CARE HOMES FOR OLDER PEOPLE
Coombe End Court Coombe End Court London Road Marlborough SN8 2AP Lead Inspector
Ms Sally Walker Unannounced Inspection 09:25 12th June 2006 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 Coombe End Court DS0000065400.V298361.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. Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Coombe End Court Address Coombe End Court London Road Marlborough SN8 2AP 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) 01672 512075 The Orders Of St John Care Trust Mrs Susann Linsley [application awaited] Care Home 60 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (40) of places Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The registered person will ensure that staffing levels meet the needs of residents at all times and do not fall below that stipulated in the Residential Forum `Care Staffing in Homes for Older People` Model The home may from time to time to admit residents between the ages of 60 and 65 18th January 2006 Date of last inspection Brief Description of the Service: The home was registered on 20th September 2005 to The Orders of St John Care Trust. The home is registered for a total of 60 beds for older people, including a separate unit for residents with a diagnosis of dementia. There are 10 beds in the main home registered for dementia. The building was purpose built in 2005 and comprises three named areas: Emerald, Ruby and Pearl. A day service is also attached to the building. Residents’ accommodation is all single bedrooms with ensuite toilet and shower. Mrs Susann Linsley started in post as manager on 5th June 2006 and her application to register as manager is awaited. On registration it was agreed that staffing levels have been calculated to meet the Residential Forum Care Staffing in Homes for Older People model - 1120 care hours per week for 60 residents. There were 5 staff in the dementia unit with 20 residents, 4 staff and a care leader in the main home together with a head of care and 40 residents and 2 waking night staff to each unit. Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place during 12th June between 9.25am and 4.50pm with 2 inspectors and 13th June 2006 between 9.25am and 5.25pm with one inspector. The care records, accident book, training records, medication administration records, complaints log, menus, activities programme and risk assessments were inspected. A tour of the building was made and 10 residents were spoken with and 5 staff. Mrs Susann Linsley had been in post for one week as manager, the previous manager having gone to manage another home in the organisation. Mrs Jill Mitchener, Care Development Manager, was present for part of the inspection having come to carry out an interview for staff. Joan Dawson, Quality Assurance Manager, and Sally Jones, Care and Nursing Advisor also came to the home during the inspection to carry out an audit of the administration and control of medication. As a consequence the inspectors only considered the requirements and recommendations of the last report with regard to medication. Between 20th October 2005 and 7th April 2006 there had been 7 drug maladministrations. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well:
Those residents who had moved from the local authority home to Coombe End Court reported that they were now settled and enjoyed their new accommodation and had got used to some different staff. One relative made very positive comments about a resident’s admission to the home and gave examples of how their health had improved since then. They said they were always made welcome to the home. Many of the outstanding issues noted on the first day of the inspection were either immediately addressed or actioned by the second day. Residents had good access to specialist healthcare professionals and there was good evidence of prompt referral when concerns were noted. Comments from residents, both on the day and from comment cards, were that they felt well supported by staff who provided the care that they needed. Those residents who are more self determined can spend their day as they wish; other residents must rely on staff for direction. Mrs Linsley had already started a recruitment drive and had filled many of the posts, with induction planned when all the information required by regulation was received. She had also considered allocation of duties to enable care staff to spend more time with residents. Residents enjoyed the range and quality of the meals. The menus gave 2 choices for each meal with a salad alternative for lunch. Fresh fruit was available in the serveries. Staff were recording and monitoring residents food intake and regularly weighed residents. Those residents who inspectors could communicate with said they had no complaints
Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 6 but knew who to talk to if they had concerns. Monies held on residents behalf was being properly managed with records of all transactions and regular audit by the home. The administrator was familiar with the process of reporting any allegation of financial or indeed any other kind of abuse. Staff had been trained in the local vulnerable adults procedure and the policy booklet was available. Residents’ accommodation was comfortable, clean and well maintained. All the bedrooms had ensuite shower and toilet facilities. Residents said they liked their bedrooms. What has improved since the last inspection? What they could do better:
The current format for assessing potential residents does not aid assessment of people with complex care needs. There was no written evidence that residents who went to hospital had their care needs assessed to make sure
Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 7 that the home could continue to care for them. Mrs Linsley intends that a format she had previously used to gather social history from supporters of people with dementia will be implemented as part of the pre-admission assessment. Whilst most of the requirements and recommendations regarding medication had been actioned, there is still some work to be done to ensure that prescriber’s instructions are detailed in the care plans. If these instructions are not followed for any reason this must be documented. The organisation must provide the manager with a full set of policies and procedures relevant to its purpose, for example, use of a nebuliser. Mrs Linsley had already identified missing policies and procedures which had been sought from the organisation. Whilst there had been much improvement to residents’ care plans, there is still some work to do to make sure that staff record specific details, for example, size, exact location and nature of any wounds. Assessments of residents risk of developing pressure sores showed little understanding of tissue viability. However Mrs Linsley intended to provide training to staff then implement the Tissue Viability Specialist Nurse’s new assessment tool once it was published. Any immediate care charts must be filled out, including when no intervention was needed for any reason and fluid charts should be totalled for monitoring purposes. Risk assessments must detail guidance to staff, for example, whether residents can spend time alone in the bath and for how long. The home was recruiting for a 20-hour post for activities; this was a reduction from the 30-hour part time posts proposed when the home first opened. Given the range of activities detailed in the programme and the number of residents who said they would like to go out into the town, and Mrs Linsley’s proposal to develop a specialist dementia activities programme, a 20 hour post would not reasonably achieve all this for 60 residents. There was no policy on male staff working with female residents, although there was evidence that one resident had been consulted about receiving intimate personal care and medication from male staff, there was no evidence that other residents had been consulted. There must be a policy in place for the protection of residents and indeed male staff. Staff response time to a call bell during the inspection was poor. However by the second day, the head of care had addressed the matter with staff with guidance that calls must be answered within 3 minutes. The residents in the dementia unit were better groomed that some of those in the main home. Some residents had been left sitting in wheelchairs in the sitting rooms. It is expected that reallocation of housekeeping duties will enable staff to spend more time with residents, particularly in the main home. Whilst records showed that staff had received training in infection control and moving and handling 2 incidents occurred where soiled laundry was placed with clean and one observation of poor moving a resident. The laundry room was poorly ventilated and in need of a clean. Residents, particularly those in the dementia unit, were potentially at risk from access to the various kitchen and electrical equipment in the serveries by the drop down counter top being in an upright position. Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 8 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. Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The organisation’s current format for assessment does not assist staff to carry out a full and detailed assessment of prospective residents care needs, particularly those with complex care needs, for example, dementia. The home could not evidence that further assessments were made after admission to hospital to make sure that needs could be met if the resident returned. However the admission process for some of the residents and their relatives had been a positive experience. Given Mrs Linsley’s previous history of ensuring proper pre-admission assessments were carried out, the Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A number of the residents transferred to this newly built home when the local authority home in the grounds was demolished. Many of these residents said that although it took time to adjust to a bigger home, they were now happy. The requirement that suitable formats for pre-admission assessments were in place to cover all aspects of care needs in order to produce a full care plan had not been actioned. The organisation continues to use a form, which does not aid assessment of often complex care needs. There was no evidence that assessments were being carried out before residents returned from hospital to
Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 11 establish whether the home could continue to meet their needs. Mrs Linsley intended to use processes that she was familiar with in her previous home in order that proper assessments were carried out, these would include a social history for those residents with dementia who could not necessarily remember details. One comment card was received to say that the person had a contract and enough information before they moved to the home. A relative made very positive comments about a resident’s admission to the home; how they were kept in touch with progress in the resident’s health, how the resident had improved since admission and the friendliness of the staff. It was noted that beds in empty rooms had been made up with continence sheets as a matter of course when it had not yet been established whether they were needed. Mrs Linsley immediately removed the sheets. Coombe End Court DS0000065400.V298361.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, part of 9 & 10 Care plans were improved since the last inspection. Whilst staff are very knowledgeable when asked about detail of residents care needs, they are not always recording what they know. Evidence suggested that residents’ healthcare needs were being met with good access to healthcare professionals and prompt referral when needed. The majority of the requirements regarding medication have been actioned. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Between October 2005 and the last inspection in January 2006 there had been 4 medication errors. Since then there had been a further 3 medication errors, one resulting in hospital admission. The previous manager and the organisation have carried out extensive investigations resulting in some disciplinary action and providing the Commission with an action plan showing how they planned to address the matter. Only those staff who have had their continued competency assessed are able to give medication. All staff have received training and 2 staff are now administering medication and signing the records. There have been no further reports of maladministrations since 7th April 2006. Mrs Linsley asked whether the number of staff giving medication could now be reduced from 2 to 1. The inspector advised that she must satisfy
Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 13 herself by risk assessment that this reduction protects residents from further maladministrations. Given that Joan Dawson, Quality Assurance Manager and Sally Jones, Care and Nursing Advisor, were carrying out an audit of the home’s arrangements for administration and control of medication on the day of the inspection, the inspectors did not inspect these standards in full, save to consider whether previous requirements and recommendations had been met. Mrs Linsley is advised to consult with the organisation’s senior specialist advisors with regard to the risks of only one person giving medication. The requirement that medication prescribed ‘as required’ as part of a behaviour management plan was evidenced in the records has been actioned. Clear guidance was noted in care plans of when to administer with descriptions of what the behaviour might be. The requirement that the organisation’s own procedures are followed if there are questions over staffs competence in administering medication and that competent staff must be available when needed to do this had been actioned. The recommendation that the training of staff who administer medication should be expanded beyond local policies and competencies had been actioned with some training from the supplying pharmacist. However this should be broader in range of subjects. The requirement that medication must only be given according to the prescriber’s instructions; including ‘as required’ and variable doses had been actioned for the most part. A separate sheet now accompanied the medication administration records for this medication. Staff were now not just giving these medications depending on what the previous administration had been. It was clear that staff now had an understanding of these medications and that they had to establish whether it should be given, either by asking the resident or from knowledge of their daily record or immediate care charts. However it was noted that one medication prescribed for one day each week had on one occasion been given the following day. There was no record of why or any indication in the care plan as to why it was prescribed in this manner. One of the senior staff knew these details and was able to report on the reasons for it being given a day later; they were advised to update the care plan and in future record any reasons why the prescriber’s directions were not followed. The recommendation that the organisation’s new medication policy and procedure should accompany the medication administration record for easy access had been actioned. The recommendation that handwritten entries in the medication administration record were witnessed, signed and dated by 2 staff had been actioned. The duplicate medication administration record handwritten by the supplying pharmacist had been removed to avoid confusion as recommended. The recommendation that controlled medication records should start with a received balance to avoid confusion in monitoring storage had been actioned. The recommendation that large prescription order should be discussed with the prescriber if difficulties in storage were encountered had been actioned. By the second day the master keys, including medication Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 14 storage keys which had been kept under the desk, were removed to a safer place in a locked room. One resident was receiving medication throughout the day via a nebuliser. There was little detail in their care plan on when it should be given, whether the resident was able to use the equipment or cleaning and maintenance. There was no policy or procedure in the manual on the use of this equipment. The requirement that care plans must identify residents current care needs with full detail of how those needs are to be met, particularly with regard to dementia, tissue viability, behaviours, infection, medication, bowel management and nutrition, is in progress. The long term care plans gave a good picture of the residents needs but short term care plans did not fully identify all care needs. Nutritional monitoring charts were being filled out to a degree but as the amounts taken each day were not totalled, the home could not show that full monitoring was taking place. One care plan identified that the residents must have a water jug in their bedroom but when it was visited at 12.20 there was no jug. Not all of the residents had direct access to drinks throughout the day in addition to the midmorning and afternoon drinks that staff provided. The inspectors advised that all residents must be encouraged to drink with jugs of juice or water made available to them where they are in the home, particularly on a hot day such as the inspection. There was good evidence of staff monitoring food intake with one member of staff making sure a resident who missed their lunch as they were sleeping, had this meal when they woke up. Residents were regularly weighed. Care plans gave a more detailed picture of how the care was managed and monitored. The practice of identifying those residents with a specific infection with a coloured mark on their door had ceased as recommended. Any specialist care for these