Inspection on 04/12/07 for Cottingley Hall Nursing Home

This inspection was carried out on 4th December 2007.

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

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

Other inspections for this house

Cottingley Hall Nursing Home 05/02/09

Cottingley Hall Nursing Home 12/12/06

Cottingley Hall Nursing Home 23/11/05

Cottingley Hall Nursing Home 12/07/05

Cottingley Hall Nursing Home 03/11/04

Cottingley Hall Nursing Home 27/04/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Cottingley Hall Nursing Home Bradford Road Bingley West Yorkshire BD16 1TX Lead Inspector Nadia Jejna Key Unannounced Inspection 4th December 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cottingley Hall Nursing Home DS0000019866.V356798.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. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cottingley Hall Nursing Home Address Bradford Road Bingley West Yorkshire BD16 1TX 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) 01274 592885 01274 532563 www.bupa.com BUPA Care Homes (BNH) Ltd vacant post Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51), Physical disability (51) of places Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2006 Brief Description of the Service: Cottingley Hall Nursing home is on the outskirts of Bradford between Saltaire and Bingley. It can provide care with nursing for up to fifty-one older people or people with physical disabilities. At the time of this visit a decision had been made that care would be provided to a maximum of thirty-eight residents as some of the double bedrooms were being used as single rooms. The home is an adapted, period property that has been extended in keeping with the style of the original building. It has it’s own grounds with car parking areas and pleasant gardens. Accommodation is provided in thirty single and five double bedrooms, most of which provide pleasant views of the gardens and surrounding area. All except one have en-suite facilities and there are communal toilet and assisted bathing facilities throughout the building. There are two lounges, two dining rooms and a library that have been tastefully furnished and decorated. Information about the home is given to all residents in information files that are kept in every bedroom and the reception areas. Copies of this information and the homes brochures are given to people who call to look round and can be posted out on request. At the time of writing this report the cost of staying at the home varies from £110 to £140 per night. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started on 4th December 2007. The home did not know that this was going to happen. Three visits were made over a two-week period. Feedback was given to the manager during the visits and then to her and the operations manager on 20th December 2007. The purpose of this inspection was to make sure that the home was being managed for the benefit and well being of the people using the service. During the visit residents, their visitors and staff were spoken to. Records such as staff files, complaints and accidents records were looked at. Before the visit was planned the provider was asked to carry out a quality assessment of the service stating what they did well, what was in place to prove this, what improvements had been made over the last twelve months and what was planned for the year ahead. This document is called the Annual Quality Assurance Assessment and will be referred to in the report as the AQAA. Other information asked for included what policies and procedures are in place, when they were last reviewed and when maintenance and safety checks were carried out. Questionnaires were sent to people living in the home, their relatives and healthcare professionals before the visit took place. These people were selected using information provided in the AQAA. When the visit took place ten surveys had been returned from people living in the home, two from relatives, four from healthcare professionals and five from staff. The information from these was used to inform the visit and is referred to throughout the report. What the service does well: Information about services provided by the home is available. This helps people and their relatives decide if the home will be suitable for them. People are encouraged to visit the home to look round, meet people who already live there and staff, before they make any decisions about staying there. Somebody from the home always visits people before agreements are made about moving in to make sure that the services and facilities provided will be suitable for their needs. The home is well maintained. There is a continual programme of redecoration and refurbishment. It has been tastefully decorated and furnished to provide people with a pleasant, comfortable and homely place to live. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 6 People said that they can bring in their own belongings to personalise their rooms and that the home was always clean and tidy and it did not smell. Visitors said that they could visit the home at any time and they were made welcome and offered refreshments. They said that staff kept them informed and up to date with any changes in their relatives care needs, and that they were satisfied with the services provided by the home. Information from people living in the home, their relatives and returned surveys said that: • They were generally satisfied with the services provided. • Staff were very good, helpful and caring. • The food was very good. Some people said they were having to watch their weight. Other comments made about meals included – ‘home cooking of the highest order’, ‘Good food and good choice.’ • They enjoyed the meals and alternatives to the planned menu were offered if they want them. • One person said that their relatives ‘state of well being’ had improved since coming to live in the home. • They could choose how and where to spend their time and whether or not they want to join in with planned activities. What has improved since the last inspection? A new system of care planning has been introduced. Training and guidance about how to use it has been given to staff. The aim is to make sure that all people living in the homes have detailed, individual, person centred care plans that provide staff with all the information needed to meet their needs. It is a ‘work in progress’ making sure that they contain all the information and guidance needed. The care plans looked at showed that detailed pre admission assessments had been carried out so that the home could be sure the person’s needs would be met. Where possible information from other healthcare professionals had also been obtained to support the pre admission process. When people come to live in the home their needs are assessed again as part of the care planning process. A sensory garden has been added to the garden areas that are accessible to people. The dining room has been provided with new furniture that has made more comfortable and pleasant for people. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 7 What they could do better: The organisation could improve outcomes for people living in the home by: • Making sure that staff follow the organisations policies and procedures about assessing people’s health, safety, personal and social care needs. They must be clearly identified in care plans that give staff have detailed, individual guidance about what to do to meet them, and keep people healthy and safe. Where specialist assessments show that an individual is at risk appropriate action must be taken to reduce the risk. This should include contacting specialist healthcare professionals for support and advice. Particularly if the person is low weight or at risk of losing weight and not able to tell staff when they are hungry or want a drink. Appropriate records monitoring the individual’s well-being should be kept, such as food and fluid intake records. Making sure that all staff are aware of the organisations concerns/complaints procedures. All concerns received should be recorded so that the manager is aware of them and can take appropriate action to investigate and deal with identified issues. This will contribute towards the homes quality assurance processes and improve outcomes for people living in the home. Making sure that there are enough staff available to meet peoples needs, respond to call bells promptly and help people to eat and drink. Making sure that all staff receive appropriate training that helps them to maintain the health, safety and well being of people living in the home and themselves. Making sure that the qualified nurses receive training that keeps them up to date with current research and good practice in healthcare, especially with regard to nutrition. This should include reminders about their personal and professional responsibilities as nurses registered with the Nursing and Midwifery Council. Making sure that the safety of people needing the use of bedrails is promoted and protected by carrying regular checks on the bedrails and protector covers to make sure they are correctly fitted and safe to use. • • • • • • Requirements and recommendations of good practice have been made and can be found at the end of this report. The manager and the operations manager took immediate action to deal with some of the issues fed back to them. They said that an action plan will be put in place that will improve outcomes for people living in 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. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and their relatives have enough information about the home to decide if it will be suitable for them. EVIDENCE: Information for residents and visitors is available in the reception areas and can be posted out on request. Files of useful information are in every bedroom. Information from people living in the home and their relatives said that they received enough information about the home, they had been to look round and were offered a trial visit. They said that contracts were in place setting out the terms and conditions of living at the home and the services that would be provided. The new care planning systems put in place by the organisation means that people’s needs are assessed before any agreements are made for them to Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 10 come and live in the home. They are assessed again when they are admitted. The manager said that she is aware that information from the pre admission assessments must be used to make sure that the individuals needs can be met the facilities, skill mix and numbers of staff. Wherever possible staff from the home will visit somebody to carry out the pre admission assessment. But if they come from another area the home will gather as much information as possible about the persons needs from the person themselves, their relatives and healthcare professionals. This was seen in the care plan for somebody who had come from the North West of the country. The manager said that there were six people living in the home who had some form of dementia, but that this was secondary to their physical/nursing care needs. Since the last inspection some staff have been attended a course about dementia provided by the local authority. This should be extended to include all staff. Information received during the inspection process said that: • The manager had visited the person at home to do a pre admission assessment and had explained everything to them. They had been given all the information they needed. • One person said that sometimes people needs that were related to their dementia were not recognised. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are set out in care plans. But links between the health care assessments and guidance in the care plans are not always being made. This means that there is risk people’s healthcare needs might not be identified or met. EVIDENCE: Since the last inspection in December 2006 the organisation has introduced a new system of care planning to all of its care homes. Training and guidance about how to use it has been given to staff. The aim is to make sure that all people living in their care homes have detailed, individual, person centred care plans that provide staff with all the information needed to meet their needs. I looked at care plans for four people living in the home. The organisations new care planning documents/systems are in use. But some of the plans looked at showed that staff are not always following policies and guidance provided when completing them. Information from people’s risk and healthcare assessments is not always being used to identify where potential and actual problems are. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 12 Therefore detailed guidance about meeting specialist care needs is not included in the care plans. This means that in some cases they have been missed and appropriate treatment is not given to people. For example: • Nutritional risk assessments are being completed but plans for two people who were below average weight and at risk of losing more weight did not give staff guidance about maintaining or increasing their weight, how meals could be enriched, how often nourishing snacks should be given or what their dietary preferences, likes and dislikes where. The kitchen staff had not been told that these people needed enriched meals and extra snacks. • Records kept about peoples dietary intake were poor and indicated that they went for long periods of time without food or drink being offered. Staff said people could have snacks and drinks whenever they asked for them but the records looked at were for people who could not ask for themselves and were reliant on staff to give them their meals and drinks. • Around wound care. One person had long standing wounds that were being redressed with different wound care products by nurses. A wound care assessment and care plan was not in place on the first day of the visit and the advice of the tissue viability nurse had not been asked for. • Care charts showing when pressure area care and change of an individual’s position had been done were not being kept – even when the tissue viability nurse had specifically requested this for one person. • Around the prevention of falls. Some people were at high risk of falling and had had a number of falls. Staff had not contacted the falls prevention team for additional support or advice for a considerable length of time. These issues were fed back to the manager during and at the end of the visit. She took immediate action to start dealing with them and improve outcomes for people. Reassurances were given by her and the operations manager that this would continue, including making sure that training and support for staff would be provided. The timings of the medication rounds have been altered to 10am, 2pm, 6pm and 10pm. On two days when I was in the home the 2pm medication round was being done over an hour late at 3.30pm. Staff said on the first day it was because the repeat prescriptions were being ordered and the second time was because things had got behind. The MAR’s (Medication Administration Record’s) for people showed that there were gaps where there should have been signatures to show the person had been given their medication. Codes or letters to show the reason why they had not been given had not been used. One of the medication stock cupboards was full of creams and lotions – some had been dispensed over six months ago and some where for people no longer at the home. Dressings for people no longer at the home had also been kept. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 13 The dressings remedy box was in the treatment room and had been used for one person. Some people in the home look after their own medication. The care plan for one of these people was looked at. There was a signed consent form for them to self medicate dated October 2006, but there was no risk assessment. The care plan about dealing with medications talked about them being pain kept pain free and they looked after some of their medicines but not all of them – there was no reason why the person was not looking after all their own medicines. The individual told me it had been difficult to get control of some of their medicines and they had wanted to do it to make sure they got them on time as some had to be taken half an hour before food and if they relied on nurses bringing them it would have been too late. As it is the medicines that are looked after by the home often come late. The manager said they would talk to the individual to see what they wanted to do. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s lifestyle in the home matches their expectations and they are helped to exercise choice and control over their lives. EVIDENCE: The home does not have an activities coordinator. The manager is in the process of recruiting somebody to fill this role and hopes that they will be able to start in January 2008. in the meantime the manager and staff have made sure that there are regular planned activities for people to join in with if they wish to. This is mainly entertainers coming in and there was an Xmas Fayre to raise funds for the air ambulance service. The ‘pat dog’ service visits the home regularly and is enjoyed by many people. People were asked if they wanted to watch the entertainers in the lounge and staff took them there. As soon as the sessions was finished staff asked some people if they wanted to return to their rooms and said to others, ‘shall we go back to our room then?’ The communal areas are only being used for activity sessions. People are not routinely asked if they want to spend time in the Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 15 lounges. The manager said that she hopes to change this when the new activity coordinator starts. Information from people living in the home, their relatives and returned surveys said that: • They were generally satisfied with the services provided. • The staff were very good, helpful and caring. • The food was very good. Some people said they were having to watch their weight. Other comments were made about meals included – ‘home cooking of the highest order’, ‘Good food and good choice but could do with more staff to help feed patients who cannot feed themselves.’ • One person said ‘it would be nice if people sat in the lounges and talked to each other rather than all staying in their bedrooms – not able to get to know each other’ • People were generally satisfied with the range of entertainment provided. But there was one comment that that staff need more awareness of dementia and that more time could be spent with bedfast residents. • One person said that their relatives ‘state of well being’ had improved since coming to live in the home. People can keep in touch with family and friends if they wish to by using the telephones in their rooms that are large push button phones that can be used ‘hands free’ suitable for people with physical disabilities or poor eyesight. The manager said that meeting peoples cultural and religious needs is an area that is being looked at so that staff can identify what they are and what support will be needed to meet them. At the time of the visit there was one person of Muslim faith living in the home. Their relatives were giving staff advice and support about meeting the persons cultural and religious needs. Training around equality and diversity has not been provided yet but the manager said that information is being made available to staff. The kitchen was clean, tidy and well organised. The last environmental health inspection gave them a 4 star ‘scores on the doors’ rating. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures are in place to protect the well being of people living in the home and respond to their concerns but they are not always followed. This means there is a risk that appropriate action might not be taken when there is a situation that affects a person’s safety and wellbeing. EVIDENCE: The organisations complaints procedure is in place and is included in the information files in resident’s rooms. It is clear and easy to follow. Information from people living in the home and their relatives said that: • They knew who to speak to if they were unhappy. • Most knew how to make a complaint and said they would speak to the nurse in charge. But one of the returned surveys said that they were not sure if their concerns were passed on. • Another survey said the way a concern was dealt with depended on who they approached and sometimes they had needed to remind staff about their concerns. The information received shows that there may be a problem with the ways concerns or complaints are dealt with by the senior person on duty and that they are not always recorded or passed to the manager. For example in one of the care plans there was an entry about the relative speaking to the nurse in Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 17 charge about concerns they had around care provided. Some action was taken at the time but the manager did not know concerns had been raised – her knowledge of the issues at an earlier stage could have meant that other actions could have been taken that would have prevented the concerns from becoming more serious. Complaints and compliments records are kept and monthly reports are sent to head office as part of the homes quality assurance processes. Since January 2007 thirteen complaints have been received by the home and responded to by either the manager or the operations manager. They were about a number of different issues such as: • Maintenance and repair issues of a radiator and one of the disabled access baths. • The length of time taken by staff to respond to the nurse call bells. • The lack of activities and stimulation for people. The records seen showed that meetings had taken place and actions agreed to deal with the concerns. But they did not all show whether or not the complainant was satisfied with the outcome or if the agreed actions had actually been carried out. The manager said that she would make sure this information was kept. One had been referred to the adult protection team; it was still being investigated at the time of the visit. The home was working with the adult protection team and other healthcare professionals as well as conducting their own in depth investigation into the concerns that had been raised around safety of bedrail protectors and care provided to an individual. The initial findings of the investigation have highlighted that new equipment was needed, such as bedrail protectors. These items have been ordered. The manager and operations manager said that an action plan was being put in place to deal with other identified issues and a copy would be sent to CSCI. The manager said she has requested training around dealing with complaints; this will help her when dealing with future concerns. Copies of the organisations adult protection procedures and the local authority adult protection procedures are kept in the manager’s office. The manager and the clinical services manager (CSM) have both applied to do the local authority two day managers course about adult protection. Most staff have received training around abuse and adult protection. The CSM has done a ‘train the trainer’ course around adult protection and will be providing it to staff in the home. Information from staff surveys and during the visits was that they were aware of different types of abuse and would not hesitate to report it to the person in charge. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People live in a safe, comfortable, clean and well-maintained home that is suitable for their needs. EVIDENCE: The home was very clean, tidy and well maintained. It has been furnished and decorated in a very comfortable, smart style. There are two large, comfortable lounges, a sunroom, a dining room and a library, which provide residents with pleasant sitting areas along with views of the gardens. The gardens are attractively planted, and have been provided with garden furniture so that people can enjoy being outside in better weather. Since the last inspection in December 2006 a sensory garden area has been added and there are plans to provide ramped access to replace the steps to the lower gardens. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 19 The dining room has been provided with new furniture that has made it more comfortable and pleasant for people. From February 2008 the home will be starting a refurbishment programme. The manager said that she would be looking at making the communal areas more homely and inviting so that they will be used more often. There are thirty single bedrooms, twenty-nine of which are en-suite and five double bedrooms with en suite facilities. Six communal toilets, three bathrooms and two showers have been provided which are suitable for older people with disabilities. The bedrooms seen were spacious, clean and comfortable. It was clear that people can bring in their own belongings to personalise their rooms. People said that they were pleased that the home was always clean and there were no smells. The manager said that all staff have now done some training around infection control and the home has got an infection control action plan. People said they were pleased with the laundry services. Clothes and linens were clean and well laundered. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a risk that the numbers and skill mix of staff on duty at any one time might not be enough to maintain the health, safety and well being of people living in the home. EVIDENCE: Information from surveys and speaking to people in the home said that they thought that sometimes there were not enough staff on duty or that there are issues around the ways staff work. People did understand that staff were busy and had to attend to other peoples needs but said that at times they wait a long time for call bells to be answered. One person said that on average they had to wait five minutes and that would be a quick response, sometimes they waited fifteen minutes or longer. Then if staff were busy they would be asked to wait ‘five minutes’ but it could be half an hour or more before they came back to them. The size and layout of the home means that at times staff have to go a long way to respond to a call bell. Comments were made that it nearly always carers who responded to them rather than the nurses. Other information from returned surveys said that: • People and their relatives had seen that there had been a large changeover of staff. • The staff genuinely cared about the people living in the home. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 21 On the first day of the visit one room was buzzing and two nurses ignored it even though one of them could have answered it. It was at least six minutes before it was answered. A comment was made that care staff were around to respond to them but at that point in time all the carers on duty were busy with people. Another area of work affected by the staffing levels or systems of working in the home was the medication rounds. On two of the visits the lunchtime medication round was being done over an hour late, once because the morning round had finished late and on the second occasion because staff had been too busy to start at the allocated time. From talking to the manager and using information provided in the AQAA it is clear that at least eleven of the people living in the home have a high level of dependency on staff to meet their needs, such as needing help to eat and drink, use toilet facilities and to get in and out of bed or change their position. The staff rotas showed that for thirty-six people there were eight staff on duty in the morning and six in the afternoon/evening, this includes 2 qualified nurses. Agency staff are used to maintain these numbers. The manager is in the process of recruiting staff and is waiting for pre employment checks to be returned. The manager has been revising the training records to make sure they are up to date and identify where gaps in training provision are. This will be used to put a training plan in place. The manager said that some staff have completed ‘train the trainer’ courses in: • Fire safety, • Health and safety, • Moving and handling • Food hygiene awareness • Abuse • The Mental Capacity Act 2005 • The manager said that these people will provide regular training sessions to keep staff up to date as well as for new staff who are doing the organisations induction training programme. During feedback we talked about the need for training and updates for nursing staff that is relevant to their role in the home and to remind them about their professional responsibility and accountability as nurses registered with Nursing and Midwifery Council. This is because of the problems that were identified in the section about ‘Health and Personal Care’ where appropriate action had not been taken to meet some people’s health care needs. Four staff files were looked at. These showed that: • Application forms had been completed. Two applicants had provided curriculum vitae but the application from only asked for the last ten years employment history rather than a full one. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 22 • • • • • Two written references were in place but in two files they were not from the most recent or current employer and there was no explanation why this was the case. Interview checklists were seen but only the file for a registered nurse had a written interview record. Three files showed that a satisfactory POVA (Protection of Vulnerable Adults) first check was in place before they started working but one person had been employed seven days before the date on the POVA first. All four files had the top section of the returned enhanced CRB (Criminal Records Bureau) disclosure but the date of issue was not on it, therefore it was not possible to identify when it had made. The nurse had completed a structured five day induction programme but the care staff had signed a document stating that they had completed the homes induction training on the day they started working at the home. The manager said that what these staff had done was an ‘in house’ introduction. All new staff are enrolled on the organisations induction training package that is equivalent to the Skills for Care common induction training. She was looking at the induction training and hoped to put together a four or five day package that would cover all the areas new staff needed. Information from the AQAA said that twelve of the twenty-five care staff had achieved a National Vocational Qualification at level 2 or higher. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 23 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are areas where the outcomes for people can be improved. The manager has worked with the organisation and other professional bodies to identify them and take appropriate action so that the home is being run and managed in the best interests of people living there. EVIDENCE: The manager took on this role in June 2007 after starting at the home as the Clinical Support Manager in May 2007. She is an experienced registered nurse who has already completed an NVQ level 4 in management, the registered managers award and a Certificate in Palliative Care. She is in the process of making an application to become registered with the CSCI. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 24 The home had received a complaint about the safety of bedrails and bedrail protectors and during the visit one bed was seen where the protectors were not secure. The manager audited all of this type of equipment that is in use. Some of the bedrail protectors were not the right ones for the rails they were on; they did not fasten correctly which could lead to the risk of an injury. New protectors have been ordered urgently for all beds that require them and should be delivered before Christmas. From looking through the records of the complaint investigation it was clear that the individual had had at least nine accidents or falls from the end of December 2006 to the end of March 2007. One accident in January 2007 resulted in a head injury and others resulted in injuries to their legs that needed medical attention. None of these were reported to CSCI as required under Regulation 37. The manager was not working at the home at that time. She said that all notifiable incidents will be reported. The organisations quality and compliance team have visited the home to help with the complaint investigation. Together with the manager they have audited some of the services provided and are working at putting an action plan together that will deal with identified issues and improve outcomes for people living in the home. The manager and the operations manager have been given feedback about the findings made during my visits to the home and have given reassurances that individual issues will be dealt with and other actions needed will be added to the action plan. The home has successfully achieved the Investors In People quality assurance award. The organisation carries out an annual survey of residents views of the home. Questionnaires were sent out late autumn and the results for the 2007 are not available yet. The results of the 2006 survey could not be found. The manager said another copy would be requested from head office. Copies of the outcomes of the survey are normally kept in the home after being discussed at staff and residents/relatives meetings. Policies and procedures are in place. They are revised and updated by the organisation as needed and when laws change. Copies are kept in the managers office and nurses station and are easily accessible to staff. Information from the AQAA showed that safety and maintenance checks of gas and electrical installations in the home were carried out and kept up to date. People or their relatives look after their own financial matters. The home will keep small amounts of money in safekeeping for people. Money held in safekeeping is put in a bank account, computerised records of all monies received and returned are kept along with signed receipts. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 4 4 4 3 X 4 X 4 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 Requirement The care plans must be detailed and individual to the person they have been written about. This will make sure that they provide staff with clear guidance about how to meet individual’s identified and assessed health, safety, personal and social care needs. The manager must make sure that the information and outcomes of the health care assessments are used to identify where an individual needs additional support from healthcare professionals. Appropriate care plans and guidance for staff on how to meet these needs must be put in place. Particular attention must be paid to people who are at risk of losing weight. Steps must be taken to make sure that the systems for dealing with medications are safe. Accurate records must be kept of all medications received into the home and when they have been given to people. Medication for DS0000019866.V356798.R01.S.doc Timescale for action 31/03/08 2. OP8 12 (1)(2) (3)(4) 13 (1)(b) 30/03/08 3. OP9 13 (2) 30/01/08 Cottingley Hall Nursing Home Version 5.2 Page 27 people no longer in the home must be disposed of correctly. 4. OP16 22(1)(2) (3) The organisation must make 30/03/08 sure that all staff know how to respond to concerns and complaints made by people living in the home or their relatives/visitors. This will make sure that the manager can investigate and respond to them appropriately and improve outcomes for people living in the home. There must be enough staff on 30/03/08 duty at all times, or work/shift management systems should be revised, to make sure that: • People’s needs will be met. • People receive the help they need to eat and drink. • Staff respond to call bells promptly. • People receive their medication at the correct times, with correct intervals between doses. The size and layout of the building should be taken into consideration when doing this. This will make sure that peoples health, safety and well being is monitored and maintained and that their personal, social and psychological care and support needs are met. Steps must be taken to make 30/03/08 sure that all staff receive training that equips and helps them to maintain the health, safety and welfare of people living in the home and themselves. Training about specialist care needs of service users should also be provided such as stroke, physical disability and spinal injury. Particular attention must be paid to making sure that qualified DS0000019866.V356798.R01.S.doc Version 5.2 Page 28 5. OP27 18 (1)(a) (b)(3) 6. OP30 18(1)(c) Cottingley Hall Nursing Home nurses receive this training as well training about their professional responsibility and accountability in line with the codes of conduct produced by the Nursing and Midwifery Council. 7. OP38 13(4)(c) (7)(8) Steps must be taken to make sure that all bedrails and protectors used in the home are safe and fit for purpose. Regular safety checks must be carried out and records kept. This will make sure that the safety of people needing the use of bedrails is promoted and protected. 30/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP18 Good Practice Recommendations All staff should receive training about the different types of abuse, how to recognise it and what to do if they suspect it is happening. This will help to protect the health, safety and well being of people living in the home. The application process should be revised so that: • Application forms request a full employment history, with dates so that any gaps in employment can be identified and explored. • Interview records are kept for all employees. • Records are kept of the date when an enhanced CRB was issued. • At least one reference is from the current or most recent employer, or written information is kept about the reasons why this is not possible. The manager should make sure that she applies to become registered with CSCI so that people will know the home is being run and managed by somebody who fit to DS0000019866.V356798.R01.S.doc Version 5.2 Page 29 2. OP29 3. OP31 Cottingley Hall Nursing Home be in charge and able to discharge their responsibilities fully. Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cottingley Hall Nursing Home DS0000019866.V356798.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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