Inspection on 05/06/07 for Coombe End Court

This inspection was carried out on 5th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Coombe End Court 12/06/06

Coombe End Court 18/01/06

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Coombe End Court London Road Marlborough SN8 2AP Lead Inspector Ms Sally Walker Unannounced Inspection 5th June 2007 09:15 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.V335200.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.V335200.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coombe End Court Address 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 Susann Linsley 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.V335200.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may from time to time admit residents between the ages of 60 and 65 12th June 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. On registration it was agreed that care staffing levels of 1120 care hours per week would be provided. There were 5 care staff in the dementia unit with 20 residents. There were 4 care staff and a care leader in the main home with 40 residents. The home has a head of care. There were 2 waking night staff to each unit. The weekly fees for the home are between £436.28 and £680.00. Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over the two days of the 5th and 6th June 2007. The inspection started at 9.15am on both days and finished at 5.15pm on the first day and 7.00pm on the second. Mrs Linsley was present on both days. Eight residents and 5 staff were spoken with in detail. As part of the inspection process the views of residents, relatives, healthcare professionals and care managers was sought. One healthcare professional said that the healthcare needs of their clients were usually being met and the home always sought and acted on advice. They said that staff always respected residents’ privacy and dignity. They said that residents were supported to manage their own medication appropriately. Also that complaints were responded to as they arose and staff were skilled and experienced. A relative said that they and the resident had been given sufficient information about the home before admission. They said their relative’s needs were being met and they were kept informed of developments. Their relative knew how to make a complaint and the home responded appropriately as concerns were raised. Staff were described as very, very nice and very helpful. Other comments included: “I am very satisfied as it is very happy it is so nice here.” A care manager reported: “my client is younger and has different needs but the home still try to make activities interesting for [the resident]. [The home] ring me on [the resident’s] behalf. [They keep me up to date] through reviews and by telephone. [The home] often have to be reminded [about agreed and expected support]. I have raised concerns and staff have responded appropriately. Good atmosphere, no smells, lots going on, tries to be inclusive. [they need to be] proactive in encouraging residents who are slightly reclusive to join in and be aware of what is going on. Have always had a positive feeling about Coombe End. Manager always has time to talk to me.” Other comments included: “Always very caring and listens to requirement of individual residents. It all seems very satisfactory. All staff are very friendly and welcoming, including domestic staff, and nothing seems to be too much trouble.” 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: Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 6 Since her appointment as manager, Mrs Linsley has improved standards in the home. She has a good understanding of how she intends the home to develop and what needs to be done to achieve her aims. Staff have good relationships with residents, particularly keyworkers. Staff engage with residents and treat them with respect and dignity. All of the residents spoken with made very positive comments about the staff. Residents have good access to healthcare professionals who visit regularly and provide training to staff. Mrs Linsley and senior staff are quick to address any advice given during inspections. Staff are providing good care and support to residents but this is not always evidenced in the care plans or daily reports. Those residents in the dementia unit were very well groomed. Chairs were placed at different places along the corridors so that residents did not necessarily have to walk the long distances to sitting rooms, lift or outside. Residents were also offered wheelchairs to move around the home if they wished. The gardens were well tended and there was plenty of seating. The home operates a “resident of the day” system whereby the keyworker reviews the care plan and talks to the resident about any issues. The housekeeper will also undertake a thorough cleaning of their bedroom. Whilst awaiting the organisation’s gender working policy, staff had discussed with residents their preferences with regard to staff of a different gender providing intimate personal care. The activities person provided an excellent programme of varied activities in the 26 hours that was allocated. Activities provided some ‘one to one’ time with residents as well as some group work. Many of the activities were interhome contests and parties within the organisation’s homes. Activities and events were published on notice boards, in a newsletter and in a leaflet. Residents enjoyed the variety and range of meals provided. Each meal had a choice of dishes. All meals were cooked from fresh ingredients and residents could help themselves from the fruit bowls in the sitting areas. Residents who could make their comments known were aware of who they should complain to. Records showed that complaints and concerns were thoroughly investigated. Complainants were informed of outcomes, changes and apologies given if complaints were upheld. Staff had been trained in the local Safeguarding Adults procedure and were generally aware of reporting procedures. A robust recruitment system was in place. All staff are required to undertake training in dementia care. Mrs Linsley had set up support meetings with relatives to discuss aspects of dementia and had invited healthcare professionals to talk about related issues. She had also sent relatives questionnaires to ask them about what information and support they wanted. What has improved since the last inspection? Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 7 The organisation was piloting a new pre-admission assessment document. Although the document did not suit an assessment of the often complex care needs of residents, staff were making their own notes. Staff also used a social history format to aid their care planning. The organisation was also piloting a new care planning document. Staff were due to undertake tissue viability training from the district nurse. The organisation was piloting a tissue viability assessment tool. Mrs Linsley has consulted with the district nursing service to provide relevant training in specific conditions associated with old age. Staff are gradually helping residents to personalise their bedrooms with their own possessions and redecoration. Infection control practice had improved. Moving and handling practices had improved. The laundry area is now included in the cleaning schedules and was much cleaner. The drop down counters in the serveries had been risk assessed to ensure they remain down. This related to the dementia unit, to prevent residents accessing kitchen equipment or other risks when staff were not present. Use of agency staff had greatly reduced with the appointment of more full time staff. Care support staff had been employed at the weekends. They were not involved in providing personal care but would help out with bed making and serving meals to enable care staff to spend more time with the residents. What they could do better: The organisation’s new format for pre-admission assessments, currently being piloted, does not allow staff to gain all of the personal information required in order to compile a care plan. Staff who had used the format had identified various areas for improvement and would be feeding them back to the organisation. Recording systems do not always show evidence of the good care and support that is offered to residents. More detail is needed in stating the assessed need and how that need is to be met. Supplementary records and charts must show totals of food and fluid intake so that progress is monitored. The tissue viability assessment tool filled out as part of the preadmission assessment must continue to be used in the care plan part of the records for proper monitoring. If bed rails are prescribed, records must be kept to show this, including risks, agreements and monitoring. Unclear and unhelpful statements for example, “staff to assist”, “to observe”, “suffers with incontinence” and “no problem” must not be used. Some of the residents in the main home were less well groomed than in the dementia unit. Evidence suggests that staffing levels of 5 care staff with 20 residents in the unit enables higher levels of personal care and monitoring than the four care staff with 40 residents in the main home. Whilst care support staff have been employed to make beds and assist with meals so that care Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 8 staff spend more time with residents, care staffing levels need to be reconsidered. Some of the residents in the main home gave examples of how staffing levels affected the support they received. This included response times to call bells and support with getting ready for bed. Some of the residents said they did not have the opportunity to go out as much as they wanted. Although the gardens were well appointed with plenty of seating areas, those residents who were not as mobile or could not operate the lift, had to rely on staff or the activities person to access the gardens. Whilst the provision for activities had been increased by 6 hours a week, it still did not meet the 30 hours proposed by the organisation when the home was first registered. The organisation was in the process of producing a gender working policy. Consideration should be given to the invasiveness of the intercom system, which is relayed to staff at different points around the home. 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. Coombe End Court DS0000065400.V335200.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.V335200.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the organisation’s new format for assessing needs prior to admission does not suit the level of personal detail needed by the home, staff still ensure that a full and detailed assessment of often complex needs is carried out. EVIDENCE: The requirement that suitable formats were in place so that pre-admission assessments covered all aspects of care needs in order to produce a full care plan was in progress. This requirement has been outstanding since the first inspection of 18th January 2006. However the organisation was piloting a new pre-admission format in this and some of its other homes. Staff were to feedback their findings in using the format. Much of this format is a tick list, which does not allow the assessor to record the often complex care needs of potential residents, particularly the personal details needed to inform a good care plan. Some of the staff said that they wrote their own separate notes to Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 11 augment their assessment. They were also using a life history format developed by Mrs Linsley. This enabled staff to gain useful information from family and friends if the resident was not able to remember significant events in their life. Mrs Linsley required a diagnosis of dementia before admission to the unit was considered. One resident said how they had been able to look around and choose a bedroom before they came to live at the home. The good practice recommendation that continence sheets were not automatically placed on beds until it was established that the new resident required them had been actioned. Mrs Linsley was noted to invite a caller wishing to view the home to arrive unannounced so that they could see the home as it was. Coombe End Court DS0000065400.V335200.