 27/09/07

Cooksditch House Nursing and... 30/05/07

Cooksditch House Nursing and... 18/05/06

Cooksditch House Nursing and... 17/01/06

Cooksditch House Nursing and... 06/09/05

Cooksditch House Nursing and... 11/03/05

Cooksditch House Nursing and... 03/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Cooksditch House Nursing and Residential Home East Street Faversham Kent ME13 8AN Lead Inspector Anne Butts Unannounced Inspection 31 March 2008 07.45 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 Cooksditch House Nursing and Residential Home DS0000023399.V361108.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. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cooksditch House Nursing and Residential Home Address East Street Faversham Kent ME13 8AN 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) 01795 530156 Mrs Gillian Ilsley Care Home 55 Category(ies) of Old age, not falling within any other category registration, with number (55) of places Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. DE(E) is restricted to those persons whose dates of birth are 08/01/1922, 26/05/1931, 23/05/1915, 21/10/1914, 27/10/1912, 15/10/1913 with 1 under the age of 65 - 24/10/1943. LD(E) is restricted to one (1) person with a date of birth of 07/09/1938 27th September 2007 Date of last inspection Brief Description of the Service: Cooksditch House is a large detached property situated in the centre of Faversham. The original house is a grade 2 listed building. It offers care to up to 55 people. This includes up to 35 Older people with nursing needs, 19 Older people and One Service User with a learning difficulty. Buses stop outside the Home. There is a local park and church within a few minutes walk of the Home. The Home has two lifts to enable access to all the areas. Accommodation is provided in both single and double rooms many of which offer en-suite facilities. All bedrooms have a call bell system and television point in situ. The fee range for residential is £326.33-£488.00 and £445.28£583 for nursing excluding the RNCC. (The nursing element) Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This was a key inspection that took place over a period of time and consisted of gathering information and concluding in an unannounced site visit. This was carried out by two inspectors, Anne Butts and Sue McGrath. We were accompanied by a specialist pharmacy inspector who looked at medication only. Time was spent touring the building, talking to staff, people living in the home and relatives who were visiting at the time of the inspection. Time was also spent observing as to how people are assisted in their day-to-day living. A selection of documentation was reviewed including assessments, care plans, medication records, financial records, health and safety records and staff files. It is now a legal requirement for services to complete and return an Annual Quality Assurance Assessment (AQAA). The home returned the AQAA at the site visit and information from this has been used as part of the inspection process. We (The Commission) have made judgements for each outcome area in this report, based on records viewed, observations and verbal responses given by those people who were spoken with. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable (CSCI) to be able to make an informed decision about each outcome area. Further information can be found on The Commission for Social Care Inspection (CSCI) website KLORA’s and AQAA’s. At the last key inspection there were sixteen requirements and one recommendation made. Three of these requirements had remained outstanding from a previous visit. The focus of the inspection was to assess progress made to meet all requirements and look at key standards. The home is registered to provide care for people with both residential and nursing care needs, with people primarily occupying different ‘sides’ of the building. People are able to access the communal areas as they wish. For the purpose of this report we will refer to the different services provided as nursing care or residential care. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose is not clear about the range of needs that the home caters for or whether any specialist services such as short-term care is provided. Where care plans or assessments referred to people as having dementia, short-term memory loss or behavioural problems there was no supporting assessments by a suitably trained person to support these judgements. The registered provider must make sure that people living in the home are in receipt of an assessment carried out by an appropriate healthcare professional Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 7 such as a psycho-geriatrician that will inform the home as to the exact needs of the individual. This must be done so the registered provider can determine as to whether or not the home can meet their needs. Ongoing assessments are not benefiting people by giving clear guidance on how to meet changing needs, and in some cases there is no follow up to an identified need or risk. People are not always supported with their meals in a manner that suits their individual needs in particular in the nursing care unit. This was primarily due to availability of staff supporting at the mealtime. Peoples healthcare needs are not monitored effectively especially with regards to nutrition and behaviour management. There is some inequality around the deployment of senior staff on different days and times. Complaints are not always dealt with appropriately with relatives saying that their concerns, especially with regards to the laundry, are not always followed up. The managing of peoples individual spending money is not robust with people being overdrawn and funds used to pay tradesman for work carried out in the home and not replaced in a timely manner. People are not supported safely with their movement and handling needs as some equipment has not been serviced and staff are using incorrect procedures. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 8 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 Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose does not clearly reflect the service provided to the people living in the home so prospective service users will not be able to make an informed judgement as to whether the home will meet their needs. Ongoing assessments do not detail outcomes for people that will make sure that staff can support them with their changing needs. EVIDENCE: At our visit we requested and were given a copy of the most recent Statement of Purpose. We have referred to this in this inspection report. We have also made reference to the information contained within the Annual Quality Assurance Assessment. (AQAA). Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 10 There have been no new service users admitted to the home since we carried out a random visit on 29 and 30 January of this year. We have, therefore, not reviewed the pre-assessment process for the home for any newer residents at this visit. The last key inspection in September 2007 identified that people are given an assessment of need prior to moving into the home. This assessment process is used for the regular reviewing of the care provided in the home and we viewed six of these. This consisted of three for people with residential care needs and three for people with nursing care needs. The assessments are being reviewed on a monthly basis and are carried out by senior carers in the residential side and allocated nurses in the nursing side of the home. The assessment process uses a scoring system with each score giving an associated level of need i.e. low, medium or higher risk. There are different assessments for different needs and this includes mobility, falls, nutrition, skin integrity (waterlow pressure score) and an overall dependency assessment. We saw that where people have been identified as having a higher risk then there was no guidance on how to support in reducing this risk. For example: a waterlow pressure score stated that the outcome score was twenty-four and this meant that this was a very high risk but there was no guidance on how to monitor or reduce risk. Another example was that an assessment indicated that there was a high risk of falls but there was no guidance on how to reduce the risk of falls. The home has now employed a lead nurse for the nursing unit, who had been in post for three weeks when we visited. She had recognised the shortfalls in the assessments and is reviewing how the assessments are being completed so that they are more accurate in their outcomes for people. For example: a previous falls risk assessment had identified a person as having a high risk of falls with a score of twenty-eight, the falls risk assessment had been reviewed this month and now gave an outcome score of fifteen. This is because the person is nursed in bed, with safeguards and is not independently mobile or at high risk of getting out of bed and falling. She stated the overall dependency assessment had proved to be unreliable as it is putting people in the wrong dependency level and does not work in conjunction with the other assessments. She is currently reviewing all the assessments in order to make sure that people’s individual needs can be met in respect of their health and welfare. In order to maintain accurate records as required by the Care Homes Regulations 2001, it is being recommended that there is an audit trail that evidences why there are changes in need. The last key inspection in September 2007 and the random visit in January 2008 evidenced that there are people living in the home who have been identified within their care plans or the homes assessment as having dementia, memory loss or behavioural problems. At this visit of the six care plans we viewed we saw that three referred to dementia or memory loss and one Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 11 referred to memory loss and behavioural problems and one referred to a persons behavioural problems. Conversations with staff and relatives supported that there are people who have levels of confusion. One member of staff stated, “out of the nursing needs clients there are three people who are more with it – the rest have varying degrees of dementia”. A relative stated that their relative “has dementia – they were admitted with slight dementia but has got a lot worse over the last six months”. The AQAA stated that there were three people in the residential care unit and three people in the nursing care unit with a diagnosis of dementia and two people with mental health needs. We spoke to the Head of Care who confirmed that some people living in the home had received a full assessment to determine if they had a diagnosis of dementia. Other people, however, had not had an appropriate assessment to review their mental health needs. The Care Homes Regulations 2001 establishes the need for people to be assessed by a suitably qualified person. The registered provider must make sure that people living in the home are in receipt of an assessment carried out by an appropriate healthcare professional such as a psycho-geriatrician that will inform the home as to the exact needs of the individual. This must be done so the registered provider can determine as to whether or not the home can meet their needs. The Statement of Purpose does not fully detail the range of needs that they intend to meet including any reference to how they will meet the needs of people with dementia. It also does not contain reference to providing short term intermediate or convalescence care. The AQAA, however, states that they “provide short-term respite care for people requiring convalescence after surgery”. The Statement of Purpose must clearly state the homes intentions and be in accordance with Regulation 4 and Schedule 1 of the Care Homes Regulations 2001. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People have an individual plan that meets their needs, however the ongoing development of these plans would further benefit people. People are not safeguarded by the Home’s administration and recording of medication. EVIDENCE: We looked at six care plans and since our last visit we saw that the care plans have been re-written. There have been improvements with sections of the care plans now containing more detail and giving more guidance to staff. They are more reflective of what people can manage and how to support. However not all areas of the care plans give detailed guidance. For example: a care plan in the residential care unit stated, “Staff need to ensure that all transfers are being carried out as the care plan states”. This was the care plan and there was no other guidance as how to support with transfers. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 13 The lead nurse has recognised that there is room for further improvement in care plans and has started work in the nursing unit to address this. For example: A newly written plan gave detailed guidance on how to support a person when they refused their medication with a structured strategy in place on action to take and what advice to seek if the person continued to refuse. Another part of the care plan also identified that this lady liked to have her handbag with her at all times. Guidance from care plans or risk assessments which indicate that there are areas of care or support that need to be monitored are not supported with records that evidence that this has occurred. We viewed records for people with regards to their dietary needs and these lacked detail or guidance and were not supported by a robust monitoring system. For example, one person had been identified in a part of their care plan as being diabetic but this was not referred to in another part and there was no diabetic monitoring sheet in place. A nutrition assessment for another person stated that their dietary needs were of a high risk and further dietary advice should be sought – there was no evidence that this having occurred. Where a care plan stated that food intake must be monitored there were no records to support this, with only brief details contained in daily notes. The home does have some systems for recording food and fluid intake for some people but the audit trail was seen to be disjointed with no comprehensive system in place to robustly monitor people’s ongoing dietary needs and food / fluid consumption. A care plan stated that that a person could be verbally aggressive and that any incidents should be recorded and monitored. The care plan stated to calm the person, but did not give details on how. There was a behavioural monitoring chart in place but this was not completed. A review of the daily notes showed that there had been three entries over the course of two days relating to the lady being aggressive towards staff and other people in the home. This evidences that behavioural management and support are not being monitored. In the residential unit the waterlow pressure score assessment was being carried out by untrained staff, and where a high risk had been identified there was no plan of care on how to reduce the risk to the person. Information was also seen to be contradictory in different records. For example: a care plan stated that the person was allergic to a medication but the Medication Administration Record (MAR) sheets said that there were no known allergies. There is a limited use of records to support peoples assessed needs and to monitor their healthcare. The daily notes do not contain detailed descriptions of care and support provided and do not relate to the care plans. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 14 Monitoring records for pressure sores has improved with more robust records being maintained in individual files. All pressure sore areas have been reviewed with a detailed body map in place and updates on skin integrity and when to change dressings. A requirement made at the last visit with regards to healthcare monitoring had addressed the issues surrounding pressure sore areas but other areas of healthcare monitoring are not meeting peoples assessed needs and a new requirement has been made. Medication policies and procedures in the main file were dated 2007 but those in the residential unit were dated 2004. The general manager and a senior carer said all policies and procedures would be reviewed. New medicines fridges were in place and staff monitored temperatures daily. The general manager said that new medicines storage was planned for the first floor and it was agreed that the medicines fridge would be removed the next day, from the current room, which was too warm. Unwanted medicines from both units were collected by the waste disposal company and staff kept detailed records. A senior carer had completed monthly audits for the residential unit and said that the system of ordering repeat medication had improved, so that staff had more time to deal with any problems before the monthly delivery of medicines were put into use. A printed ordering schedule was available for both nursing and residential units. Receipts were recorded and no medicines were found to be unavailable. A senior nurse said that medication audit would be implemented in the nursing unit by the end of May 2008. Most tablets and capsules were supplied in a monitored dose system (MDS). Inaccuracies were found in medication administration records (MAR) for five people, out of the eleven looked at. Six doses initialled on the MAR were still in the MDS blister. For another nine doses, there was no record to show that the medicine had been given or not, of which four doses were still in the MDS. A requirement was made for accurate record keeping. This is a repeat requirement. Following our visit we received a report on 4 April 2008 of a review of the administration errors and the action taken by the general manager at the time. Staff who were involved in the errors have been removed from administering medication and a full investigation will be carried out by the Adult Protection team. We observed that staff treated people with respect and kindness, and responded to their needs. We saw very good interaction between a member of staff and a resident, who at first refused to go into the dining area for their Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 15 meal, but the member of staff worked with them patiently and the lady was happy to go through for her lunch. We heard staff laughing and joking with a person who was in her bedroom and kept calling out to staff for attention. The home has purchased small baskets for people so that they can store their individual toiletries in their rooms and take them through to the bathroom with them, and a clothes labeller in order to make sure that people are supported with getting their own clothes returned. We did see a lady being wheeled through the hallway with her skirt raised up in an undignified manner and staff must be aware of this. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People benefit from being supported by an activities co-ordinator who has implemented a range of social activities. More time spent with people on a one-to-one basis would further enhance the quality of their lives. The home provides a range of nutritious and varied meals. Not all people benefit from getting suitable assistance with eating and nutritional records do not serve to protect all people. EVIDENCE: There is an activities co-ordinator in place and we spoke to her at the time of our visit. She explained the different activities that she carries out and this included organised group sessions such as quizzes, bingo and keyboard sessions. Group outings have been arranged and they have visited local attractions such as Farming World, Druidstone Park and Herne Bay seafront. She explained that they participate in the local carnival and vote in a King and Queen of the carnival for a year. Before the last carnival Morris Men had Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 17 visited and performed a show for the people living in the home. Outside entertainers also visit the home on a regular basis. She also stated that she arranges baking sessions, manicure and beauty sessions including aromatherapy and is currently working with some people in potting plants and seeds to be placed in the garden in the summer. People are individually escorted to local shops. The home has a pet rabbit that she brings into the home and she said that people really enjoy this interaction. A ‘pat’ dog sometimes visits them, which is a specially trained dog that visits people and is used to promote well-being. The activities co-ordinator is also assisted by a resident who talks to other people and finds out their preferences for activities. We spoke to this person and she stated she enjoyed helping out with this as it kept her busy. She said that sometimes people get frustrated, as there isn’t enough time to spend on one-to-ones with people, especially the people who spend time in their own rooms. Care staff do not have the time to talk to people and they are not always aware of their individual preferences. An activity record is now maintained in people’s files. This is in the form of a tick list to identify if someone has participated in an activity or has refused. Some additional detail is then written into the daily notes section of the care plan. Records did show that not all people benefited from a high input of activities with one lady’s records showing an average of fifteen recorded activities per month over the last three months. The Annual Quality Assurance Assessment (AQAA) stated that the homes plans for improvement in the next twelve months includes a programme of using volunteers to assist the activities co-ordinator. Visitors are welcome at any time and people are able to meet their visitors in the privacy of their own rooms. There is also a quieter lounge area that they can use if they wish. We spoke to relatives and they confirmed that they could visit whenever they wanted. The staff support people in exercising choice and control over their own lives. For example, people have a choice about what time they get up or go to bed. One lady likes to get up between 4.00 – 5.00 am and this was reflected in her care plan. A member of staff said that another lady sometimes wants to get up in the middle of the night because she is uncomfortable. She said that they go in and talk to the lady and try to make her comfortable, if however she insists that she wants to get up they support her with this. Staff were aware of the individual diverse needs of the people living in the home. For example: one lady does not like to be assisted by men, and the home respects this preference. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 18 There is a four-week menu in place and this is alternated between a summer and winter menu. Breakfast is served either in the dining areas or if people prefer in their own rooms. At teatime a trolley is taken around the nursing care side of the building with a choice of sandwiches or hot snacks so people can choose what they want. Meals are homemade and on the day of our visit there was a choice of homemade chicken and ham pie or toad in the hole. Fresh fruit and vegetables are used and there is a range of good quality food stored in the home. People are supported with a liquidised diet where needed. We observed the lunchtime meal and one inspector sat in the dining room in the residential care unit and one inspector sat in the dining room in the nursing care unit. We observed good practice is both areas with people being supported in a sensitive manner and good staff interaction. In the residential care unit staff were seen to have time to spend with people who needed assistance. We saw, however, in the nursing unit that there was a limited amount of staff available to assist people. This meant that some people had to wait with their dinner in front of them before they were assisted. We also saw that one lady did manage to eat her meal, but with some difficulty and when she spilt it on the table she used her hands to eat with. Staff were busy and did not observe this. This lady was also heard to ask for some more, but again staff were busy and did not hear her. There were mixed messages about the amount of food with one person saying there was too much and another saying that there wasn’t enough. People we spoke to did confirm that they enjoyed their meals. We also saw in the nursing care unit that there was some confusion from staff as to who was a diabetic, when it came to serving dessert. One member of staff said that there were four people who were diabetic, she then left the dining area to serve someone in their own room and the remaining staff could not remember how many she said and eventually decided that there were three people who were diabetic. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home and their relatives cannot be confident that all complaints are investigated and resolved. Additional training in adult protection procedures has served to help safeguard the people living in the home. EVIDENCE: There is a written complaints procedure and this is made available to all people living in the home. It is also contained in the Statement of Purpose and displayed on the notice board. The Annual Quality Assurance Assessment (AQAA) stated that there had been five complaints made in the last twelve months. We looked at the complaints record for the home and saw that there had been no complaints recorded since 30 June 2007. We spoke to six relatives and three of them said that there had been problems with the laundry, in that clothes sometimes got lost or damaged. This included clothes being dyed or torn or scorched from the ironing. They stated that they had reported this to the manager but there had still been no improvement. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 20 One relative said that they “have a lot of questionnaires to fill in but never get a response from any negative comments that are made”. We spoke to the Head of Care about the laundry and she stated that if complaints were not put in writing then they were not recorded in the book. Both she and the general manager were aware that there had been problems but did not realise that they had not been resolved satisfactorily. The National Minimum Standards for Older People and the Care Homes Regulations state that a record is kept of all complaints and includes details of investigation and action taken. There is currently a safeguarding adults investigation underway, which is being carried out by Kent County Council. As part of this the home has received input from care managers and representatives of the local primary care trust. We spoke to members of staff in the home and they all were able to demonstrate a knowledge of the action they would take if they suspected any abuse. A requirement was made at the last key inspection in September 2007 for staff to receive further training in safeguarding adults. The Head of Care said that fifteen people had attended this training in March and they were arranging for the remaining staff to attend as soon as there was an available date. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People benefit from pleasant communal areas although areas of the home would benefit from some re-decoration and replacement of furniture. Infection control procedures need to be improved to ensure people live in a safe, hygienic environment. EVIDENCE: We toured the building and viewed communal areas and a selection of bedrooms. Since our last visit in September 2007, the home has worked hard to improve the cleanliness of the environment. This was particularly reflective in the kitchen, where the kitchen staff stated that they had carried out a deep clean. Conversations with three relatives also supported that the environment was now cleaner. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 22 At this visit bathrooms were also seen to be cleaner, although bins in the bathrooms contained incontinence pads and were full or over-flowing after the weekend. During our visit we observed domestic staff cleaning walls and furniture throughout the home. The general manager informed us that there are 120 hours per week allocated for domestic duties. The registered provider needs to make sure that these are deployed appropriately so that the level of cleanliness is maintained. Infection control procedures are not as robust as they should be. For example: in one bedroom we saw that there was an open bag on a chest of drawers that contained soiled wipes and faeces. There were soiled wipes on the floor and the commode and a chair was smeared with faeces. In another bedroom we saw that the commode had not been emptied and was full of urine. In another bedroom there were dark dirty marks on the carpet, the origin of which we could not establish. A wheelchair was stored in a hallway and there were dried faeces on the seat. A member of staff was observed to collect the wheelchair to take a person through to the dining room. We advised them about the condition of the seat and another wheelchair was used. A hoist was stored in the front room and this was dusty, and the sling smelt of urine and was stained. Areas of the home smelt of urine particularly in the reception area. We looked at the laundry and at the time of our visit there was a backlog of washing to be done. We were informed that one of the tumble dryers had been out of action for three days. The home uses the red alginate bag system for soiled washing although staff were unsure as to the exact procedures for washing different items. One member of staff stated that all washing needed to go into the bags regardless of colour or condition and another member of staff stated that clothes needed to be sorted into colours and stained items washed through the bag system. The sink and the floor in the laundry were not clean and there were cobwebs hanging from the ceiling. There is a dedicated laundry assistant who works from 6.30 – 12.00 during the week, but there is no dedicated allocated time at the weekends or in the afternoons. As stated elsewhere within this report relatives had voiced concerns about the condition of returned laundry. We saw broken chairs positioned around the home; there was one in the dining area of the nursing care unit and one in the quiet lounge in the residential care unit. Various clocks around the home were either not working or told the wrong time which could cause additional confusion for people living in the home. The Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 23 remote controls for televisions in individual people’s bedrooms did not always have batteries in. There are no lampshades in any of the bathrooms. There were four light bulbs in main lounge in the residential care unit that were not working and one of the electric radiators was very noisy and made a continual rattling noise. Individual bedrooms all contained personal items and were generally clean, although as previously stated infection control standards were not being maintained in places. People who were spoken to in their own rooms all stated that they were happy with their rooms. People are free to access the communal areas of the home as they wish, and these were clean and spacious, in particular the conservatory is airy and light. People are supplied with specialist beds where their needs indicate and in individual en-suites we saw raised toilet seats and grab rails. The Annual Quality Assurance Assessment (AQAA) stated “the decoration of two main corridors, a lounge, dining room and several bedrooms has taken place since September 2007”. There are areas of the home that are in need of redecoration and maintenance but the AQAA also states that there are plans for further improvement in the next twelve months. These are “to undertake significant capital expenditure and replace lounge chairs, dining tables, W.C. sanitary ware and floors”. The Statement of Purpose also states that the homes intends to “Continue with a cycle of maintenance, redecoration etc. and invest heavily in new furniture”. The registered provider must make sure that the maintenance and renewal programme is implemented with records kept. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 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. People benefit from being cared for by staff that have a good basic understanding of their needs, however their care may be compromised, as staff have not received adequate training. The deployment and number of staff available at different times of the day is not sufficient to meet the needs of the residents. EVIDENCE: At our visit in January 2008, we evidenced that there were not sufficient and experienced nurses on duty in the nursing care unit. At this time we made a requirement for this to be addressed. Since then the registered provider had employed a lead nurse for this unit along with additional nursing staff, including a nurse for night duty. We looked at the rotas for the nursing staff for the 24 March – 20 April 2008. These showed that there are two nurses on duty in the morning, one in the afternoon and one during the night. The home is still using Agency staff to supplement the nursing care input, but are maintaining regular staff. The lead nurse has currently been allocated some time as an additional member of staff in order to review care plans and assessments. This, however, is only planned Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 25 for the short term and there are still significant issues that need addressing as detailed in the relevant parts of this inspection report. We looked at the rotas for care staff for the week beginning 31 March 2008. This showed that there were usually eight members of care staff on duty in the home during the morning shift and six members of staff on duty for the afternoon shift, there are then three care staff on duty for the night shift which is from 20.00 hours until 07.00 hours. There are also three senior members of staff who work a rota system, not including the head of care. The rota showed, however, that there is some inequality around the deployment of staff on different days and times described as below: On Monday there are two senior staff from 7 – 2 and one senior staff from 2 – 9. On Tuesday there is one senior staff from 7 – 4, then two senior staff from 4 – 8 and then again one senior staff from 8 – 9 On Wednesday there is one senior staff from 7 – 2 and two senior staff from 2 – 8 and then one senior staff from 8 – 9. On Thursday there are two senior staff from 7 – 2 and one senior staff from 2 – 9. On Friday there is one senior staff (the Head of Care) on duty from 7 – 2 and one senior staff from 2 – 9. The Annual Quality Assurance Assessment (AQAA) stated that there are eleven people in the residential care unit and twenty-one people in the nursing care unit who need assistance with dressing and undressing. A relative informed us that they felt there were times when the home was under staffed as people were often left alone in the main lounge in the nursing care unit without staff coming to check on them. Another relative, however, did state, “The staff are very kind and I am happy to leave Mum in their care”. A member of staff stated that there was not enough time to spend with people and our observations at the mealtime in the nursing care unit evidenced that there were not enough staff to support people with their meals. The AQAA also gave us information about the dependency needs of people living in the home this included that there are nineteen people who require two or more staff to help them with their care. The Care Homes Regulations 2001 require care homes to be staffed in such numbers that are appropriate for the health and welfare of service users. The registered person must make sure that this is happening through the appropriate deployment of staff. There was a requirement at the last visit for the home to make sure that staff have either achieved a National Vocational Qualification (NVQ) at level two or above in accordance with the National Minimum Standards for Older People. The head of care confirmed that an assessor would be visiting the home on 28 April to enrol fifteen people on the NVQ training programme. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 26 We looked at the recruitment for two new members of staff. These records showed that there was a fully completed application form in place, two references are sought, proof of identity obtained and a Protection of Vulnerable Adults (POVAfirst) and Criminal Records Bureau (CRB) check are obtained. Staff work supervised until an appropriate CRB check is received. Nurses PIN numbers are checked, this is to verify that they are still registered with the Nursing and Midwifery Council (NMC). Staff are issued with a contract and the General Social Care Councils (GSCC) code of conduct. For care staff there is an initial in-house induction programme that takes place over the course of a week. Care staff then follow a programme based on the Skills for Care common induction standards. As yet there is no induction programme for the nursing staff. We were informed that this is being developed but is not yet in use. The Care Homes Regulations 2001 require that persons employed by the registered person have structured induction training. A requirement is being made with regards to this. It was recognised that an improved training programme is now being implemented. A requirement was made at the last visit with regards to relevant health and safety training and we were informed that some training had taken place and this included catheter care, pressure sore awareness, infection control and adult protection. Further training has been booked in for April and this includes first aid for thirty members of staff, health and safety for thirty members of staff, fire training for fifteen members of staff and manual handling for ten members of staff. There is also further infection control training arranged for May. The general manager was aware of other shortfalls and was in the process of arranging further training. There are, however, significant shortfalls in medication training and there has been no training in areas such as dementia care or managing challenging behaviour. The Care Homes Regulations 2001 require that people receive training appropriate to the work they are to perform and therefore a new requirement is being made with regards to training. We spoke to people living in the home and relatives who were visiting and everyone spoke highly of the staff. Comments included: “All of the