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Inspection on 15/08/07 for Cowbridge Nursing Home

Also see our care home review for Cowbridge Nursing Home for more information

This inspection was carried out on 15th August 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.

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

What the care home does well

Residents appear to have their personal care needs addressed appropriately for instance they appear clean, dressed well and appropriately and receive suitable portions of food. Staff appear to be caring and show compassion and concern regarding resident`s needs. There is a suitable and safe system for the administration of resident`s medicines. There is good communication with GP`s and other healthcare professionals. Nutritious food is on offer and in sufficient quantities. The home is warm and clean with no unpleasant odours. There are suitable laundry facilities and resident were observed wearing clean clothes. The management team have a positive approach to improving the home and are endeavouring to address the requirements set by the Commission for Social Care Inspection.

What has improved since the last inspection?

There has been further refurbishment of communal areas and individual bedrooms and this is ongoing. The quiet lounge is now in use and residents appeared comfortable seated in a selection of specialist chairs. Music was playing in the background, which was a pleasant change to the television being on. Relatives said this was a lovely room. They also said that the management have been doing a lot of work to improve the home. Some of the locks have been removed from doors and the people using the service can now move freely around the home. This has been a vast improvement and is a huge benefit for the residents, one in particular who spends her time continually walking around. An office has been provided for the business consultant and the manager has an office although this could be improved if not shared with the nursing and care staff. Some staff training has been undertaken and further courses have been booked. The new care plans have been implemented and are an improvement on the previous system; there is still work to do to meet the National Minimum Standard. The staff facilities have been improved with the provision of a staff room where staff can eat their meals and spend time away from the resident`s accommodation. The shower and toilet facilities are now working and a small kitchen area allows staff to make drinks and snacks. Lockers are provided for the storage of personal belongings. The electrical hardwiring test has been completed and a copy of the documentation sent to the Commission. The boilers also appear to have been serviced on 22nd June 2007. The care documentation for individual residents is now held together in one file, which makes it much easier to access and reference. The carers now write in the daily records but this is in its infancy and requires monitoring. The business consultant said she has approached relatives for information about the resident`s life histories. This will help staff to care for residents as individuals and to provide activities suited to the people accommodated. The operations director has been nominated as the responsible individual for the company and has commenced monthly visits to the home. A report has just been sent to the Commission as required by law. This must be a monthly occurrence.

What the care home could do better:

Despite the efforts of the management team this key inspection has again produced a significant number of statutory requirements, many of which are re-notified. These are legal requirements, which must be implemented by law. An improvement plan has been in place for this home and another will be requested. The management of the home has been poor and there is still a great deal to be done and many regulatory issues to address. Whilst recruitment takes place the registered provider has nominated Jean Bennett, Registered General Nurse, as manager of the home with the assistance of Caroline Jasper as a business consultant. The Commission has concerns as to the role of the business consultant as she appears to be running the home and is not qualified for this position. The manager is working as part of the nursing team with little time allotted for management duties. There must be more liaison between the manager and the business consultant to ensure that both of their skills are utilised and the home is managed appropriately. The designated manager must be in control and fully consulted about operational management decisions in the home. This person must be given ultimate responsibility for decisions regarding the health and wellbeing of residents, including all clinical decisions. The statement of purpose requires updating but it is suggested that this be done by the new registered manager when appointed. The resident`s guide must be supplied to each resident and their representative as appropriate to ensure they know what the home has to offer. A suitably qualified person must undertake the pre-admission assessments; the business consultant does not have the knowledge or the appropriate qualifications for this task. The assessment document needs to evidence who was involved in the assessment and all sections should be appropriately completed, dated and signed. Efforts must be made to compile and agree the care plans with the resident or their representative. If this is not possible it must be documented. More detail is required in the written care plans to ensure staff are fully informed of the care to be provided. Individualised risk assessments are needed for those requiring restraint such as bed rails or wheelchair lap straps. There must be an indication as to how risk assessments are scored and the actions to be taken must be recorded in the care plans to direct staff. The care plans need to include information regarding the person`s previous life history and interests.Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 8The daily records require monitoring to ensure that all of the information is recorded, as these are legal documents. There needs to be a photograph of each resident on care plans and medication records, as many residents have limited cognitive skills and some are now unable to speak clearly. Significant improvement still needs to occur regarding the arrangements for residents` daily life and social activities. At present there is little stimulation to help individuals maintain a sense of their own personhood, or attempts by staff to respect people`s individuality. Residents need to be offered more choices on how to live their daily lives. The manager said the menus are under review, which should improve choices. All staff must receive appropriate adult protection training and management need to be fully aware of the local procedures and the reporting of incidents. The physical environment is poor although it is appreciated that improvements are still in progress. The registered provider has started to redecorate some bedrooms. There are insufficient specialist bathing facilities and this must be reviewed. Some yale locks still need to be removed from doors such as bathrooms and toilets and suitable locking devises must be installed for resident`s use, with an overriding facility if necessary. An office has been made for the business consultant using part of a lounge that was designated for resident`s use. The registered provider must write to the Commission confirming the sizes of communal rooms and fully justifying any reduction [if any] in the previous space. This office and the files must be freely available to the manger when the business consultant is not in the home. CSCI inspectors must also be able to access the documents, required to be in the home, at any time. There needs to be a review of staffing to ensure there are enough staff to provide activities and to ensure there are always enough staff on duty. The manager and staff have said that the duty rota can be changed without them being consulted and this has meant staff not arriving for work or extra staff arriving. This has also been relayed to the commission anonymously along with other concerns. The manager should have control of the duty rota for and ultimately decide who should be on duty and when. The skill mix and competency of nursing staff must be reviewed to ensure that there are enough skilled

CARE HOMES FOR OLDER PEOPLE Cowbridge Nursing Home Rosehill Lostwithiel Cornwall PL22 0JW Lead Inspector Diana Penrose Key Unannounced Inspection 15th August 2007 09:00 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 Cowbridge Nursing Home DS0000009169.V348701.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. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cowbridge Nursing Home Address Rosehill Lostwithiel Cornwall PL22 0JW 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) 01208 872227 01208 873109 Cornwallis Care Services Limited Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30) Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2007 Brief Description of the Service: Cornwallis Care Services Ltd, own two nursing and one residential care home in Cornwall. Cowbridge Nursing Home is registered to provide accommodation and care to 30 residents who may experience mental health problems or dementia. Cowbridge Nursing Home is a detached property situated on the outskirts of Lostwithiel. The original house has a modern day extension. The grounds are extensive with views over the surrounding countryside. There is an area of garden and a patio that are enclosed and accessible to people using the service. Accommodation is provided on two floors with a very small passenger lift for access. There are rooms for both single and double accommodation - only one room has en-suite facilities. Assisted bathing and shower facilities are provided. All rooms have call bells. There are three sitting rooms and a dining room. Refurbishment is currently taking place. Information about the home is available in the form of a statement of purpose and residents’ guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees range from £478 to £580 per week; this information was supplied to the Commission on the day of inspection. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors visited Cowbridge Nursing Home on the 15th August 2007 and spent eight and a half hours at the home. This was an unannounced visit. The purpose of the inspection was to undertake a statutory inspection and to gain an update on the progress of compliance to the requirements identified in the last inspection report dated 10th May 2007. All of the key standards were inspected. On the day of inspection 24 people were living in the home. The methods used to undertake the inspection were to meet with residents, visitors, staff and the business consultant to gain their views on the services offered by Cowbridge Nursing Home. The manager was not working on the day of the inspection the business consultant was the person in charge. Records, policies and procedures were examined and the inspectors toured the building. This report summarises the findings of this inspection. There is still no registered manager employed and this has an impact on the management of the home and leadership of the staff team. What the service does well: Residents appear to have their personal care needs addressed appropriately for instance they appear clean, dressed well and appropriately and receive suitable portions of food. Staff appear to be caring and show compassion and concern regarding resident’s needs. There is a suitable and safe system for the administration of resident’s medicines. There is good communication with GP’s and other healthcare professionals. Nutritious food is on offer and in sufficient quantities. The home is warm and clean with no unpleasant odours. There are suitable laundry facilities and resident were observed wearing clean clothes. The management team have a positive approach to improving the home and are endeavouring to address the requirements set by the Commission for Social Care Inspection. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? There has been further refurbishment of communal areas and individual bedrooms and this is ongoing. The quiet lounge is now in use and residents appeared comfortable seated in a selection of specialist chairs. Music was playing in the background, which was a pleasant change to the television being on. Relatives said this was a lovely room. They also said that the management have been doing a lot of work to improve the home. Some of the locks have been removed from doors and the people using the service can now move freely around the home. This has been a vast improvement and is a huge benefit for the residents, one in particular who spends her time continually walking around. An office has been provided for the business consultant and the manager has an office although this could be improved if not shared with the nursing and care staff. Some staff training has been undertaken and further courses have been booked. The new care plans have been implemented and are an improvement on the previous system; there is still work to do to meet the National Minimum Standard. The staff facilities have been improved with the provision of a staff room where staff can eat their meals and spend time away from the resident’s accommodation. The shower and toilet facilities are now working and a small kitchen area allows staff to make drinks and snacks. Lockers are provided for the storage of personal belongings. The electrical hardwiring test has been completed and a copy of the documentation sent to the Commission. The boilers also appear to have been serviced on 22nd June 2007. The care documentation for individual residents is now held together in one file, which makes it much easier to access and reference. The carers now write in the daily records but this is in its infancy and requires monitoring. The business consultant said she has approached relatives for information about the resident’s life histories. This will help staff to care for residents as individuals and to provide activities suited to the people accommodated. The operations director has been nominated as the responsible individual for the company and has commenced monthly visits to the home. A report has just been sent to the Commission as required by law. This must be a monthly occurrence. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 7 What they could do better: Despite the efforts of the management team this key inspection has again produced a significant number of statutory requirements, many of which are re-notified. These are legal requirements, which must be implemented by law. An improvement plan has been in place for this home and another will be requested. The management of the home has been poor and there is still a great deal to be done and many regulatory issues to address. Whilst recruitment takes place the registered provider has nominated Jean Bennett, Registered General Nurse, as manager of the home with the assistance of Caroline Jasper as a business consultant. The Commission has concerns as to the role of the business consultant as she appears to be running the home and is not qualified for this position. The manager is working as part of the nursing team with little time allotted for management duties. There must be more liaison between the manager and the business consultant to ensure that both of their skills are utilised and the home is managed appropriately. The designated manager must be in control and fully consulted about operational management decisions in the home. This person must be given ultimate responsibility for decisions regarding the health and wellbeing of residents, including all clinical decisions. The statement of purpose requires updating but it is suggested that this be done by the new registered manager when appointed. The resident’s guide must be supplied to each resident and their representative as appropriate to ensure they know what the home has to offer. A suitably qualified person must undertake the pre-admission assessments; the business consultant does not have the knowledge or the appropriate qualifications for this task. The assessment document needs to evidence who was involved in the assessment and all sections should be appropriately completed, dated and signed. Efforts must be made to compile and agree the care plans with the resident or their representative. If this is not possible it must be documented. More detail is required in the written care plans to ensure staff are fully informed of the care to be provided. Individualised risk assessments are needed for those requiring restraint such as bed rails or wheelchair lap straps. There must be an indication as to how risk assessments are scored and the actions to be taken must be recorded in the care plans to direct staff. The care plans need to include information regarding the person’s previous life history and interests. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 8 The daily records require monitoring to ensure that all of the information is recorded, as these are legal documents. There needs to be a photograph of each resident on care plans and medication records, as many residents have limited cognitive skills and some are now unable to speak clearly. Significant improvement still needs to occur regarding the arrangements for residents’ daily life and social activities. At present there is little stimulation to help individuals maintain a sense of their own personhood, or attempts by staff to respect people’s individuality. Residents need to be offered more choices on how to live their daily lives. The manager said the menus are under review, which should improve choices. All staff must receive appropriate adult protection training and management need to be fully aware of the local procedures and the reporting of incidents. The physical environment is poor although it is appreciated that improvements are still in progress. The registered provider has started to redecorate some bedrooms. There are insufficient specialist bathing facilities and this must be reviewed. Some yale locks still need to be removed from doors such as bathrooms and toilets and suitable locking devises must be installed for resident’s use, with an overriding facility if necessary. An office has been made for the business consultant using part of a lounge that was designated for resident’s use. The registered provider must write to the Commission confirming the sizes of communal rooms and fully justifying any reduction [if any] in the previous space. This office and the files must be freely available to the manger when the business consultant is not in the home. CSCI inspectors must also be able to access the documents, required to be in the home, at any time. There needs to be a review of staffing to ensure there are enough staff to provide activities and to ensure there are always enough staff on duty. The manager and staff have said that the duty rota can be changed without them being consulted and this has meant staff not arriving for work or extra staff arriving. This has also been relayed to the commission anonymously along with other concerns. The manager should have control of the duty rota for and ultimately decide who should be on duty and when. The skill mix and competency of nursing staff must be reviewed to ensure that there are enough skilled nurses, at all times, especially Registered Mental Nurses to care for the people using the service. The kitchen porter arrangements must be reviewed to ensure appropriate use of staff time, deployment of skills and reduce the risk of cross infection. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 9 The management must ensure that suitable employment checks are undertaken prior to staff working in the home. These issues have been raised with the registered manager at previous inspections and requirements have been re-notified several times. An immediate requirement was notified during this inspection. Failure to comply could result in the Commission taking enforcement action. Because of the way the records are laid out, it is difficult to ascertain if individual staff have had suitable training at the correct recommended frequencies. Evidence of other training required by law is not sufficient. Induction records were unavailable. Records must be improved and staff must receive appropriate training to ensure they have the necessary skills to provide a good standard of care to the residents and to ensure the residents are safe in their hands. The registered provider still does not have a quality assurance system, although inspectors were told this was in hand at the last inspection. There is subsequently no formal method of ascertaining residents and other stakeholder’s views or for developing quality practice and improvement in the home. The registered provider must address health and safety issues: • • • • • • There must be a suitable system of health and safety risk assessment to prevent Legionella. Any essential maintenance work on the passenger lift, which could affect the safety of staff, residents or visitors, must be completed. Confirmation of work completed must be sent to the Commission within the timescale. Health and safety risk assessments need to be reviewed and appropriate action taken to ensure the system is effectively managed. Hot water temperatures are tested before residents bath, and the temperature is recorded. Any pipe work containing hot water and which could present a risk to residents is boxed in. Thermostatic valves are fitted to hot water outlets to prevent scalding. Deaths, any serious injury to a resident, unexpected hospital admissions, events in the care home which adversely affect the well-being or safety of any resident, allegations of misconduct by the registered person or any person who works at the care home must be reported to the Commission. 