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recording systems do not show evidence of the good care and support offered to residents. Care planning is not sufficiently detailed in all cases. Residents have good access to healthcare professionals. Staff treat residents with respect and dignity and strong relationships have developed. EVIDENCE: The requirement that care plans must identify residents current care needs with full details of how those needs were to be met was in some progress. This requirement was set at the first inspection of 18th January 2006. Whilst some progress was being made at the inspection of 12th June 2006, the organisation was piloting a new format, so staff were still getting used to the system, whilst continuing to use the old system. The requirement identified that care plans 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. Care plans Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 13 were varied in the level of detailed guidance for managing assessed care and support needs. A resident told the inspector that they had had a stroke but there was no mention of whether they needed support in their care plan. One care plan stated that bed rails [often referred to as ‘cot sides’] were in place. There was no reason given or approval for their use. Staff said that the district nurse had authorised their use due to a risk of falling out of bed. The home was advised that more written detail must be included to show evidence of confirmation from the district nurse, risk of entrapment, safety and monitoring. Mrs Linsley confirmed that bedrails would never be used unless prescribed by the district nurse. Other care plans stated “staff to assist” or “to observe” with different aspects of residents care and support needs. However there was no detail as to what actions staff should be taking with supporting these residents with their care. One daily record stated that a resident was to see the district nurse for a new condition at the beginning of May but there was no record of whether this had been achieved. Another daily record stated “district nurse took bloods today”. There was no record as to the reason for this. There was however good evidence in one care plan of guidance to manage continence in a sensitive manner. Fluid intake charts were being filled out but without daily totals. There was no evidence that intake was being monitored. One resident was indicated as having a poor diet but no food intake chart was being completed or indicated on their care plan. However they were being given food supplement drinks and a dietician had been consulted. The daily report stated that the dietician had advised a diet high in calories and fibre but this was not in their care plan. Staff said they encouraged the resident with regular snacks and that the family were involved in bringing food. However this was not in the care plan. One resident was noted not to have drunk the tea and squash that was given them. They said they did not like the beakers and would prefer a cup. They said that staff would not allow them to have a cup as they had spilt a drink once. They said they had asked their GP who said they should have a cup. There was no evidence that this resident’s fluid intake was being monitored. One resident was identified as having swallowing difficulties and a thickener was prescribed to be used with fluids. Further investigation showed that this no longer applied as the resident could now eat all foods including toast. The inspector advised a review of the care plan. Those residents who spent their day in the dementia unit appeared to be better groomed than those residents in the other part of the home. Other care needs described by staff were not necessarily identified in the care plans. Some care needs that did not have management strategies in the care plan were described by staff as ‘the resident’s choice’. There was no guidance as to when staff must intervene appropriately as a duty of care to uphold the resident’s dignity or prevent deterioration in condition. Mrs Linsley said that staff did intervene for the residents’ own dignity, for example, ensuring Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 14 washing of clothing at night so that a resident could wear the same clothing if they wanted. Mrs Linsley described other strategies to ensure that residents grooming was managed. One resident said that they could have a bath whenever they wanted. Residents’ weights were regularly monitored each month. In some daily reports staff had written inappropriate language, for example, “very uncooperative”, “suffers from incontinence” and “no problems”. Mrs Linsley said that staff should not be writing these remarks as they had been made aware of good report writing many times. As a matter of good practice residents who could not walk long distances were to be offered a wheelchair. Other care plans identified residents preferred times for going to bed and getting up. The home operates a ‘resident of the day’ system. This involves a review of their care plan, checking appointments, discussing issues with the keyworker as well as a thorough cleaning of their bedroom. Residents have good access to healthcare professionals with the GP visiting twice a week. The community psychiatric nurse visits once a month as does the clinical psychologist. The district nurses visit every day. Mrs Linsley reported particularly good support from the nurses for residents who may be terminally ill. One resident said the staff had looked after them very well when they had been ill. Another talked about how the district nurse came to dress their leg, which was now healing. Another resident said they were always given their painkillers when they asked. The requirement that care staff received training in tissue viability in order that they could assess the residents’ potential risk of developing pressure sores was in some progress. A further