residents was now more detailed in their care plans. The requirement that care plans were reviewed and revised at least once a month or as needs changed had been generally actioned. A system was in place for evidencing monthly reviews and there was evidence of amendments to a care plan following falls and a period of illness. However when it is reported that residents choose not to sleep in their beds at night, there must be established reasons for this and a night care plan must be implemented with interventions to ensure that their health is not affected, for example, swollen legs. It is not sufficient to state that this is their choice when clearly their health is affected. Moving and handling assessments had not been reviewed and updated to reflect changing care needs. The requirement that care staff were trained in tissue viability in order that they could assess residents’ potential risk of developing pressure sores remains. No tissue viability training had taken place. Staff had watched a video and Mrs Linsley had attended 2 training sessions by the Tissue Viability Specialist Nurse in her previous home. The requirement that residents must have their risk of developing pressure sores assessed was in some progress.
Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 15 Some assessments were in place but showed little understanding of when residents should be assessed, or what action staff should take to prevent deterioration, save alerting the district nurse once concerns were noted, clearly too late. Other tissue viability risk assessments found in files had not been reviewed for three months. Some pressure relieving equipment was in place. The Tissue Viability Specialist Nurse is currently piloting a format to be completed by non nursing staff to assess risk. It is understood that training will be made available as part of this pilot. It was noted that the district nurse was involved with some residents and that pressure relieving equipment was in place. The inspectors advised that the home must complete its own records of progress and monitoring of wounds and not rely on those of the district nurse kept in the home. These records must be more detailed. Some files recorded “blister on leg” or “ulcers on leg”. Some body maps were in place as recommended and staff when questioned were able to give a very detailed verbal account of the missing details in the records; size of wound, exact position and healing. Turning charts had not been filled out. The home must urgently review residents nursing care needs when there is an acute change in need resulting in increased input from the district nurse or when their dependency increases. The home had good access to the clinical psychiatrist who visited every 2 weeks and the senior practitioner for mental health was available to discuss issues. There was evidence of prompt referral to healthcare professionals when concerns were noted. The requirements that risk of daily living were assessed was in some progress. Some assessments were very detailed. Bathing assessments must detail whether residents need staff presence when bathing and if not how much time they can safely spend alone. One comment card said that the person always received the care that they needed and the medical support they needed. Coombe End Court DS0000065400.V298361.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Those residents who were self determined could spend their time as they wished, others depended on staff for direction. Staffing levels, particularly with regard to activities, could not support residents to access the level of activities published or residents’ wishes to access the community. Visitors were encouraged and made welcome. Decision making was limited to meals, what to wear or where to sit. Residents enjoyed the high quality and range of meals provided. The Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There was an activities programme displayed on notice boards. Staff were providing some activities until a co-ordinator was appointed. There was a separate activities room on the ground floor and a sensory room with some light and music equipment, neither room appeared well used. Mrs Linsley said that she was interviewing that week for a 20 hour post. When the home was first registered rotas were supplied to the Commission to show that there were 2 activity posts of 12.5 hours and 17.5 hours, totalling 30 hours each week. Considering the range of activities in both the dementia unit and the main home proposed by the programme, 20 hours could not reasonably provide this together with any one to one time for those residents who do not respond in large groups. Residents confirmed that some activities were held. It was clear from talking to Mrs Linsley that she intended to improve the range of activities,
Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 17 particularly a specialist programme for those residents with dementia. She had contacted some entertainers who had provided events at her previous home, planned a barbeque and raffle. An artist was booked to run an art class. There had been visits to other homes in the organisation to competition events but very little in the locality: a trip to a farm and to Wilton. One resident was going out to a day club. A number of residents told inspectors they would like to be accompanied to the town for shopping or a coffee. One resident said they enjoyed the word games and would like more of them; another enjoyed the singing sessions. One resident was provided with wool to knit blanket squares for charity. One comment card said that there were usually activities that they could take part in. Those residents who could make decisions said they could spend their day where they wished. Some residents knew how to access the grounds. Other residents who could not necessarily make decisions on their own had to rely on staff to plan their day for them. There was no real evidence that residents were consulted about decision making, save