staff are very good to me and very kind” “The staff are very kind” “I am happy here, the staff are nice – they are helpful” Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are benefiting from being supported by a new management team that are making improvements in their best interests. The health, safety and welfare of people living in the home are put at risk by poor movement and handling practices and use of equipment that has not been serviced. People cannot be confident that their personal money will be safeguarded by the homes accounting system. EVIDENCE: Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 28 Since our last visit the registered manager has left the service. A general manager has now been employed and he had been in post for three weeks at the time of our visit. He is a registered nurse and has worked in a nursing environment for over twenty years. The general manager informed us that he would be applying for the registered managers position. There are now clear lines of accountability within the home with the general manager overseeing the overall running of the home and he is supported by a head of care in the residential care unit and a lead nurse in the nursing care unit. They are working hard to address the shortfalls within the home but due to their short time in post they have not had the opportunity to make significant headway. The Statement of Purpose and Annual Quality Assurance Assessment (AQAA) state that questionnaires are distributed to people living in the home and their relatives. People confirmed that they received regular questionnaires. There has been limited supervision taking place and this is now being addressed. We were informed that the general manager and the lead nurse are completing medical supervision with the nursing staff. Two members of the nursing staff confirmed this and stated that it had been helpful and beneficial. There is a programmed being developed for a structured supervision programme for the residential care staff. The domestic and kitchen staff are to be included in this. The activities co-ordinator told us that she had not had any supervision and she should be included in the supervision programme. We looked at how people are supported with their individual spending money. The home does not hold money for all the people living in the home. Each person has an individual account sheet that identifies what money has been spent and gives running totals. All money, however, is kept pooled into one moneybox. At the time of our visit the actual money held in the moneybox did not correspond with the written balance with a difference of £60.31. There were still records for people who were now deceased and we were informed that if a person became overdrawn then they would use other people’s money and replace when funds were available. On the day of our visit we advised the general manager and head of care that the system needed to be reviewed and that the missing money needed to be investigated and accounted for. On the following day we received a phone call from the general manager to inform us that £50.00 of this money had been used to pay a plumber, the registered manager who had left in December 2007 had done this. A further conversation with the representative of the registered provider confirmed this and that the money had now been replaced. The Care Homes Regulations 2001 state that service users individual money cannot be used in connection with the running of the home and we advised the representative of the registered provider that a referral would be made to the safeguarding adults team. A requirement is also being made in this report. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 29 Records are maintained in the kitchen for monitoring food temperatures and fridge and freezer temperatures. Food was covered up and dated and stored appropriately in fridges. There is a schedule in place for cleaning the kitchen. Not all hoists had been serviced and we observed wheelchairs with either no footrests or only one in place. The head of care toured the building and addressed the wheelchairs at the time of our visit. We were informed at the time of our visit by a relative that their relation had fallen and had been picked up by a member of staff. We looked at the accident record and although it identified the accident it did not say how the lady had been helped up. Another person was refusing to use the hoist and a member of staff informed us that this was because he said that there was someone who would help him without the hoist. We observed a member of staff assisting someone to stand using an incorrect procedure of an underarm lift and another relative informed us that staff often helped her mum up by her arms. A previous visit had also evidenced poor practice. The Care Homes Regulations 2001 state that ‘the registered person must make suitable arrangements to provide a safe system for moving and handling service users’. The home had commissioned the service of an external training consultant to carry out an infection control audit, which had identified areas that needed addressing. Our observations, as detailed in the environment section of this report, also evidenced that there are shortfalls in infection control procedures. The Care Homes Regulations 2001 state that there are suitable arrangements to prevent infection and toxic conditions in the home and the registered provider must make sure that there are the appropriate systems in place for maintaining infection control in all areas. During our visit the lead nurse informed us that a service user had been identified as having MRSA. She had immediately put into place specific infection control measures for this person and updated the care plan giving detailed guidance for staff to follow. We looked at records for maintaining the safety of equipment in the home. We saw evidence that there were regular fire alarm checks and fire drills, water temperature checks, emergency lighting checks. The AQAA stated that the lifts were serviced regularly and as was other electrical equipment. The AQAA did not state if gas appliances had been serviced. The registered person needs to make sure that the home complies with the relevant legislation as identified in the National Minimum Standards for Older People and a requirement had been made with regards to this. On the day of our visit the home was not displaying a current insurance certificate, we requested that this was forwarded to us within forty eight hours. This was not received. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 30 An office space has been allocated in the nursing care unit, to improve storage and a new telephone system has been installed for improved communication. The AQAA identified that not all policies and procedures are in place for the effective running of the home, this included emergency and crises, food safety and nutrition and clinical procedures. We identified at our visit that that the medication procedures in the residential unit were out of date and that there was confusion amongst staff about laundry procedures. The registered person must make sure that the policies and procedures are reviewed, implemented and communicated to staff in order to promote the smooth running of the home. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 2 2 2 X 2 2 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 1 X X 1 Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 (Sched 1) Requirement (1) The registered person shall compile in relation to the care home a written statement (in these Regulations referred to as “the statement of purpose”) which shall consist of— (a) A statement of the aims and objectives of the care home; (b) A statement as to the facilities and services which are to be provided by the registered person for service users; and (c) A statement as to the matters listed in Schedule 1. In that the Statement of Purpose must accurately detail the range of needs and services provided. (1) The registered person shall make arrangements for service users— (b) To receive where necessary, treatment, advice and other services from any health care professional. In that arrangements must be made for people to be assessed by an appropriate healthcare professional in relation in relation to DS0000023399.V361108.R01.S.doc Timescale for action 30/06/08 2 OP4 13 (1) (b) 31/05/08 Cooksditch House Nursing and Residential Home Version 5.2 Page 33 13(1)(b) Schedule 3(3)(m) 3 OP7 14 (1) (a) (2) 4 OP9 13 (2) 5 OP15 17 (2) Schedule 4 (13) 16 (2) psychological welfare. In that there are full details of any plan relating to people in respect of medication, nursing, specialist healthcare or nutrition and there are detailed records on how people are supported with this. (1) The registered person shall 31/05/08 not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so— (a) Needs of the service user have been assessed by a suitably qualified or suitably trained person; (2) The registered person shall ensure that the assessment of the service user’s needs is— (a) Kept under review; and (b) Revised at any time when it is necessary to do so having regard to any change of circumstances. In that risk assessments give clear guidance to staff on how to reduce the risk and this is incorporated into the care plans. The registered person must have 23/05/08 a system in place to ensure that complete and accurate records are kept of all medication administered, to demonstrate that service users receive their medicines as prescribed. This is an outstanding requirement with a previous timescale of 31/10/07 (2) The registered person must 23/05/08 maintain in the care home the records specified in Schedule 4. In that records of food provided for people are maintained in sufficient detail to determine that dietary DS0000023399.V361108.R01.S.doc Version 5.2 Page 34 Cooksditch House Nursing and Residential Home 6 OP27 18 (1) (a) (c) (i) 7 OP31 8 8 OP35 17 (2) Schedule 4 (9) (a) 9 OP38 13 (3) outcomes are satisfactory. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users— (a) Ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. In that there is a suitable induction programme for nurses employed in the home In that there is a staff training development programme that identifies the training needed to meet the needs of the people living in the home. Any person who carried on or manages an establishment or agency of any description without being registered under this part in respect of its (as an establishment or, as the case may be, agency of that description) shall be guilty of an offence. Care Standards Act 2000 (11 (1)) In that an application be made for a registered manager by date set. (2) The registered person shall maintain in the care home the records specified in Schedule 4. In that there must be a robust system for managing peoples individual spending money. People’s personal monies must not be used to pay tradesman carrying out duties at the home. (3) The registered person shall make suitable arrangements to DS0000023399.V361108.R01.S.doc 31/05/08 30/06/08 31/05/08 30/04/08 Page 35 Cooksditch House Nursing and Residential Home Version 5.2 10 OP38 12 (1) (a) prevent infection, toxic conditions and the spread of infection at the care home. In that infection control procedures are followed and soiled wipes are disposed of promptly and safely. Dried faeces on chairs and wheelchairs are cleaned promptly. Bins containing soiled waste are emptied regularly. Commodes are cleaned after use. The registered person shall ensure that the care home is conducted so as— (a) To promote and make proper provision for the health and welfare of service users; In that there are safe systems for the movement and handling of people living in the home. 30/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4 4. Refer to Standard OP4 OP12 OP16 OP19 OP33 Good Practice Recommendations That where assessments are reviewed clear records are maintained to evidence as to why there are any significant changes in need. That all people benefit from having the opportunity to take part in pastimes or activities that suits individual needs, preferences and choices. That when verbal concerns are raised by relatives they are dealt with through the formal complaints procedure. The registered provider continues with their improvement and development plan. That the quality assurance and quality monitoring systems are developed. DS0000023399.V361108.R01.S.doc Version 5.2 Page 36 Cooksditch House Nursing and Residential Home 5. 6. OP36 OP37 That the supervision programme is maintained. That the registered provider develops the policies and procedures. Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cooksditch House Nursing and Residential Home DS0000023399.V361108.R01.S.doc Version 5.2 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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