requirement that residents must be assessed as to their risk of developing pressure sores with strategies in place to prevent further risk to be recorded in the care plan was also in progress. However these 2 requirements were outstanding from the first inspection. A new compliance date was agreed at the last inspection of June 2006 as assurances were given that this was being addressed by the organisation. Mrs Linsley had received training from the Tissue Viability Specialist Nurse in her previous post. The district nurse was due to provide the training the following Friday. The organisation had produced a format which was part of the care planning pilot. However the forms were initially being filled out as part of the assessment process and left with the assessment documentation. Another form was then started again once the person was admitted. There was no continuity in the process of monitoring residents’ potential risk. The assessment form did not state when the district nurse should be notified of the risk. The care plans showed that staff did not necessarily have a good understanding of tissue viability. One care plan stated “no breaks in skin at present, propad mattress in place, pressure areas to be observed and record on daily report. District Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 15 nurse to be advised of any concerns”. There was no guidance of what should be monitored or what constituted ‘concerns’. Another resident’s daily notes stated “bottom sore, cream applied” and “district nurse redressed shin” but there was no mention of how these wounds were being managed in the care plan. One resident was sitting on a pressure relieving cushion in their chair in their bedroom. Their feet did not touch the ground and they said that the chair was uncomfortable. When asked if they had talked to staff about this they said that there was no point. They said that if they rang the call bell they would have to wait as staff had other residents to support. The requirement that all risk of daily living were assessed for each resident was in progress. This was also in progress at the last inspection. Some of the risk assessments had good detail of the residents preferred bathing routines but did not indicate whether the resident was able to bath alone and for how long. One care plan did state “stay with me” when bathing. Where some residents were identified as at risk of falling at night, there was detailed guidance on reducing the risk. The requirement that the organisation provided the home with its policy and procedure for the use of specialist equipment, in this case a nebuliser, did not now apply as no nebuliser was in use. However should this equipment be needed in the future the home must ensure that staff are aware of how the equipment must be used, cleaned and maintained. The requirement that a gender working policy was in place for the provision of intimate personal care had not been actioned. However assurances were given that the organisation was in the process of producing a policy. In the meantime there was evidence on file that residents had been consulted as to their preference for intimate personal care from staff of a different gender. Where residents were not able to verbalise their preference, the home had consulted with their representatives. Many of the female residents said they had been asked about whether they could have personal care provided by a male staff. The member of staff with the delegated responsibility for medication showed the inspector the arrangements for the administration and storage. The home operates a monitored dosage system put up by the supplying pharmacist. Medication is checked as it comes to the home. New residents medication was confirmed by fax with their GP before admission. Records were kept of all disposal of unwanted or unused medication. Staff cannot administer medication unless deemed competent through training and interview with the head of care. Staff’s continued competency is monitored every 6 months by the head of care. On the first day it was noted that indicators for some medication prescribed to be taken only when required were not detailed in the resident’s care plan. There was no records of where slow release patches for pain were to be placed on the resident’s body. The head of care had remedied this by the second day, having gone through the medication administration Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 16 records and checked with the GP for what initiates an administration. As a matter of good practice, by the second day, the head of care had undertaken a review of all the medication administration records to establish which medication needed specific guidance in each of the care plans. All handwritten entries on the medication administration record were witnessed, signed and dated by 2 staff. The inspector advised that creams and eye drops with a limited life after opening must be dated when opened. This was immediately addressed by the head of care. The home has a list of signatures and initials of staff designated to give medication. The diabetic nurse had trained named staff in blood sugar monitoring. Staff were recording daily levels but some care plans did not always identify the parameters for the residents well being or what action to take when concerns were noted. Where a resident was administering their own insulin and staff were supporting them with this, there was no record of the site for the injection although the resident was aware of this. It was not recorded whether the district nurse was involved in monitoring the residents conditions. Mrs Linsley was consulting with the district nursing service for training in specific conditions associated with the ageing process. The good practice recommendation that staff training in medication should be expanded beyond local policies and competency had been actioned. Staff had received training in certain medication prescribed to residents by the Clinical Psychiatrist. Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 17 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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff ensure that they ask residents and their families residents social history before they come to the home. The activities organiser provides an excellent programme of activities in the time available. Those residents who were able to choose spend their day as they wish. Residents enjoyed the range and variety of the meals provided. EVIDENCE: Those residents who were able to decide, could choose to spend their day as they wished. The majority of the care plans examined stated residents preferred daily routines. There was little evidence of other decision making in care plans or the daily reports. However it was clear from discussions with residents and staff that residents were encouraged to choose and make decisions about how they spent their day and what they had to eat. One resident said they could not go out as they needed staff to take them. They said they had only been out once since they had been at the home. They said they felt restricted as they relied on staff to assist them around the home Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 18 as they could not walk the long distances to the sitting room or dining room. This resident said they had to shout for help as they could not reach the call be by the bed. Another resident said that they liked to go out and went out with a family member. They said that staff could not take them out as they needed a wheelchair and a member of staff all the time. One resident said they did not like activities and preferred to follow their own entertainment. Another said there was not much to do in the evenings so they went to bed. The requirement that sufficient staff hours are provided exclusive of the care hours to enable residents to access the community and the published activity programme had not been actioned. When the home was opened the organisation proposed that the home would have a 30 hour activity post. At the last inspection the hours were reduced to 20 hours a week. The post had now been increased by 6 hours to 26, still short of the number the organisation agreed when the home first opened. Mrs Linsley said that residents were taken out into Marlborough and regularly went out for tea. It is recognised that the activities person does provide an excellent programme of varied activities in the time that is allocated. However 26 hours a week for 20 residents in the dementia unit and 40 residents in the main home, restricts the amount of one to one time with each resident. The member of staff providing the activities to the dementia unit and the main home said they would like to have more hours to provide a more extensive programme. They said that they would ask care staff to help them on occasions. They said they had an outline programme each week but provided what residents wanted. This would include one to one time as well as group activities. Activities and events were advertised on notice boards around the home. A yearly programme identified celebrations and national days where events would be held, for example, St David’s day. Activities included: church services, garden club, arts and crafts, ‘sit and be fit’, word association, quizzes and darts. The activities person said they tried to make time to talk to all the residents and tailor some of the activities to individuals, for example, painting. They said that they saw chatting with residents as an important part of the job. Activities in the dementia unit were short and based on what had been successful for residents. Many of these sessions took place in the garden, weather permitting. That afternoon the activities person was planning to play scrabble with a group of residents and had prepared a tray of tea to make it a social occasion. The activities co-ordinator had published a leaflet showing the kind of activities on offer. This leaflet has a picture of the co-ordinator with an invitation to discuss preferences. The weekly programme of activities was displayed on notice boards around the home. The home also published a monthly newsletter with details of special events. Some of the events included going to the pub every other week, shopping trips, trips to other homes in the organisation, darts contests with other homes, cream teas and gardening. The activities person was aware of the potential for some residents to be isolated; Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 19 particularly those who could not operate the lift or keypads to some of the doors. The home does not have its own transport so residents rely on accessible taxis having to come from Devizes which worked out to be expensive. However the drivers were reported to be attentive to residents. The home published a five week menu with choices for each meal. A new cook had been appointed and the menus had been changed. The menu showed a good range of traditional dishes with plenty of variety. There were 3 choices for the lunch menu including a daily salad. The daily lunch menu was written on a small white board in each dining room. Both boards showed small writing, one in green. The inspector had a discussion with residents as to whether they could read the menus from where they were sitting in the room. Only one could read the script, so the staff writing the next menu on the board did it in black ink with larger print. Mrs Linsley showed the inspectors the printed menus that she would have laminated to go on each of the dining room tables which would be easier to read for residents. Mrs Linsley said that she had taken all processed food off the menu and everything was now cooked from fresh ingredients. She went on to say that if residents wanted something not on the menu they would let the cook know and it would be provided. The meals were distributed in hot trolleys from the central kitchen to each of the dining rooms on the different units. Residents were offered a choice of orange or cranberry juice with their lunch. Mrs Linsley had said that staff took the 2 choice hot dishes to residents so that they could make a better