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. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (6 is N/A) Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered provider’s statement of purpose requires updating and a copy sent to the Commission. The updated resident’s guide (Service User’s Guide) must be provided to the Commission and to residents (and where appropriate their representatives) so that suitable information is available about the services offered. These documents must also be available in the home. Residents receive a contract on admission. However copies of this information were not available in some resident files. Where necessary this information needs to be reissued or a duplicate obtained so residents and their representatives have information regarding rights and responsibilities. There is a pre-admission assessment procedure and a form to complete. On occasions a suitably qualified nurse has not undertaken the assessment, the documents are incomplete and have not been dated or signed. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 12 EVIDENCE: Evidence was provided in the form of documentation and talking with the business consultant and staff. Copies of several different statements of purpose were inspected. There needs to be a review and a definitive statement of purpose produced. It was suggested that this be undertaken when a registered manager is appointed. A copy of this documentation subsequently needs to be forwarded to the Commission. The business consultant explained that the resident’s guide (Service User’s Guide) is being updated. There was no copy available for inspection. The business consultant said she was not sure if the information had been issued to residents and their families in the past, so it would be reissued next week. However, before this documentation is issued care needs to be taken to ensure all of the information contained in the revised Care Homes Regulations 2001 is contained; particularly in relation to nursing care. The revised regulations are available on the CSCI internet site. A copy of the final Service User Guide needs to be sent to the Commission. A copy of either a social services contract (if the person is state funded) or the registered provider’s contract (if the person is privately funded) was contained in some of the residents’ files inspected. However some contracts are missing, and the registered provider either needs to re-issue the documentation to relevant parties or obtain duplicates. Contracts should specify contributions made for nursing care (i.e. by the state). Full information regarding what is required is contained in the revised Care Homes Regulations 5a (dated 01/09/06). A master copy of this documentation should be sent to the Commission. Staff said that prospective residents are generally visited prior to admission. The person undertaking the assessment must be a suitably qualified nurse, as many of the people requiring this type of service have complex nursing needs. It is not appropriate for the business consultant to undertake nursing assessments or make decisions as to who is admitted to the home. Records of assessments including that of the most recent resident admitted were inspected. The forms used are satisfactory although they are titled ‘admission assessment’; the business consultant stated that they are used on admission as well as pre-admission. This is confusing and a specific form should be used for the initial assessment. Some of the forms inspected were incomplete. There needs to be evidence of where the information was gathered and who was involved in the assessment. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 13 Documents should all be dated and appropriately signed by the nurse undertaking the assessment. Intermediate care is not provided by this service. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 14 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. Individual care plans are generated for each resident but it is not clear that the resident or their representative are consulted. Improvement is required so care plans more fully outline resident’s needs and risk factors are included. Residents have access to health care services as necessary and specialist equipment is provided. There is a system for dealing with resident’s medicines that is generally satisfactory and residents are safeguarded. Staff approaches are generally good but in some cases require improvement to ensure residents respect and privacy are maintained and enhanced. EVIDENCE: Evidence was provided in the form of documentation, records, and observation, talking with residents, staff and the business consultant. The new style care plans are an improvement on the previous versions. Five plans were inspected including those of new residents. There is no evidence that the resident or their representative have been involved in the compilation Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 15 of the individual’s care plan. Not all of the documentation has been fully completed, dated or signed. There is little information regarding the person’s previous life history and interests, the business consultant said that she is asking resident’s families to provide this and hopes to have it done by the end of next week. This information is vital to assist staff to get to know individual residents, and to help the resident to maintain their sense of personhood and individuality. Care plans did not cover all the person’s needs, for example, there were no social care plans and only one night care plan. The pressure sore / wound care plans and records are held in the clinical room and there is no plan or reference made in the care files. Some care plans need to be more specific to fully inform and direct staff. Phrases such as ‘regularly’ or ‘as appropriate’ must be more definitive. This will ensure consistency of practice, and minimise the risks. There are various risk assessments included with the care documents but they are not all referred to in the written care plans. There is a form used to state whether or not restraints, such as bed rails, are being used. There is no specific risk assessment undertaken or consent signed by the resident, representative or GP, for example, when restraints are in use. How to obtain information regarding the use of bedrails was provided at the last inspection and was given to the business consultant at this inspection. The previous requirement is re-notified. It is essential there is a photograph of each resident on care plans and also on medication records, as many residents have limited cognitive skills and some are now unable to speak clearly. This has not been addressed since the last inspection. The review of care plans could not be fully evaluated as several plans had recently been compiled and not yet subject to a monthly review. Some were seen to have been reviewed on a monthly basis. It was apparent from the records that some residents had died since the last inspection but the Commission has not been notified. The registered provider must ensure that deaths are reported to the Commission under Regulation 37 of the Care Homes Regulations 2001. Care files are stored in the manager’s office and care staff have access to them The carers now write in the daily records as well as the nurses, with a nurse countersigning their entries. This practice is very new and does not appear to be working efficiently at the moment. Care staff do not always have time to write the records and the nurses may not necessarily have all of the information to complete it for them. Care must be taken to ensure the daily records are completed in sufficient detail each day, as these are legal documents. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 16 One inspector was based in one of the lounges to work and observe practices. Staff generally interacted well with the people using the service, and appeared kind and caring. Staff assisted residents well when they were upset and distressed. Relatives spoken with said the staff work hard and their relatives are well looked after. There was evidence within the care documentation of visits by healthcare professionals and a GP visited during the inspection. However interaction with at least one of the residents on this occasion was poor. The GP carried out their consultation in the lounge and in front of other residents. Personal information was discussed. The nurse in charge should have led the GP and resident to a private space and carried out the consultation there. Suitable equipment is available to staff for moving and handling purposes and pressure relief. However concern is expressed in the final section of the report regarding servicing of equipment. New mattresses arrived during the inspection. Records are maintained for the treatment of pressure sores and other wounds and there are records to show that the community tissue viability nurse specialist visits the home. None of the nurses specialise in a particular subject such as continence or tissue viability, for example, or act as links with external specialists. The medicines policy is suitable although very generic and long, it does not state simply what the home does therefore it is not very directive for staff. This will be reviewed when a new registered manager is appointed. A monitored dose system is in use. Medicines are only administered by registered nurses. The medicine administration records were complete however handwritten instructions on the medication administration charts must be witnessed with two signatures recorded. This requirement had been met previously but has lapsed. The business consultant agreed to discuss this with the manager; a requirement has not been notified on this occasion. The disposal of medicines was appropriate. There is an approved list of homely remedies signed by a GP and a suitable policy in place. The storage of medicines and medicinal gases is satisfactory. There is a very large stock of creams and other items in the clinical room, one of the nurses agreed that this stock should be reduced and the business consultant said she would discuss it with the manager. The medicines policy and a copy of the The royal pharmaceutical guidelines for care homes should be available in the clinical room for nurses to refer to. The business consultant said that medicines training is being arranged for staff. Resident’s privacy was generally respected and their freedom to move around the home has improved. Although exits are locked, residents can move around the downstairs or the upstairs areas. The kitchen, staircase and staff only areas are restricted. The business consultant said she wanted to improve part of the garden area so residents could go out there alone. This would be a very good idea, however the area needs to be made safe for people with dementia. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 17 Toilet and bathroom doors are no longer kept locked and people were seen to move around the home and access facilities as necessary. Locks are still inappropriately fitted to some doors and need to be removed, if they are not removed, this unnecessary restriction could still be used. For example toilets and bathrooms should not have a ‘Yale’ type lock on them, and these should be removed. There should however be an internal lock on bathrooms and toilets, for resident’s use, with an overriding facility if this is deemed necessary. It may be considered appropriate to have a 180-degree hinge on toilet/ bathroom doors. This is the case if there is a danger of residents falling against the door, and staff not being able to get into the bathroom / toilet. The previous requirement is therefore re-notified. The Commission for Social Care Inspection has now renotified the registered provider three times regarding a statutory requirement regarding this matter. Failure of the registered provider to take satisfactory action within the timescale set could result in enforcement action. There was some temporary restriction during the inspection due to two communal rooms being refurbished. Screening still needs to be provided in one of the shared rooms. The business consultant said the screens from another room, presently single occupancy, are to be moved to this room. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 18 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 poor. This judgement has been made using available evidence including a visit to this service. Only limited activities and stimulation are provided for residents. Routines tend to be institutional and currently do not consider individual wishes and needs. Staff do their best to help residents maintain links with family and friends. Opportunities for individual residents to maintain choice and control over their lives are limited. Food provided is to a satisfactory standard and improvements are progressing in respect of the eating arrangements and support offered at mealtimes. EVIDENCE: Evidence was provided in the form of documentation, records, and observation, talking with residents, visitors, staff and the business consultant. Stimulation for the people using the service is limited. Some staff were engaging in conversation with a few residents but no organised activities were taking place. The television was on in one lounge but no one was watching it, a resident finally asked for it to be turned off. Music playing in another lounge seemed more appropriate. A small collection of magazines and newspapers were seen and one or two people were looking at these. One person who Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 19 constantly walks around is no longer restricted to the lounge and one corridor, which is a huge benefit for her. Other people were seen walking freely around the home despite the current refurbishment work taking place. The business consultant said she plans to employ two care staff to co-ordinate activities. She also plans to introduce further activities such as an entertainer and possibly trips out. The business consultant said a minibus would be purchased which will be a very good resource. The business consultant showed the inspectors some artwork that has been undertaken with the people using the service. A list was displayed of some activities dated July 2007 although there was no current list available. There is a sheet for each resident in their care file for recording activities undertaken, these showed that some activities take place, for example manicures, walks in the grounds, singing, painting and general chatting. Staff said they are trying to spend talking with residents whilst providing their care but organised activities are more difficult due to staffing and time restrictions. One inspector sat in one of the lounges for several hours. Although staff were kind and caring there was no structured activity either for the group or individuals. At least one person was not moved or toileted throughout this period which if a regular occurrence may lead to sores developing. The business consultant did say there is usually more activities, but because of building work there is restricted opportunity at present. The business consultant did say that changes to the staff rota would result in there being more opportunity for one to one, and structured group activities. However the previous requirement regarding this matter is re-notified. The Commission for Social Care Inspection has now re-notified a statutory requirement, in respect of this matter, to the registered provider three times. Failure to take satisfactory action within the timescale set could result in enforcement action being taken. Visitors are welcome at any time, and it is evident from the visitors book many residents have friends and family to visit them, sometimes on a regular basis. The inspector was able to speak to two visitors who said they were happy with the care provided and they are welcome in the home at any time. Visitors can meet with residents in one of the lounges or personal bedrooms. There still does not appear to be any contact with the local churches or chapels. This should be developed so peoples’ spiritual needs are maintained and enhanced. There is little evidence that the people using the service choose or are able to choose how to spend their time. The business consultant said management have worked with staff to ensure the times residents get up and go to bed is more flexible. However, care plans do not state preferred times for getting up or going to bed and times are not recorded. These things may be addressed when the business consultant has gathered information about residents from Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 20 their families. There are some choices available in respect of diet. Many residents lack the skills to communicate their wishes and some show little interest and sleep a great deal. The cook has left since the last inspection and the part time cook is now working full time hours. She said she is enjoying the work and is happy in her new role. Everyone spoken with said the food is very good. One inspector enjoyed lunch with the residents. This was roast chicken for the main course, followed by rice pudding. The meal was to a high standard. Teas and coffees are served mid morning, and cakes and fruit were brought around on a trolley with the afternoon tea. Residents appeared to enjoy their meals. Nutritional needs are assessed but not all people have a care plan in respect of eating and drinking. Mealtimes have been changed and felt by staff to be more appropriate. There is a four-week set menu but the cook said that people do have alternatives; this was evidenced in the records. The menu was due to be revised at the last inspection but this has not yet happened. Homemade cakes are provided every day and there were fresh vegetables and fruit. The dining arrangements for people using the service are in the process of changing, one lounge is being converted into a designated dining room. This will be a considerable improvement on the past and current arrangements. Meals on the day of the inspection were served in the lounges. This was not appropriate, and some people appeared to have difficulty in eating their food because there were no dining tables available. Staff however did their best to assist residents, and some people required physical assistance with feeding. It would have been much more appropriate if the refurbishment of the two lounges had been staggered, so there could have been a dining area; essential considering the needs of some of the people living in the home. Staff spoken with also voiced concerns about the two communal rooms being refurbished together. Staff support during the observed mealtime was only adequate. Unfortunately one of the staff loudly complained in the lounge about having to clear up some food dropped by one of the residents in another area. This was not appropriate, and her grievances should have been aired in private. There was also some confusion about the availability of cutlery for one resident, which resulted in the resident being fed by staff because the cutlery could not be found. There was some confusion about the sweet being served which led to delay, also confusion as to whether someone had eaten the sweet or not. It is hoped there will be considerable improvement when the dining area is finally reinstated. The previous requirement is therefore renotified. The Commission for Social Care Inspection has now re-notified the registered provider three times regarding a statutory requirement in respect of this matter. Failure of the Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 21 registered provider to take satisfactory action within the timescale set could result in enforcement action. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 22 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 poor. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, which should ensure complaints will be listened to and acted upon. Arrangements are in place for the protection of residents from abuse, however further staff training is required and the management need to be fully aware and act upon local inter agency procedures. EVIDENCE: Evidence was provided in the form of documentation and talking with the business consultant and staff. The home has a suitable complaints policy and a method for recording complaints. There have been no complaints received by the home since the last inspection. Anonymous concerns have been voiced recently to the Commission and have been investigated during this inspection. Some have been substantiated. The home’s adult protection policy is suitable and there is a copy of the interagency policy in the manager’s office. Management need to be fully aware of the local inter-agency procedures and the reporting of incidents. An incident that took place recently was investigated by the home but not referred to the Department of Adult Social Care (DASC) or reported to other agencies such as the Commission for Social Care Inspection. The business consultant was Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 23 advised to write to the Department of Adult Social Care, retrospectively explaining the situation and ascertaining if they are satisfied with the internal investigation. A copy of the letter, and the response from DASC, should be sent to the Commission. In future, any allegation of abuse must be reported to DASC, who is the lead agency in deciding how any allegations should be responded to. The registered provider will need to consider if any staff involved need to be suspended (as occurred on this occasion). Incidents should also be reported immediately to other agencies such as CSCI or the Police etc. The business consultant said some more staff have received training, regarding the protection of vulnerable adults from abuse, since the last inspection. However documented evidence of this is currently very limited, partly because the business consultant said certificates are due to be forwarded to the home. The remaining staff must also receive appropriate training. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 24 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 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is a suitable size for the people who live there. There has been improvements in the decoration and facilities provided since the last inspection and the home is beginning to look and feel more comfortable and homely. There are sufficient toilets in the home however bathroom facilities require significant improvement to assist residents who are frail and / or have mobility problems to bathe. In some cases toilets and bathrooms need redecoration. The home is kept clean and the building has no unpleasant odours. EVIDENCE: Evidence was provided in the form of documentation, observation, a tour of the building, talking with staff and the business consultant. There is no doubt that the current management team are endeavouring to improve the premises and make it a more comfortable and homely place to live Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 25 in. Two communal rooms are currently out of use as they are being fully refurbished; one will become a dining room and the other a lounge. It is hoped that the work will be completed by 23 August 2007. Although this work is well overdue, it is a pity the work had not been staggered, as available communal facilities were minimal at the time of the inspection. This presented particular problems at mealtimes. Corridors are being re-decorated to make them brighter and dark wood window frames are being painted white. Some bedrooms have recently been refurbished and two that were shared accommodation are currently being used for single occupancy. This has reduced potential health and safety risks, especially when using equipment such as hoists, and has improved the privacy arrangements for people using the service. The ‘quiet’ lounge is now being utilised; there are only finishing touches still to be done. The business consultant has an office off of this lounge. The Commission raised concerns about this in the previous inspection report dated 10th May 2007 and it is disappointing that the registered provider has still developed this communal space into a private office for the business consultant. The registered provider must ensure there is sufficient communal space, and there is no decrease on the amount of space available to residents from what was previously available. The registered provider must write to the Commission confirming the sizes of communal rooms and fully justifying any reduction (if any) in the previous space. Consideration needs to be given to the amount of ‘traffic’ by staff and visitors to the office, via the ‘quiet’ lounge. This may result in residents not having a ‘quiet’ area to sit in, and it may unintentionally become an ‘annex’ for staff use. The Commission were informed that staff would use the external door to the business consultant’s office but this was not the case during the inspection, everyone walked through the ‘quiet’ lounge. Bathing facilities are still to be reviewed and the business consultant said that equipment to bathe people in bed is being sought. She also said the upstairs bathroom is now in use although staff said it is not used very often. This is probably because the facilities available here are not appropriate for people in many of the nearby bedrooms. The business consultant said a ‘wet room’ would be installed in the downstairs part of the building. Consideration still needs to be made regarding whether a ‘Parker’ type bath is purchased as outlined in the requirement set. Advice could be sought from an Occupational Therapist regarding the type of equipment to be purchased. Some of the current bathroom and toilet facilities are still poor. Although clean, many of the toilets and bathrooms are decorated to a very basic standard and are subsequently not at all welcoming. Redecoration is required to make these rooms more inviting. Although most of the bathroom Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 26 and toilet facilities were not locked at the time of the inspection although ‘Yale’ type locks are still fitted to the doors. As stated earlier in the report, these need to be removed. The business consultant said she hopes to review the toilet facilities in the home and purchase new toilet pans and washbasins where required. Suitable equipment to wash residents’ hair, if they cannot get out of bed, has been purchased and is in use. Some fire doors have been replaced and an emergency door release facility provided on the front door. New radiator covers are to be provided and some hot water pipes in an upstairs bedroom boxed in. There is a shaft lift to the first floor. The lift is small and not really appropriate for wheelchair users who need an escort. The maintenance contractor, in a recent report, has said the lift now needs replacing. As a minimum the equipment must be safe for the use of staff, visitors and residents. The staff facilities are now being utilised and a small staff lounge has been incorporated. Carpet is to be fitted in the lounge and the rest of the floor area tiled. The areas also need redecorating. A small office has been provided for the manager but the nurses and care staff also use this room so it is not always a private room. The manager should be able to utilise the office used by the business consultant and must have access when she is not in the home as files significant to her role are held there. These must also be available to CSCI inspectors if the business consultant is not in the home. The home was clean and hygienic on the day of the inspection and there were no unpleasant odours. A sluice facility is provided downstairs; the business consultant said the washer disinfector needs replacing. It is still recommended that a sluice be provided upstairs. All laundry is dealt with in house, there is suitable equipment provided but the room is very small and noisy. The business consultant pointed out that the area designated for ironing is cramped, not well lit or well ventilated and solutions are being sought to improve this. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 27 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 poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are only just adequate, as improvement is required to ensure there are suitable numbers of personnel to provide therapeutic and recreational activities and suitable levels of stimulation. Cover of nurses registered to work with people with mental health needs (RMN) also needs improvement. Staff recruitment procedures, although improved need further development so residents can be assured they are satisfactorily protected by staff pre-employment checks. There are suitable numbers of staff that have a National Vocational Qualification in care, although staff records need to better evidence this. Other staff training, required by law, still requires significant improvement so residents can be assured staff are trained and competent to do their jobs. EVIDENCE: Evidence was provided in the form of documentation, talking with the business consultant, staff and visitors. Rotas show there are currently satisfactory numbers of care staff on duty. This includes a registered nurse being on duty at all times. The Commission has concerns regarding the skill mix of nurses employed. The majority of nurses employed are Registered General Nurses (RGN); the manager is also a RGN. There has been no assessment of the competency of these nurses to work with people with mental health needs and be left in charge of up to 30 residents. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 28 Previously the registered manager was and RMN and there was an on call rota. There was no evidence of an on call rota at this inspection. The business consultant said that only three Registered Mental Nurses (RMN) are currently employed; some of whom are ‘bank’ staff or work part time. This is of particular concern due to the home being registered to provide care for up to thirty people with mental disorder (over 65 years of age). The business consultant said the registered provider has been trying to recruit more RMN’s but this has proved difficult. Additional work urgently needs to be undertaken in this area, including, assessment of the current RGN competency and, if possible, the appointment of a registered manager with a suitable nursing qualification and relevant experience in caring for people with mental health needs. The business consultant said the current duty rota is being reviewed and a new rota will be introduced shortly. Any changes in staffing arrangements and allocations must not lead to a reduction of the numbers of staff on duty, as previously been agreed with the Commission and as outlined in previous inspection reports. A copy of the draft rota model should be forwarded to the Commission before implementation. The manager and staff have said that the duty rota can be changed without them being consulted and this has meant staff not arriving for work or extra staff arriving. This has also been relayed to the commission anonymously along with other concerns. The manager should have control of the duty rota for and ultimately decide who should be on duty and when. Staff throughout the home voiced concerns regarding the kitchen porter arrangements; there is no kitchen porter anymore. The main issue was in respect of the washing up and cleaning. This appears to be undertaken by care staff or housekeeping staff at certain times of the day. The kitchen porter arrangements must be reviewed to ensure appropriate use of staff time and reduce the risk of cross infection. Recruitment records were inspected. A total of sixteen staff files were assessed. Of these four files for staff, who had started since the last inspection in May 2007, were inspected. Of the four staff who commenced employment since May 2007: • All four staff had an application form which contained a full employment history. • None of the staff had a declaration regarding satisfactory physical and mental health (although this was evident on the application form for most of the staff recruited prior to May 2007). Law requires this. • Only two of the staff had evidence that a ‘Protection of Vulnerable Adults First’ (POVA First) check had been completed. This is required by law and ensures that staff employed are not forbidden from working with vulnerable people. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 29 • • Three of the four staff had a full Criminal Records Bureau check (CRB). The other person appeared to be awaiting a disclosure and there was evidence it had been applied for. One of the staff had proof of their identity (although such evidence must have been seen for all the staff, at some point, in order to get a CRB check completed). Although there is an improvement in staff recruitment procedures since the last inspection in May 2007, it is still not satisfactory. Evidence still does not show satisfactory checks are being completed. Previous inspection reports also highlight how this standard, and associated regulations, have not been met. The registered provider has now been notified seven times regarding this matter. From the inspection of the other staff files, it is clear that the registered provider has failed to carry out an audit whether appropriate checks were carried out on staff employed prior to the last inspection. Of the records for other staff: • At least five staff (including one of the registered nurses) had not had a POVA check or a CRB despite starting employment at the home since July 2004. Some of these staff had a CRB check from a previous employer but these checks are not transferable, particularly because each member of staff has to be checked against the POVA list (to check they can work with vulnerable people) before they commence employment. • Three of the staff had no CRB check despite working at the home for a considerable period of time. This included one registered nurse. Considering the significant concerns expressed in the previous report dated 10th May 2007, and a subsequent letter of concern written to the registered provider, it is of grave concern that inadequate action has been taken regarding this matter. The registered provider has now been notified four times regarding providing suitable CRB /POVA checks. This included an immediate requirement regarding CRB /POVA checks made on 15th May 2006. Previous reports have detailed how this standard has not been met. The Commission is now considering serving an enforcement notice regarding this matter. It is also of concern that two of the three nurses files did not have satisfactory evidence that their Nurses and Midwifery Council (NMC) accreditation was valid. This matter needs to be addressed as a matter of urgency. Training records were also inspected in regard to the same personnel. By law all staff must have: Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 30 • • • • • • Regular fire training in accordance with the requirements of the fire authority There must always be at least one first aider on duty (at appointed person level). All staff must have moving and handling training. All staff must have basic training in infection control. If staff handle food they must receive training regarding food hygiene. All new staff must have an induction and there should be a record of this. Regarding the sixteen staff records inspected, training did not appear to be satisfactory: • For fire training - the inspector could only find evidence that five of the sixteen staff had received any fire training. One of these had only received training in 2005, and the other four had received training in May 2007 • For infection control training - only two staff, of the files sampled, had received this training, and although the business consultant said this training was scheduled. • For moving and handling training - eight staff had evidence of receiving this training, three of which had received training in July 2007, and the other staff had received this training between 2003 and 2005. The business consultant said ‘five or six’ staff had attended this training recently and the home was awaiting certificates. Further training she said was scheduled. • First Aid - there is evidence that two of the staff had received training in 2005 or 2006. There is however always a nurse on duty in the home, but it is not clear what checks have been completed to assess their competency in the area of first aid. The business consultant said further first aid training is planned to take place shortly. • Food Hygiene - there was evidence according to records that two staff have training in this area. Both staff received training in 2004. The business consultant said thirteen people had recently attended training in this area and were awaiting certificates. • There was no evidence of staff induction being completed for staff that have commenced employment since May 2007. The business consultant said the staff had their records at home. The business consultant said over 79 of staff have at least an National Vocational Qualification in care at level 2. However only 9 of the 16 staff files inspected (56 ) contained a certificate to verify this. A previous requirement was made regarding managing challenging behaviour / restraint, and also the needs of people with dementia and /or mental health issues. Of the sample only two people had a certificate to state they had attended training regarding dementia awareness. Three people had attended training regarding violence and aggression. The business consultant said staff Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 31 had attended training regarding dementia awareness recently and the home was awaiting certificates. Some care staff spoken with said they had recently attended training in respect of dementia, food safety and moving and handling. The cook also said she had received the food safety training. However bank nurses on duty were unaware that training was on offer. Local training updates, previously attended by the nursing staff, have lapsed mainly due to time restraints. The registered provider has now been notified three times regarding providing suitable training. However the timescale from the previous report has not yet lapsed. The registered provider must note that if suitable progress has not been made regarding the provision of training within the given timescale the Commission may take enforcement action. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 32 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management arrangements need to be improved so residents can be assured the home is managed effectively and there is leadership for the staff. There are some improvements in care practices since the last inspection, and further evidence of ‘work in progress’, which may lead to better outcomes for people living in the home. There is still a need for significant progress, and the development of effective organisational and management systems, so residents can have a good quality of life and be assured they live in a safe environment. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with staff and the business consultant. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 33 The registered manager’s post has now been vacant for a significant period of time. The registered provider is still actively trying to recruit a new manager, although so far has had no success. When this person is appointed they will need to be registered with the Commission for Social Care Inspection. The deputy manager is currently acting up as the manager of the home until a permanent manager is employed. The registered provider has also employed a ‘consultant’ (business consultant) to bring improvements to the home. Some positive changes have occurred regarding basic care practices, and changes are underway to improve the communal areas. The manager, business consultant and operations director seem keen to develop the service and bring about change. They also seem to have a positive ethos to the care of the elderly. However the Commission is concerned that the designated individual who is ‘acting’ manager is doing so in name only. This view is shared by a majority of the staff the inspectors have spoken with. It appears the business consultant is leading many of the changes with little consultation with the person who is designated as the manager. The business consultant’s ‘vision’ is a very positive one, and one which hopefully will be seen through. However there does appear to be a need for more of a partnership with the ‘acting’ manager who has greater knowledge, experience and skills as a clinician; absolutely essential for a service such as Cowbridge. Concerns have been expressed in this report about the role of key personnel in assessment decisions. The Commission requires greater assurance that the ‘acting’ manager is an integral part of the management team. Staff have voiced concerns about the amount of change and the speed at which it is taking place. Communication with the manager and staff regarding the changes does not appear to be taking place effectively and the inspectors were told that staff morale has been very low. The manager has stated that things have been decided without any discussion with her and she feels her authority has been undermined. After the inspection, the operations director forwarded a copy of a recent monthly visit, carried out on behalf of the registered provider. This is required under regulation 26 of the Care Homes Regulations 2001.Copies of these reports need to be forwarded to the Commission on a monthly basis. A quality assurance policy was inspected. This seemed satisfactory, but despite concerns raised in the previous report there is no evidence this has been implemented. For example there is no system to ascertain resident (and other stakeholder) views, no annual development plan or other systems, which may assist in bringing about change, and improving quality. This report still details significant concerns regarding how the service is run, and a number of serious omissions on the part of the management team which place staff and people living in the service at serious risk. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 34 The registered provider has now been notified three times regarding setting up a quality assurance system. The registered provider must note that if suitable progress has not been made regarding this matter within the revised timescale set, the Commission may take enforcement action. Since September 2006 this service has been included in the Commission for Social Care Inspection’s Regional Improvement Strategy. As a consequence, the registered persons were required by the Commission to submit an improvement plan in October 2006, and a revised version in May 2007. They will be required to do this again following this report. Although progress in some areas is noted, a significant number of the requirements in the last report are re-notified as further action is required either in part or full. This is detailed fully throughout this report. With regard to personnel checks the Commission is now considering the serving of enforcement notice as the registered provider has failed to take satisfactory action in this area. Further enforcement action will be considered in other areas, as outlined in this report, if the registered provider does not take urgent action. As also outlined in the previous report, to avoid this course of action, it is essential for the registered provider to set up a suitable system to bring about service improvement. The registered provider has a policy regarding the management of residents’ monies. Resident’s money is held in a non-interest account and the acting manager is a signatory. Individual records are kept. Staff do not act as signatories or as appointees for residents’ monies or state financial benefits. The business consultant said no valuables held for residents, although a ring was deposited later during the inspection of which a written record was to be kept. There is some evidence of recent staff supervision. For example records show that nine staff have received formal staff supervision in July 2007, and a further four staff have received staff supervision in May 2007. However there is no record of eight staff having received formal supervision. Although the previous requirement is not re-notified, staff do need to receive formal supervision regularly, and preferably six times a year as outlined in the National Minimum Standards. Day to day staff supervision seems satisfactory. For example a registered nurse is always on duty. The registered provider has a health and safety policy. Despite significant concerns expressed in the previous inspection report in May 2007 standards remain poor. There is no record that fire alarm call points, fire doors and emergency lighting are being regularly tested. Of the records presented the last recorded test was on 11th May 2007. The business consultant however said she completed the fire tests herself ‘about three weeks ago’ but did not produce any documentary evidence of this. An immediate requirement notice was served at the end of Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 35 the inspection regarding this matter, and this requirement is repeated in the report. The fire system and emergency lighting was however tested by an external contactor on 19th July 2007. The lift has recently been serviced on 20/7/07. However the company has recommended the lift either be refurbished or replaced. The report states although some work is required, the lift was left in a ‘satisfactory condition’. Confirmation of any essential works must be provided to the Commission within the timescale set. Portable electrical appliances were tested between January and March 2007 and records show these are satisfactory. An electrical hardwire circuit test was completed on 25/10/2006. Although the ‘installation was in good order’ some works were required. The operations manager has since confirmed this work was completed, and has forwarded invoices to the Commission detailing works carried out. A gas safety certificate dated 14th March 2007 was available for inspection and the contractor deemed the equipment satisfactory. Boilers appear to have been serviced on 22nd June 2007. Health and safety risk assessments have been completed, however these do now need to be reviewed. The system also needs to be more active; for example to proactively address some of the issues detailed in this section of the report. There does not seem to be a system of tests to prevent legionella, although the home does have a policy regarding this. The requirement regarding health and safety risk assessment is re-notified. The operations director has confirmed that any substandard glazing has been replaced. Despite assurances given by the operations director, and documented in the previous report thermostatic values have not been fitted to baths and showers. Sink and bath water temperatures were lasted tested on 11th July 2007, and testing before this date was erratic. The bath water temperature book is not being regularly completed. Restormel council has completed testing regarding the private water supply, and this was seen as satisfactory. Moving and handling equipment had not been serviced within the recommended timescale of the servicing company (i.e. by 11th August 2007). An immediate requirement was served at the end of the inspection for urgent action to be taken. The operations director has subsequently said he was aware this work was required and the work is due to take place on 20 August 2007. Significant concerns regarding various aspects of training required by health and safety legislation have been outlined elsewhere in the report. Urgent action must be taken regarding this matter. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 36 Accident reports are maintained and accidents were also recorded in the daily records. There is no evidence that a risk assessment takes place or that care plans are reviewed following accidents in the home. One resident was admitted to hospital following a fall, there was no risk assessment following this and a report has not been sent to the Commission. The registered provider must ensure, accidents and incidents (where appropriate) are reported to the Commission under Regulation 37 of the Care Homes Regulations 2001. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 37 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 Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 38 CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 1 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 1 1 1 X X X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 3 X 1 Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 39 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4, 6 Requirement The registered person shall compile in relation to the care home a written statement (in these Regulations referred to as “the statement of purpose”) which: (i) shall consist of the information as outlined in the regulation. (ii) shall be supplied to the Commission and made available on request by service users and their representatives. Timescale for action 01/10/07 Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 40 2 OP1 OP2 4, 5, 5(a)(b), 6 01/10/07 The registered person shall produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”). (i)This should include information as outlined in the regulations including the terms and conditions of accommodation, personal care and nursing care. Full information of what is required in this documentation is outlined within the regulation. (ii) The registered person shall supply a copy of the service user’s guide to the Commission and each service user. (iii)Where a local authority has made arrangements for the provision of accommodation, nursing or personal care to the service user at the care home, the registered person shall supply to the service user a copy of the agreement specifying the arrangements made. (Previous timescale of 01/08/07 not met 2nd Notification) Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 41 3 OP3 14 The registered person shall not 20/08/07 provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so— (a) needs of the service user have been assessed by a suitably qualified or suitably trained person; (b) the registered person has obtained a copy of the assessment; (c) there has been appropriate consultation regarding the assessment with the service user or a representative of the service user; (d) the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. (For example: a suitably qualified person must undertake Assessments. Assessments must also be thorough, state where the information was obtained and forms must be dated and signed) Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 42 4 OP7 15 The registered person shall: 17/12/07 After consultation with the resident, or a representative of her/ his, prepare a resident plan for each resident outlining the resident’s needs in respect of their health and welfare. Make the resident’s plan available to the resident Keep the resident’s plan under review Where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the resident or a representative of his, revise the resident’s plan; and notify the resident of any such revision. (Previous timescale of 01/08/07 not met 3rd Notification) Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 43 5 OP7 13(4)(b) (c) The registered person shall ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety, any activities in which residents participate are so far as reasonably practicable free from avoidable risks and unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. (For example, relevant risk assessments must be undertaken for each resident and there must be a specific risk assessment undertaken for the use of any form of