day to day choices of food, what to wear or where to sit. One example was whether they agreed to male staff caring for them. Visitors were encouraged and one said they were always made welcome. The home had a form entitled ‘resident of the day’ which showed good evidence of how staff made sure key tasks were carried out, for example, tidying room, checking appointments for chiropody and other keyworker duties. The inspector advised that one to one activities could be added to this list. The lunch was well presented. All of the residents spoken with made very positive comments about the quality and range of the meals provided. They said the food was freshly made and this was evidence from the main course lunch and pudding. One comment card said that the person always liked the meals at the home. There were 2 choices at each meal and a further salad alternative for lunch. Records were kept of lunch and the evening meal only. Records also showed if a resident had had something different to the menu. Two of the residents did not know whether they could use the serveries to make a drink or have their own kettle in their room. A large bowl of fresh fruit was seen in one of the serveries accessible to residents. All of those residents who were visited in their rooms had their call bells within easy reach. However staff supervision of the sitting rooms was intermittent. A relative asked the inspectors for help on behalf of one of the residents in a sitting room. They had not been made aware of the call bell in this room. The inspector rang the call bell which was answered after 5 minutes. Unfortunately the staff who responded had only started that day so could not assist with moving the resident as they were not trained in moving and handling. The staff who then responded, 6 minutes after the call, was observed to carry out poor manual handling practice. The following day a notice was posted in the care offices that call bells must be answered within 3 minutes. Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 18 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Systems are in place to ensure that residents or their families can raise issues with the home or make complaints. The organisation’s new guidance on investigating and responding to complaints for managers is clearer. Staff have been trained in the local vulnerable adults procedure. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home had a complaints procedure which was included in the service user’s guide given to all residents on admission. The organisation continues to use 2 forms for complaints, one for verbal and one for serious complaints. The form for verbal complaints does not show investigations or outcomes and suggests that verbal complaints were not serious. The organisation had updated its guidance to managers following training for all its managers. The process is now clear to follow for investigators giving clear information on the process and how to respond to complainants with timescales. The complaints log showed the home had received 2 complaints, both related to medication, together with actions taken to resolve each matter. Those residents spoken with appeared to be familiar with the complaints procedure although they said they had no reason to complain. Most of these residents said they would talk to Mrs Linsley or other staff if they were unhappy. The inspector was pleased to note that Mrs Linsley was already well known either in person or as the new manager to those residents with whom the inspectors could communicate. One comment card said that the person usually knew who to speak to if they were not happy and they always knew how to make a complaint. Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 19 The home’s administrator ensured that any monies or valuable held on residents’ behalf was safely held, well managed and regularly audited. Records were kept of all transactions including receipts and two signatures required for any withdrawals. Residents can access their money at all times but only very senior staff have access to the safe. The home will not hold any valuables for new residents; this was an arrangement for those residents who had transferred from the local authority home. The administrator was not an appointee for either pensions or savings accounts. Families or solicitors were encouraged to act on residents’ behalf if residents were not able to. Those residents who were able to manage their own finances had lockable storage in their bedrooms. The administrator was very aware of the local policy for the protection of vulnerable adults and would have no hesitation in reporting any concerns or allegations of financial or indeed any other form of abuse. Training records showed that staff had had training in the local vulnerable adults procedure and the booklet was available with contact telephone numbers. Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 20 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 & 26 Residents are provided with a comfortable, homely, well maintained environment. Residents’ bedrooms were personalised and they benefited form ensuite facilities. Lack of attention to infection control procedures by some staff does not protect residents. Areas of the home used by residents were however cleaned to a good standard. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home was newly built in 2006 and opened in September of that year. All of the bedrooms have en-suite toilet and shower facilities. Since the last inspection in January 2006 considerable efforts have been made to individualise the rooms with some residents bringing small items of their own furniture and having their possessions on display. Many of those residents who had previously lived in the local authority home said they had chosen their bedrooms before the new home opened. Mrs Linsley showed the inspectors one of the corridor carpets which was stained and difficult to keep clean; the manufacturer was to replace it.
Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 21 Two staff were covering the laundry duties. The room was very hot and the sole ventilation was from windows which could only be opened a few inches. The inspectors advised the use of a fan until the ventilation problem could be resolved. The room was also in need of a clean as there was a build up of dust on the floor. The drop down counter top in the kitchenettes need to have risk assessments if they are to continue to remain in an upright position. The risks associated with people with dementia gaining access to electrical equipment without staff being present and other risks in these areas must be assessed. Residents said that staff came to their bedrooms every day to clean and that they were very satisfied with the standard. One comment card said that the home was always fresh and clean. Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Efforts are being made to recruit a permanent staff group with less reliance on agency staff. Those agency staff used had a good understanding of the needs of older people. All staff engaged with residents and were working better as a team. Better distribution of staff across the week, reallocation of duties, including appointment of a person responsible for activities should mean staff should have more time for residents. Robust recruitment practice is now in place. Staff had access to NVQs and the organisation’s training programme. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: One of Mrs Linsley’s immediate plans was to recruit to the staff team and once vacancies were filled, to develop that staff team. There was a high use of agency staff as evidenced by the invoices provided by the previous manager. Mrs Linsley was interviewing that day and throughout the rest of the week. She was also interviewing for another unit leader. Currently a member of staff from one of the other homes in the organisation was seconded to the post. Staff have good relationships with residents and there was much evidence of positive interactions with residents. Staff engaged with residents; this was also true of the agency staff on duty evidenced during the inspection. The inspectors were of the view that staff were more aware of their role, were more confident and were working better as a team. Residents spoken with made very positive comments about day and night staff saying how friendly and helpful they were. One resident liked to be called by their first name. One comment card said that the staff always listened and acted on what they said
Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 23 and that staff were usually available when needed. One resident said they were not taken out shopping as the home was short staffed. The requirement that all new staff were inducted into the work with records kept had been actioned. Further induction was planned for a group of recently appointed staff. The requirement that care staffing levels were maintained throughout the week in all areas of the home and not reduced at weekends had been actioned. Mrs Linsley was working on the new care rotas as the inspectors arrived. The allocation of domestic tasks must be considered. By 10.30 there was a build up of crockery from breakfast which was awaiting the dishwasher in the serveries in the dining rooms. By a quarter to twelve the morning drinks crockery was also stacked up awaiting the dishwasher. Care staff were attempting to process the dishwasher in between carrying out their caring duties. There was some covered food in one fridge which was not dated. Butter and marmalade were in one fridge uncovered and undated. It was clear from talking to Mrs Linsley that she was dealing with these matters but had difficulty in securing the task lists for the housekeeping posts which were not available in the home. She also intended that a member of the senior staff must have responsibility for supervising and managing the ancillary staff. There were 4 housekeeping staff on duty during the mornings. Mrs Linsley later reported that housekeeping staff had covered the 2 housekeepers who were on annual leave that week by allocating those duties amongst themselves. There was also housekeeping allocated from 12.00 noon to 6.00pm. By the second day Mrs Linsley had ensured that housekeeping staff processed the dishwashers and new task schedules were in place. There were 4 care staff on duty with a care leader in the main home with 40 residents, up to 10 of whom may have dementia and 5 care staff in the dementia unit with 20 residents. There was also the head of care who was exclusive of the care hours. The residents in the dementia unit were much better groomed than those in the rest of the home. Some residents were left in wheelchairs in the dining rooms. Clearly 5 staff in the main home had some difficulty in carrying out all the caring, domestic and administrative duties that were expected of them. It was clear from talking to Mrs Linsley that she intended to resolve the allocation of duties in consideration of task lists. Mrs Linsley and her line manager, Jill Mitchener, had already started on reorganising the personnel records as information had been stored in different files. Those files inspected had all the information required by regulation. Mrs Linsley reported that all staff would eventually undertake the organisation’s training pack on dementia in association with the Alzheimers Society. She went on to say that the community psychiatric nurse had provided some training. Mrs Mitchener and Mrs Linsley also intended to provide further training in specialist dementia care. There was a matrix to
Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 24 show where training was needed. Health and safety training was taking place that week. The organisation’s training programme was posted so staff could select relevant courses. There were a number of male care staff and there was no evidence that all residents or their families or others involved in their care had been consulted with regard to the giving of intimate personal care by male staff. There was no written policy on male staff working with female residents for the protection of residents and those male staff from allegations of abuse. Only one resident’s care plan had a written statement. Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 25 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 & 38 Mrs Linsley brings with her a proven ability to manage the home and ensure that good care is provided. It was evident that after only a week in post that she had defined her priorities and was taking steps to implement her plans. The home was run in the best interests of the residents. Proper systems were in place to protect residents personal monies held on their behalf. Although staff had received training in health and safety issues, some staff showed little understanding of their responsibilities. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There was evidence throughout the 2 days that Mrs Linsley has a clear understanding of how she intends to develop the home only after a short time in post. The inspectors were of the opinion that the home was better managed. Mrs Linsley has had over 30 years care experience mainly with people with dementia in care homes and hospital. She has also worked with children with learning disabilities. Mrs Linsley was a manager for another of
Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 26 the organisation’s homes for over 4 years and holds the registered Managers Award. Whilst Mrs Linsley’s experience is recognised the inspectors were concerned that there was no written evidence of her formal induction into the home until it was mentioned at the inspection. Mrs Linsley had covered management duties whilst the previous manager was on leave for three weeks. Mrs Linsley had already commenced working with Jill Mitchener, Care Services Manager, on developing the staff and the dementia care from the first day in post. Mrs Linsley had identified that the organisation’s policies and procedures manual was not complete and had ordered more copies. She had also identified that task lists were not available. Some staff reported that they had not previously had regular supervision. Mrs Linsley had already noted this and developed a new programme in order that it took place regularly from now on. Senior staff had received supervision training. Staff meetings had been regularly held. The requirement that all staff were aware of infection control policy, particularly when infections occur was in some progress. Two staff covering laundry duties were aware, but a red disposal bag for contaminated laundry was seen on fresh linen on a trolley used by other staff on 2 occasions. On the second day the head of care stated that large notices had now been put on the laundry trolleys to remind staff. The staff records showed that staff had received training in infection control and the Health Protection Policy guidance to care homes was available in the home. One of the staff had recently been trained as the home’s trainer in infection control. The inspectors advised that certain infections must be notified to the Commission under Regulation 37. This must also include the Notification of pressure sores of Grade 2 or over. One example of poor moving of a resident was observed. The home must ensure that staff understand the training and their responsibility to carry out safe practice for the protection of the residents and indeed themselves. There was evidence on staff files that training had been carried out and this staff said they had been trained. There were also 4 hoists in the building for staff to use. Accident recording was varied. One resident had been found outside but there was no record of how long or whether the resident had been asked what happened when falls were not witnessed. However there was very good evidence of staff following up one resident who had a number of falls with referral to GP and risk assessment review. The inspectors advised that all records must be in reasonably plain English and complex medical terms which may not necessarily be understood by all staff must be avoided. Environmental risk assessments had recently been reviewed and updated and related to all aspects of the environments and tasks around the home. The recommendation that certificates of training should be evidenced if staff were to train others in certain procedures, for example, moving and handling
Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 27 and first aid, had been actioned. One of these staff had been retrained in moving and handling. Accident records must be more detailed in describing location of falls. Mrs Linsley was asked about the home’s quality assurance system. She said, understandably, that this was not one of her priorities at the present time and she would consider it later in the year. She did however make reference to the organisation’s quality proforma and the methods for residents and families to make suggestions and comment on the service. It was later reported that Joan Dawson, the organisation’s quality assurance manager would be carrying out a full audit. Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 29 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 OP3 Regulation 14 Requirement Timescale for action 12/06/06 2. OP7 15 3. OP8 18(1)(i) The person registered must ensure that suitable formats are in place so that pre-admission assessments cover all aspects of residents care needs in order that a full care plan can be produced. (Outstanding from 18th January 2006. Current format does not aid complex care assessments. Reassessment must take place if residents spend time in hospital). The person registered must 12/06/06 ensure that care plans identify residents current care needs with full detail of how those needs are to be met. This must include, if relevant: dementia care, pressure area care or prevention, managing behaviours, managing infection, medication, bowel management, nutrition and other conditions as they are presented. (whilst improved the care plans need specific detail) The person registered must 31/08/06 ensure that care staff receive training in tissue viability in
DS0000065400.V298361.R01.S.doc Version 5.2 Coombe End Court Page 30 4. OP8 5. OP38 6. OP7 7 OP9 8 OP12 9 OP26 10 OP38 order that they can assess residents potential risk of developing pressure sores. (New compliance date set as non nursing format being piloted in Wiltshire by Tissue Viability Specialist Nurse). 13(4)(c) The person registered must ensure that residents are assessed as to their risk of developing pressure sores. Strategies must be in place to prevent further risk and recorded in the care plans. (As above) 16(2)(j) The person registered must ensure that all staff are aware of infection control policy particularly when infections occur. (training had taken place but some staff were still unaware) 13(4) The person registered must ensure that all risks of daily living are assessed for each resident. (In some progress) 13(2) The organisation must ensure it provides the home with its policy and procedure for the use of specialist equipment, in this case, a nebuliser. In the meantime a local policy and procedure must be in place. 16(2)(m) The person registered must &(n) ensure that sufficient staff hours are provided exclusive of the care hours so that residents can access the community and access the activities programme that the home publishes. 16(2)(j) The registered person must ensure that the laundry is included on the cleaning schedules. 13 The registered person must (4)(a)(b)& ensure that if the drop down (c) counter top in the serveries are to remain upright that a written risk assessment is carried out
DS0000065400.V298361.R01.S.doc 12/06/06 12/06/06 12/06/06 12/06/06 31/10/06 12/06/06 12/06/06 Coombe End Court Version 5.2 Page 31 11 OP10 12(2)&(3) 12 OP38 13(5) with regard to residents with dementia gaining access to the kitchen equipment and other risks when staff are not present. The person registered must ensure that a policy is in place to ensure that female residents or their representatives are consulted with regard to the giving of intimate personal care by male staff, for the protection of residents and the male staff. The person registered must ensure that although staff have received training in moving and handling they are aware that they must use the safe methods that they have been shown. 12/06/06 12/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The training of staff who administer medication should be expanded beyond local policies and competency. (Addressed in part at 18th January 2006 and at 12th June 2006 with the supplying pharmacist providing a session. This training should also include properties of medication and seminars). Continence sheets should not automatically be placed on beds until it has been established that the new resident requires it. Consideration should be given to increasing the ventilation of the laundry room for the health and safety of staff employed in this area. 2 3 OP3 OP26 Coombe End Court DS0000065400.V298361.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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