choice of meal. This had been the case at the last 2 inspections. However it was noted at this inspection that staff did not carry out this good practice in either of the dining rooms until it was pointed out to them. One resident said they did not get enough food and there was no choice. This resident was given a small portion for lunch. Staff said they often did not eat their meal if it was served as a large portion. Staff were aware of other residents who may need support with eating and offered assistance as necessary. Some residents had chosen to have their lunch in their bedrooms. Trays of the first course were taken to them and the pudding taken afterwards. Fresh flowers were arranged on each of the tables. The meal was not rushed. Fresh fruit was available for residents to help themselves. The majority of the residents spoken with said they enjoyed the quality and variety of the meals provided. Although standard 11 was not inspected in any great detail it was observed that significant efforts were made when a resident died to respect their passing, support the family and ensure that other residents knew about the death. This resident had been receiving palliative care with good support from the GP and district nursing service. Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 20 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place for residents, their families and staff to complain about the service and alert the relevant authorities when abuse is alleged. EVIDENCE: Systems were in place for residents and their relatives to make complaints about the service. Most of those residents with whom the inspectors could communicate said that they knew how to make a complaint. One resident said they would go to the secretary; another said they would go to Mrs Linsley. The complaints log showed evidence of detailed investigation of all complaints and concerns. There was also good evidence of response to complainants with an apology where needed. Mrs Linsley sent a monthly breakdown of any complaints to the organisation. One member of staff said that they had received training in safeguarding adults as part of their induction and had covered the subject in their NVQ. Records showed that all staff were required to undertake training in reporting any allegations of abuse under the Safeguarding Adults procedure. Staff were generally aware of the procedure for reporting poor practice or other concerns. Staff were also clear that they would notice changes in behaviour or body language of those residents with a dementia to know that they were expressing dissatisfaction. Coombe End Court DS0000065400.V335200.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a comfortable, clean and well maintained environment. Some residents have to rely on staff to access the grounds due to the nature of the layout of the building and safety locks on doors. EVIDENCE: All of the bedrooms are single accommodation each with its own ensuite shower, toilet and wash hand basin. Bedrooms were personalised to a small degree with residents’ own possessions. Some of the bedrooms were identified with pictures as well as the resident’s name for orientation. All bedrooms had a telephone point, television point, low level switches and low surface temperature radiators. All of the windows had restricted opening for the safety of residents. All residents had the use of lockable storage for valuables or medication. The handrails in the corridors had raised markers to show when Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 22 the rail would finish. The toilets and bathrooms in the dementia unit were identified by signs. There were also direction signs to them from the sitting room/dining room. Chairs had been placed at the ends of corridors so that residents did not have to walk the full length in one go. The garden area to the rear of the home has been enclosed for the safety of residents. The administrative areas, a small shop, hairdressing room, smoking room, kitchens, laundry and a large sitting room are to the entrance of the building. The residents’ bedrooms, sitting room/dining rooms and staff workstations are located behind doors locked by keypads. Those residents who could work the lift or knew the keypad numbers could access the gardens and the large sitting area. The activity person was seen to encourage residents to use the gardens and attend activities in the large sitting room. One resident said they liked having their own ensuite facility and that staff kept it very clean. The home was cleaned to a good standard and no unpleasant odours were detected at any time during the 2 day inspection. Disposable protective clothing and gloves were available to staff. Single use hand washing and drying facilities were available in all the bathrooms and toilets. Mrs Linsley was advised that toilet brushes must be of a type that did not allow the brush to stand in liquid. They must also be cleaned regularly as there was a build up of brown particles on some of the brushes. The requirement that all staff must be aware of the home’s infection control policy had been actioned. This requirement was outstanding at the second inspection of June 2006 when it was clear from the records that staff had been trained in infection control but poor practice was observed. At this inspection it was noted that care plans identified guidance to staff on infection management and no poor practice was observed. The requirement that the laundry was included in the cleaning schedules had been actioned. The laundry was seen to be much improved with regard to cleanliness. The good practice recommendation that consideration was given to increasing the ventilation of the laundry for the health and safety of staff employed in this area had been actioned. One resident said that their bed linen was changed regularly which they liked. They also said that the laundry service was very good with items returned promptly. There was a member of staff working 30 hours each week on laundry duties; 9 – 3, 5 days a week. Staff said that a housekeeper covers