restraint. There must be an indication as to how risk assessments are scored and the actions to be taken must be recorded in the care plans to direct staff) (Previous timescale of 01/08/07 not met 5th Notification) 01/10/07 6 OP12 16 (2) (m) The registered persons shall 17/12/07 consult with residents about their social interests and spiritual needs, and make arrangements to enable them to engage in local, social and community activities. (Previous timescale of 01/08/07 not met 3rd Notification) Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 44 7 OP14 OP10 12(2)(3)1 6(2)(i) The registered persons must, so far as practicable, enable residents to make decisions with respect to the care they are to receive and their health and welfare. They shall so far as practicable take into account their wishes and feelings. For example: (i) The registered persons need to monitor and ensure residents can get up and go to bed according to their wishes (ii)Arrangements for mealtimes, support provided to residents and food provided must be reviewed. Residents’ preferences regarding food must be considered, for example there should be a choice of meal. Suitable records to evidence this must be kept. (iii) Freedom of movement around the building must be assessed and confinement of residents kept to a minimum. Residents must be individually risk assessed regarding their ability to use bathroom / toilet facilities, and where necessary suitable support measures put in place. The registered persons should seek specialist advice from external professionals regarding alternative strategies to locking bathrooms / toilet doors to prevent access. (Previous timescale of 01/08/07 not met 3rd Notification) 01/10/07 Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 45 8 OP18 12(4)(5) 37(g) The registered person shall make 01/09/07 suitable arrangements to ensure that the care home is conducted— (a) In a manner which respects the privacy and dignity of service users; (b) Maintain good personal and professional relationships with each other and with service users and staff. (c) To ensure any allegation of misconduct by the registered person or any person who works at the care home is reported to the Commission without delay, and confirmed in writing. (For example the allegation referred to in the text must be reported to the Department of Adult Social Care to ascertain if they are happy with how the matter was investigated by the registered provider. CSCI must be informed about the outcome). 9 OP18 13(6) The registered person shall make 01/09/07 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 46 10 OP19 23(a)(e)(f) (g) 01/09/07 The registered person shall having regard to the number and needs of the service users ensure that— (a) the physical design and layout of the premises to be used as the care home meet the needs of the service users; (b) adequate private and communal accommodation is provided for service users; (c) the size and layout of rooms occupied or used by service users are suitable for their needs; (d) there is adequate sitting, recreational and dining space provided separately from the service user’s private accommodation. (For example, the registered provider must write to the Commission confirming the sizes of communal rooms and fully justifying any reduction [if any] in the previous space) (Previous timescale of 01/08/07 not met 2nd Notification) Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 47 11 OP19 OP20 OP21 OP22 16, 23 The registered provider must 01/12/07 ensure the care home is suitable for achieving the aims and objectives set out in the statement of purpose. For example; the registered person shall having regard to the number and needs of the residents ensure that— (i) Suitable adaptations are made, and such support, equipment and facilities, as may be required are provided, for residents who are old, infirm or physically disabled; (for example specialist-bathing facilities such as a ‘Parker’ type bath.) (ii) The premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; (iii)All parts of the care home are kept reasonably decorated; (iv)The physical design and layout of the premises to be used as the care home meet the needs of the residents; (Previous timescale of 01/08/07 not met 3rd Notification) Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 48 12 OP27 18 The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. (For example ensure a satisfactory number of registered mental nurses [or equivalent] are employed, and where possible ensure a registered mental nurse [or equivalent] is on duty at all times. The kitchen porter arrangements must be reviewed to ensure appropriate use of staff time, deployment of skills and reduce the risk of cross infection.) 01/12/07 13 OP29 17 (2) The registered persons shall maintain in the care home the records specified in Schedules 3 and 4. (For example: All of the recruitment records required by legislation must be obtained and maintained. there must be a photograph of each service user). (Previous timescale of 01/08/07 not met 7th Notification) 01/09/07 Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 49 14 OP29 13, 19 The registered persons must ensure all staff have a Criminal Records Bureau check / Protection of Vulnerable Adults check. (Previous timescale of 01/08/07 not met 4th Notification) Suitable supervision arrangements for staff that do not have appropriate checks returned must be in place. (Previous timescale of 01/08/07 not met 2nd Notification) 01/10/07 15 OP30 18 (1) (c) The registered persons must ensure that the persons employed to work at the care home receive, training appropriate to the work they are to perform including structured induction training. This includes training: (i) In the management of challenging behaviour and restraint techniques. (ii)Required by regulation such as fire training, first aid, food hygiene, infection control and moving and handling. (iii)Regarding medication (iv) Regarding abuse and protection (v) Regarding people with mental health needs and dementia (vi) Regarding induction to the home (Previous timescale of 01/02/07 not met 3rd Notification) 01/12/07 Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 50 16 OP31 7, 8, 9 The registered provider shall appoint an individual to manage the care home where— (a)There is no registered manager in respect of the care home; and (b)The registered provider (i) is an organisation or partnership; (ii) is not a fit person to manage a care home; or (ii) is not, or does not intend to be, in full-time day-today charge of the care home. (In the interim until a full time appropriately knowledgeable, skilled and experienced manager is employed, the designated acting manager must be in control and fully consulted about operational management decisions in the home. This person must be given ultimate responsibility for decisions regarding the health and wellbeing of residents, including all clinical decisions). The registered persons shall establish and maintain a system for evaluating the quality of the services provided at the care home. (Previous timescale of 01/08/07) not met 3rd Notification) 01/12/07 17 OP33 24 (1) 01/12/07 Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 51 18 OP38 13(4)(ac)13(5), 23(2), 23(4), (ae) The registered person shall 15/08/07 ensure that: (a) Any unnecessary risks to health and safety of service users are identified and so far as possible eliminated. (b) The registered person shall make arrangements to provide a safe system for moving and handling of service users (c) Equipment provided is maintained in good working order (d) Adequate precautions are taken against the risk of fire. For example: (1) All moving and handling equipment must be tested by an approved contractor and serviced regularly. (2) Fire Equipment must be tested at regular intervals as recommended by the fire officer. (Immediate RequirementWritten confirmation of satisfactory action must by received by CSCI no later than 1/9/07) (2nd Notification regarding emergency lighting) 19 OP38 13(4) 23(4) (5) The registered person shall ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety, any activities in DS0000009169.V348701.R01.S.doc 01/10/07 Cowbridge Nursing Home Version 5.2 Page 52 which residents participate are so far as reasonably practicable free from avoidable risks and unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. The registered persons shall take adequate precautions against the risk of fire and undertake appropriate consultation with the authority responsible for environmental health. (For example: (1) There must be a suitable system of health and safety risk assessment to prevent Legionella. (Previous timescale of 01/08/07) not met 4th Notification) (2) Any essential maintenance work on the passenger lift, which could affect the health and safety of staff, residents or visitors, must be completed. Confirmation of work completed must be sent to the Commission within the timescale. Health and safety risk assessments need to be reviewed and appropriate action taken to ensure the system is effectively managed. Hot water temperatures are tested before residents bath, and the temperature is recorded. Version 5.2 Page 53 (3) (4) Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc (4) (5) Any pipe work containing hot water and which could present a risk to residents is boxed in. Thermostatic valves are fitted to hot water outlets to prevent scalding. 20 OP38 37 The registered person shall give 01/09/07 notice to the Commission without delay of the occurrence as outlined within this regulation. (for example any serious injury to a resident, any event in the care home which adversely affects the well-being or safety of any resident, any allegation of misconduct by the registered person or any person who works at the care home). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP3 OP7 OP24 OP27 Good Practice Recommendations A specific form should be used for the initial assessment of prospective residents and be fully completed. Individual life histories should be compiled for each resident. A sluice with a washer disinfector should be provided upstairs. The registered provider should forward to the Commission a copy of the draft new rota model, for consultation, before this is implemented. DS0000009169.V348701.R01.S.doc Version 5.2 Page 54 Cowbridge Nursing Home Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Cowbridge Nursing Home DS0000009169.V348701.R01.S.doc Version 5.2 Page 55 - 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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