the duties at other times. The housekeeping staff rota provided showed that there were 5 housekeepers during the mornings Monday to Friday and one housekeeper working until 18.30 each evening. At the weekends this is cut to 4 housekeepers only during the mornings. Care staff loaded the dishwashers in each of the serveries after each meal. Serving plates and dishes were returned to the main kitchen for washing. There were cleaning schedules in place. However a microwave in one of the serveries needed cleaning and food items were being Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 23 stored in the fridge uncovered. Housekeepers also had their own task list. As part of the ‘resident of the day’ system, housekeepers were involved in a thorough cleaning of their bedroom. During both days it was noted that staff used the intercom part of the call bell system to contact each other. As the system was located throughout the building the noise of these calls was very intrusive. Staff said that the level of the system was turned down at night. Mrs Linsley said that so far none of the residents had complained but she did address the matter of staff’s loud instruction on the system with staff. One resident had easy access to their call bell from their chair in their bedroom. They said that they could ring for assistance but they often did not as it took a while for staff to attend. They said they just waited for staff to come. Other residents visited in their bedrooms had their call bells within easy access. Coombe End Court DS0000065400.V335200.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some residents feel that staffing levels do not always support the care that they need. However residents reported good relationships with staff, particularly keyworkers. Staff have good access to training. A robust recruitment system is in place. EVIDENCE: The care rota showed a minimum of 8 care staff on duty with a care leader during the waking day. The allocation was 5 in the dementia unit and 4 in the main home. There were 4 housekeepers and 3 kitchen staff on duty. At night there were 2 waking night staff in the unit and 2 in the main home. At weekends there were 2 care support workers; one in each area. They were not involved in providing personal care but would support care staff with making beds and serving meals. Mrs Linsley said that the organisation was to increase the establishment hours for the home. There was a head of care and a care leader responsible for the day to day running of the dementia unit. Use of agency staff to cover vacancies has been reduced. Mrs Linsley had recruited to most of the vacant posts. A robust recruitment procedure was in place with all the documents and information required by regulation on file. However, some files did not record dates when staff had commenced duties Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 25 and some did not contain a recent photograph. Mrs Linsley had rectified this by the second day. Day staff newly appointed could commence supervised duties when a POVAfirst confirmation was received. Night staff could not start duties without a negative Criminal Records Bureau certificate. All new staff were required to be inducted into their role. Records were kept of areas covered in the induction including the organisation’s policies and procedures as well as care practices. New staff were introduced to residents and staff as soon as they started work. The activities co-ordinator was undertaking NVQ Level 2. Fourteen care staff had achieved NVQ Level 2. Two of the care leaders had achieved NVQ Level 3. All staff were required to undertake training in first aid, fire prevention, health and safety, infection control and moving and handling. Many of the staff were trained trainers in these areas. Some staff had been trained in visual awareness. Mrs Linsley keeps a list of which training is required and which has been completed for each member of staff. A new electronic system was being implemented by the organisation to identify when training was needed. Much of the training is provided by the organisation. All staff were required to undertake training in dementia care. The organisation had set up a system of e learning which staff were expected to sign up to. A number of residents gave examples of how staffing levels affected the support they received. These were with regard to going out, response times to call bells and support with getting ready for bed. However residents were also very complimentary about the relationships with staff. One said staff were very friendly and polite and would always chat when they came into their bedroom. Another said they took great care of them and were always “cheery happy people”. All of those residents spoken with were very complimentary about their good relationships with their keyworkers. Staff were observed to have good relationships with residents. All residents were greeted by staff as they were encountered during the day. All staff were seen to engage with residents. Housekeeping staff were employed during the mornings Monday to Friday. One housekeeper worked until 6.30 each evening. At the weekends this is cut to only 3 housekeepers during the mornings. Care staff are expected to do cleaning or laundry at other times. One member of staff said they had had previous experience of working in a care home. They said they had had an in depth interview, supplied referees and undergone a Criminal Records Bureau check. Their induction had comprised formal induction at the organisation’s local office and shadowing a member of staff. They said they had regular supervision, bringing any issues to the agenda. They went on to say that they had NVQ Level 2, had done fire training, moving and handling and were due to do first aid training the following day. They said staff worked well as a team and were very supportive of one another. They talked about offering residents choice, negotiating with Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 26 them for when care should be carried out. They described the staff group as very happy. Regular staff meetings were held with minutes kept. Coombe End Court DS0000065400.V335200.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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mrs Linsley continues to improve standards in the home. The home is run in the best interests of the residents. Systems are in place for safe holding of any money residents wish to keep at the home. Systems are in place to ensure the health and safety of residents. EVIDENCE: Mrs Linsley has run the home since June 2006. She is very clear about her aims for the home and how she plans to achieve them. She has already improved standards in the home since the last inspection. She has a good relationship with the staff and residents. Mrs Linsley has over 30 years experience of working with people with dementia in care homes and in Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 28 hospital. She has been a registered manager for over 5 years and holds the Registered Managers Award. Mrs Linsley keeps herself up to date with current good practice with regular training. She recently attended seminars run by the Dementia Society and the Alzheimers Society. She is undertaking a qualification in dementia care from the University of Sunderland. Mrs Linsley said she had recently had training on the Mental Capacity Act 2005 and Safeguarding Adults. Mrs Linsley was planning to cascade this to other staff. As a matter of good practice, Mrs Linsley had set up support meetings with relatives to discuss aspects of dementia and invite various healthcare professionals to talk about dementia and related issues. She had sent questionnaires to the relatives asking what support and information they wanted. Senior staff have delegated areas of responsibility, for example, medication and fire prevention. These areas are monitored through regular supervision. All staff had regular supervision. The organisation had recently carried out an audit of the home. The format showed a tick list and stated conforming to different statements rather than reporting on the quality of the service. Mrs Linsley had received feedback at the end of the audit. Questionnaires had been sent to residents and their relatives for comments on the home. These had been collated and changes made where necessary. Some of the residents spoke about the monthly residents meetings where they could talk about anything. They gave examples of changes made when issues were raised. Many of the residents said that Mrs Linsley regularly came to see them and ask them how they were. The requirement that if the drop down counter tops in the serveries were to remain upright, that a written risk assessment was carried out had been actioned. This related to those residents with dementia gaining access to the kitchen equipment and other risks when staff were not present. Risk assessments were in place for the environment and they were regularly reviewed. Two handymen deal with day to day maintenance and repairs. The administrator explained the system for residents to keep small amounts of money in the home’s safe. Records were kept of all transactions together with receipts for any purchases. Two signatures were required for all transactions. The system was audited regularly. Only senior staff had access to the safe. The administrator was very aware of the Safeguarding Adults procedure and had completed training in dementia awareness. The requirement that staff must only use safe methods of moving and handling that they had been shown, had been actioned. No unsafe moving or handling was seen. Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 29 The accident log showed good detail of how residents were found if a fall was un-witnessed. Mrs Linsley was required by the organisation to render monthly audits of the accidents occurring in the home. These highlighted any patterns of significant events. Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 30 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 X 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 3 13 3 14 2 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 X X 3 Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 31 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 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 being piloted is mainly a tick list and does not aid complex care assessments. Staff are having to write their own notes.) Timescale for action 31/08/07 2. OP7 15 05/06/07 The person registered must 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 some progress has been made, this is outstanding since 18/01/06) DS0000065400.V335200.R01.S.doc Version 5.2 Page 32 Coombe End Court 3. OP8 13(4)(c) The person registered must 31/08/07 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. (Training was due to take place. The organisation was using a new format as part of the pilot of recording systems. This is outstanding since 18/01/06) The person registered must ensure that all risks of daily living are assessed for each resident. (Continues to be in progress. Outstanding since 18/01/07) The person registered must 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. (The hours had increased from 20 to 26 a week. However the organisation proposed 30 hours when the home was opened. Outstanding since 12/06/06). 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. (Outstanding since 12/06/06. Assurances were given that a policy is being written. Staff have however recorded each residents preferences). The person registered must DS0000065400.V335200.R01.S.doc 4. OP7 13(4) 31/08/07 5. OP12 16(2)(m) &(n) 31/08/07 6. OP10 12(2)&(3) 31/08/07 7 OP37 17(1)(a) 05/06/07 Version 5.2 Page 33 Coombe End Court Schedule 3 para 3(m) ensure that totals are made in fluid intake charts to ensure proper monitoring. Change in need must prompt a review and if needed a revision of the care plan. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Coombe End Court DS0000065400.V335200.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. 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