CARE HOMES FOR OLDER PEOPLE
Earlfield Lodge 29 Trewartha Park Weston Super Mare North Somerset BS23 2RR Lead Inspector
Catherine Hill Unannounced Inspection 9th & 10th July 2007 09:30 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 Earlfield Lodge DS0000008040.V337582.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. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Earlfield Lodge Address 29 Trewartha Park Weston Super Mare North Somerset BS23 2RR 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) 01934 417934 01934 622491 earlfieldcare@btopenworld.com Mr Gerald William Butcher Mr Gerald William Butcher Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (65) of places Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. May accommodate up to 65 persons aged 65 years and over requiring personal care only May accommodate two named `older person` aged 53 years or above. This condition is specific to the named individuals and ceases when that person leaves or reaches the age of 65. Date of last inspection Brief Description of the Service: Earlfield Lodge offers personal care to older people over the age of 65. Mr Butcher has owned the home for many years and is also the registered manager. The home is situated in a quiet residential area on the hillside of WestonSuper-Mare. Over the years the accommodation has been altered and refurbished. It now offers 57 single rooms, and 4 which may be shared. The majority of these rooms have en suite facilities. Residents have access to a number of lounges and dining rooms, as well as a small cinema and private chapel. The gardens are attractively laid out, and offer a range of quiet places to sit. Mr Butcher takes residents on regular trips out in the home’s minibus. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out over two days by three inspectors. Both visits were unannounced. The first visit focused mainly on residents experience of life at the home and on the homes medication practice. Two inspectors and the CSCI pharmacy inspector carried out this visit. One inspector visited on the second day and spent some time talking with residents and staff but concentrated on sampling written records. The pharmacy inspector’s findings are reflected in the Health and Personal Care, Standard 9 section of this report. She has also written a separate letter to the provider to explain some of the issues in more depth. CSCI will be taking further action regarding the unmet requirement regarding consent and risk assessment of bed rails, which was first made on 21/12/05. The inspector planned to send surveys out to some residents, relatives, and professionals associated with the home but did not receive information back from the home in time to do this prior to the inspection. The results to date of the home’s own recent survey of residents were seen. Inspectors spoke to twenty residents, six visitors, and four members of staff in depth. One inspector spent time observing six residents in the lounge of the ‘ extra care unit’, and staff interactions with them. Inspectors case-tracked seven residents, which involved talking with or observing the person themselves and looking in depth at all the records associated with them. Inspectors also did a tour of the premises and sampled a number of records, including: • Statement of Purpose and Service User Guide • pre-admission assessments • care plans • residents risk assessments • medications • complaints • the staff rota • staff recruitment files • staff training • staff supervision • accounts of residents cash held for safekeeping • health and safety assessments and checks. What the service does well:
Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 6 Residents felt that the range and level of activities meets their needs well. Some interesting and unusual activities are laid on, including a weekly Tai Chi session, and there are lots of outings. There is no charge for the chiropody service, for the service provided by the visiting hairdressers, dry-cleaning, basic toiletries, activities and outings - these are all included in the basic fee. Each resident is also offered a free daily newspaper of their choice. One person told the inspector that she had wanted some tissues recently and staff simply gave her a box. The home has an exceptionally tolerant and accepting culture: residents are treated very much as individuals, and evidently feel able to be themselves. People are not frightened of saying what they think, and the home is very open to constructive criticism. One person commented they never seem to get impatient with you - they treat you really well. Residents with whom the inspectors spoke were very positive about their lives at the home. People described a flexible and responsive service. One resident had had problems with her TV when she first moved in, and described how the home had renewed the cable and then the aerial in an effort to resolve the problem for her. A person who had problems using the taps in her ensuite said that different taps were fitted promptly to enable her independence. One person said, They fall over backwards to help you. Many residents said things like its a wonderful place and its a lovely home. Many people singled the staff team out for special praise, describing a warm and helpful attitude. The staff are good at giving them room to be independent but knowing when to step in and offer support. As one person said, when I really need them, theyre here. Some residents gave examples of how staff allow them to choose where they will eat their meals, whether they get dressed before breakfast or afterwards, and what time they receive routine support. The home’s routines are flexible. Residents said that it tends to be the same staff who give them help with personal care and that they do it the way residents have asked them to. Many people said that menus suit their tastes and that food is nicely cooked. The environment in the main home is very comfortable, well suited to residents needs and maintained to a good standard. Residents said that it is always kept spotlessly clean and that cleaning staff carry out their work with thoroughness. What has improved since the last inspection?
Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 7 The District Nursing team has assessed the needs of the very frail people who are receiving nursing care under their direction, and has confirmed that their needs are being satisfactorily met in this environment. A new care plan format is being brought into use and this provides more depth of information in an accessible way. Residents wishes and preferences are now being recorded more explicitly in their care plans. While routines were generally flexible, a number of people commented at the last inspection that they would have liked more than one bath a week. Residents have now been advised that they can request extra baths, and some people have been making use of this offer. Improvements have been made to medications systems and recording, as advised at the last inspection. An industrial dishwasher has been acquired, so staff no longer need to wash everything up by hand and it is less likely that infections can be passed along on cutlery and crockery. Infection-control practice has greatly improved but there were still some communal toiletries and creams in use. Staffing levels are now sufficient to ensure residents’ needs can be met. Staff morale is higher and staff have a much clearer idea of what is expected of them. Several of the residents’ comments indicated that the team’s attitude and approach is now more uniformly caring and professional. Residents also felt that communication between team members has improved in many areas. A formal system of staff supervision has been set up, and written records are being kept of each one-to-one supervision session. A programme of staff training needs has been drawn up, and training is being arranged to meet these. Staff now have access to a lot more relevant training than before. Some staff have had abuse awareness training. None of the fire doors seen during this inspection were wedged or propped open, and all were able to close freely in the event of the fire alarm sounding. Residents anecdotes and inspectors observations during these visits showed that the staff team is more aware of the need to place call bell cords within more able residents reach if people are ill or immobile. Staff are also taking much better care to store hazardous chemicals safely. With the exception of a spray-bottle of what smelt like Dettol but was marked
Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 8 air freshener left in the hallway, cleaning chemicals were in properly marked containers and safely stored. Moving and handling practices had improved. Staff have had further training, and the practice seen during these visits complied with current guidelines. Hoists and lifting equipment are now being serviced every six months as a minimum. What they could do better:
There is a two-tier service regarding quality of life and care for residents. Those in the main home live in a very pleasant environment, are generally well cared for and well treated. But those in the extra care wing live in a much less homely environment and receive a poorer quality service. While more able residents described a flexible and responsive service, the quality of life and of the environment in the extra care wing are significantly lower than in the rest of the home. The Statement of Purpose and Service User Guide need to be updated so that prospective residents and their representatives have accurate information before deciding to move in. A pre-admission assessment must always be carried out on prospective residents, and the home must confirm to the person in writing that they are able to offer a suitable service. Care plans must be kept under review and updated on any significant change. Comments about staff were generally very positive, but a few people said that some staff dont want to know or are grumpy and sarcastic. Some practices - which were the subject of requirements at the last inspection - do not promote residents dignity. Inspectors again advised that information on publicly displayed notices must not be of a confidential nature or detract from the persons dignity, and that communal toiletries must not be used. The home has acted on the advice given at previous inspections regarding medications practice and recording but there are some elements of the system in current use which are unsafe and need to be changed. Although most people felt that the quality of food is good, many people commented that it is often not hot enough. One person said, Sometimes its quite cold. Another said, Theyll warm it up for you if you say…but I try not to give them work. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 9 Several residents gave examples of poor communication between staff regarding meals, which had led to them missing meals or being served dishes they dislike. As advised at previous inspections, areas of specific risk must be assessed. The use of bed rails must be subject to consent, where possible, and must be risk assessed. This requirement was first made on 21/12/05 and at subsequent inspections. This matter is the subject of further action by CSCI. Trip hazards, such as unsecured rugs and curling vinyl flooring, need to be removed. Staff must have a satisfactory PoVA First check before starting work in the home. This will help to ensure that the employer is aware of any criminal record before the person starts work. It was a requirement of the last inspection that staff have abuse awareness training, but not all staff have had this yet. Some people have had abuse awareness training as part of their NVQ 2 and some others are doing a distance learning course. However, many staff have not yet had any formal abuse awareness training. All staff must have basic training to raise awareness of how abuse can happen and what needs to be done if it is suspected. 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. Earlfield Lodge DS0000008040.V337582.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 Earlfield Lodge DS0000008040.V337582.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): Of 1, 2, 3, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information given to prospective residents is out of date in some regards, so people are not able to make a properly informed choice about moving in. The home is not consistently assessing prospective residents needs and does not confirm to the person that it is able to offer a service. This means that neither the home nor the prospective resident can be reasonably sure residents’ needs can be met. Residents interests are well protected by the home’s contract. EVIDENCE: The Statement of Purpose was drawn up in May 2003 and contains all the essential information but needs some minor updating.
Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 12 The Service User Guide is presented in a smart folder but the information inside would benefit from tidier presentation in larger print. This document needs updating to provide accurate information about the current service provision and organizational structure, and more information needs to be included about staffing levels so that people reading it have a clear idea of what levels they can expect to see at various times of day. The Service User Guide seen at the time of the last inspection had been updated in August 2005. It may be that more than one version is in circulation, and that the home needs to check it is making available only the most recent version. A copy of the standard contract is in the homes Service User Guide. This contract is very clear about what residents can expect from the home, but there is not much about what the home expects from its residents. The manager said that each resident receives their own copy of the contract but that he does not keep a copy himself. The inspector recommended at the last inspection that the residents contract should be reviewed because it only asks for one weeks notice. The manager has decided to keep this short notice period in the contract. Some prospective residents had a thorough pre-admission assessment which was recorded and used as the basis for their initial care plan. However, there was no available evidence that some other residents needs were assessed prior to admission. The manager confirmed that he had visited these people to assess their needs but had not written down the results. The home needs to be able to demonstrate that it can be reasonably sure of offering the person a suitable service. The home also needs to confirm this in writing to the resident. There was no evidence that the home admits people with nursing needs but the home is not proactive about asking for reassessments when needs change. As a result, a significant number of people with nursing needs are being cared for, with input from the district nursing team. This situation needs to be carefully monitored to ensure that peoples needs are still being properly met. The home does not provide intermediate care. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 13 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new care plans document residents’ needs more clearly but these are not always being met in practice. In general, people living in the main home received a flexible service of good quality and are treated with respect. The experience of people in the extra care wing is rather different, though. Some aspects of the medication systems in place could put residents’ health at risk. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 14 EVIDENCE: A new care plan format is gradually being introduced. Those care plans that have been transferred to this new format were much clearer and more informative than the others. This format gives staff better guidance about what exactly needs to be done, when, and by whom in order to meet the individuals needs. Some care plans included a life history, which gave a useful picture of the whole person. One of the care plans seen contained no evidence that it had been reviewed over the past four months but other care plans had been promptly updated on any changes and gave very clear guidance to help ensure staff understand the persons needs properly. Information about the sort of help that is needed was also very clear. However, inspectors noted that some of the routine needs identified in care plans were not actually being addressed by staff during this visit. As examples: • One persons care plans said that he needs a regular drink, but the inspector only saw staff give him a drink at the same time as everyone else had one, and his daily records contained no evidence of additional fluids being offered. • Another persons care plans said that she needs regular assurance and interaction with staff. This persons behaviour during the inspection indicated that she would really have welcomed this sort of input. However, the inspector saw very little interaction from staff, and what there was appeared rather stilted as if staff were not accustomed to and confident with this. • One person with a pressure ulcer was being visited regularly by the district nurse. There was an air mattress on this resident’s bed. Both the district nurses notes, and the homes own care records indicated that she needed a pressure relief cushion on her chair. However, apart from a brief transfer to a wheelchair, this person was sitting in an armchair throughout the inspection, with no pressure relief cushion in place. Care records demonstrated some high dependency levels: some residents had urinary catheters, mental health needs, and two people have pressure ulcers. Care plans did not all contain clear guidance on how staff were to meet these needs. As examples: • Some people are non-insulin dependent diabetics. This was recorded in their care records, with instructions to staff to check blood sugar regularly. However, there was no guidance about what recordings would be normal for that person, and what staff should do if readings fell outside this range. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 15 • • Care plans of people with pressure areas did not include the exact strategies for pressure area care or how often and to what pattern the necessary regular turns should be done. There was no information on individual dietary needs to help improve skin condition. Two people were being nursed in bed with the aid of pressure relief mattresses, supplied by district nurses. These people looked comfortable, but turn- and fluid- charts were not fully completed, so it was not possible to tell what care had actually been delivered. The level of satisfaction with care and support among the more able residents was good. People described a flexible and responsive service, with good support to maintain their former social contacts or attend health-care appointments. They also described good relationships with staff, and particularly appreciated that it is usually the same few staff who give them support with intimate personal care. District nurses have reassessed the needs of some residents but there are a significant number of residents – particularly on the extra care unit - whose needs now require significant district nursing input. District nurses visit every weekday but not at weekends. This means that the onus for monitoring residents nursing needs falls upon care staff on the unit at weekends. The extremely high level of needs means that staff have to be especially vigilant about ensuring district nurses guidelines are thoroughly implemented at all times, and there is evidence that this is not happening consistently. However, care needs appear to be being better met than at the time of the last inspection. This needs to be very closely monitored by the manager. Care practice and staff approach differed quite markedly between the extra care wing and the rest of the home. The quality of the environments was significantly different, too. A visitor told the inspector that her relative used to be able to sit in the nice lounge but since her needs changed she now has to sit on the extra care wing lounge. The home may be inadvertently giving people the message that those who need extra care are less valued than the more able residents. The inspector first advised the home in December 2005 that consent must be sought where possible for the use of bed rails, and that a risk assessment must be drawn up in respect of each situation where bed rails are used. By the time of the last inspection, a policy had been drawn up and a copy placed on individual residents files. This policy refers to the need for a risk assessment and for consent to be obtained, and has been signed by next of kin, but there is still no record that consent has in fact been given and the use of bed rails has still not actually been risk assessed. Mr Butcher explained that staff had not understood the requirement made at the previous inspection. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 16 The inspectors advised that the manager needs to contact them promptly if they are in any doubt about the action they need to take to meet a legal requirement. The inspector also advised that where a person is unable to give consent, relevant parties need to discuss and agree a course of action in that persons best interest. These decisions, who participated in them, and the reasons for reaching them need to be recorded. Medicines are supplied by a local pharmacy using a weekly dosage system. The pharmacist inspector had concerns about some aspects of this system. In some cases staff have made changes to the contents of the boxes. To reduce the risk of medication errors, any changes must be made by the supplying pharmacist, and the label changed accordingly. A more detailed letter concerning the medication system has been sent by the pharmacist inspector to Mr Butcher. Some residents look after their own medication. One person orders their own medicines and has them delivered to the home. Staff order the medicines for other people and pass them on to the residents when they are delivered to the home, either in the weekly boxes or as a monthly supply. This helps people to remain independent. Staff record when they give the medicines to the resident to look after, which allows the stock to be audited. Each of the people looking after their own medicines has signed a document taking responsibility for this. Ample locked storage is available for keeping medicines safely. A large medicine fridge is available and temperatures are checked daily. It is recommended that these be recorded in degrees Centigrade, so that staff can easily see that they are in the safe range of 2 to 8 degrees C. A medicine procedure is available to help staff give medication safely. The pharmacy inspector watched some lunchtime medicines being given. The process involved two members of staff, one signing the record and one giving medicines to the residents. The person signing the record could not always see that the medicines had been given to the correct resident. This could increase the risk of medicines being given to the wrong person without staff becoming promptly aware of the error. Inspectors suggested that a proper medications trolley might be useful because this would enable one staff member to dispense and administer medication, locking the trolley between times. The Pharmacy provides printed medicines administration record sheets each month. The system used in the home to record administration of medicines means that staff do not sign for each individual tablet given from the weekly boxes. In some cases it was not clear from the records that medicines supplied in standard packs, such as antibiotics, had been given as prescribed by the doctor. For example one medicine prescribed four times a day had 10 gaps in the signatures over 7 days.
Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 17 A member of staff checks the medicines when they are received each week. The quantity of each medicine received is not always recorded. It is important that this is done to allow staff to audit the stock. Clear records are kept of the disposal of medication. Records made in care plans concerning medication were variable. Clear information was not always available on the use of medicine prescribed, When required. To protect residents’ health it is important that clear information about the reason for administration and maximum daily dose for these medicines is available for staff, so that they are given appropriately. A new distance learning package is being introduced, which includes modules about safe medicines administration. This should help staff to make sure that medicines are given safely, and it needs to be backed up by in-house assessment. During the inspection and outside assessor observed one member of staff giving medication, as part of their course. More independent residents, who were able to discuss their lives at the home with inspectors, felt that they are treated with respect by the staff. Many comments indicated that the staff team is adopting a more consistently caring and professional approach to residents. Observed practice in the extra care unit indicated that this standard is not uniform throughout the home. A notice above the bed of one very frail resident contained information that the person themselves might well not wish to be so publicly displayed. The first part of this notice was telling the staff team how pleased the district nurses were with the care they were giving this person, and a senior member of staff said that she had displayed the notice primarily to let staff know they were getting it right. As soon as it was pointed out that some of the later information was highly confidential, she took steps to remedy the situation. While it is accepted that this was a genuine oversight, staff need to be very careful about how they display information because it is so easy to subtly create an impression that the task is more important than the persons dignity. Earlfield Lodge DS0000008040.V337582.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, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Outcomes for service users in the main home are good but for people living in the extra care wing they are only adequate. People in the main home generally experience a flexible service with good support for leisure pursuits, and are treated with respect by staff. Routines in the extra care wing are not designed around individual needs and people get very little stimulation. EVIDENCE: The home has recently sent out its own questionnaires to 44 residents and has so far received 23 responses. The questionnaire covered food, the environment and cleaning, laundry, hairdressing and chiropody services, entertainments, the attitude of care staff, and what sort of information residents would like to see included in a possible monthly newsletter. The responses were largely very positive and indicated a significant improvement in residents overall satisfaction. Three responses echoed comments made by other residents about staff not always communicating very well regarding meal issues, and three echoed residents comments about meals quite often not being hot enough.
Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 19 Three responses said that some staff dont want to know or are grumpy and sarcastic. It was evident from these responses that residents feel very comfortable airing their criticisms of the home. More able residents described a full and interesting schedule of activities, including regular trips out and lifts to and from the town. Mr Butcher regularly takes a group out once a week and buys them tea. Several people said how much they enjoy these trips out in the minibus. The television was on in the extra care wing, but no other activities were laid on for residents over the course of the day, other than staff assistance with drinks and at meal times. One person had a cuddly toy, which she was nursing. This person obviously had a need to engage with another being, but was not offered opportunities to do so. Another resident was calling out whenever staff were not present, and many others looked withdrawn or were asleep for long periods. Several people commented that the laundry service is very good: clothes are returned promptly, beautifully ironed, and in good condition. Many residents commented that menus suit their tastes and the meals are nicely cooked but often not served hot enough. There is a hot plate for meals served to the dining rooms on the upper level but not for those served on the lower level. Proper facilities should be provided for keeping meals at the right temperature. Staff take the tea menu round every day to ask about each persons preferences. There is a choice of menu at teatime but not at lunchtime. Residents said that the cooks are really helpful about offering alternatives if they do not like whats on the menu. Several people commented on how much they enjoy the buffet tea on Sundays and said there is a good choice of breakfast items. Residents like the fact that they are regularly given homemade cakes and plentiful portions of other dishes. Residents and kitchen staff meet periodically to discuss any issues about food. Residents said they are offered lots of extras, such as drinks and ice creams. Fruit is placed in bowls around the home in communal areas, and they can help themselves to this and keep a supply in their own rooms. Fresh fruit juice was served with lunch in the main wing but squash was served in the extra care wing. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 20 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents concerns are listened to and promptly addressed. Residents wellbeing is better protected now that some senior staff have had abuse awareness training, but this is not yet sufficient. EVIDENCE: The home has recorded two complaints since the last inspection. One of these concerned medications administration and the other concerned staff attitude. The very informative record shows that each was dealt with promptly, thoroughly and positively. Many relatives have taken the trouble to write to the home thanking them for making a residents stay at the home such a positive experience. The comments on the home’s questionnaires to residents showed that people feel comfortable airing their views. This was borne out by residents comments to the inspectors. Several people gave examples of the prompt and positive way in which grumbles have been dealt with. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 21 There are clear and straightforward abuse and whistle-blowing procedures. However, as at the last inspection, most of the staff have not had abuse awareness training. Some of the seniors have completed a length the distance training course but all staff need to have basic training as soon as possible to ensure that general awareness is raised. Given the size of this service and the fact that practice can still tend to centre on routines and tasks, rather than around the residents as individuals, it is particularly important that all staff are aware of the small ways in which abusive practices can creep in. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 22 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, 22, 24, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most aspects of the environment are very pleasant, well maintained, and wellsuited to residents needs. However, some aspects of the environment in the extra care wing are shabby or clinical, creating a far less homely ambience. EVIDENCE: The regular schedule of redecoration and maintenance helps to ensure that the environment is comfortable and attractive. Passenger lifts allow easy access to all areas of the home. There are attractive gardens at the front and to the rear of the home. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 23 Residents bedrooms are grouped in wings of up to half a dozen rooms. There are toilets, bathrooms, and lounges within easy reach of each group of bedrooms. This arrangement helps to create a sense of living in a smaller community within this very large home. The home is considering creating an extra dining room upstairs so that residents can eat together in smaller groups closer to their own rooms. The extra care wing was generally clean and tidy, apart from one or two areas in the bathrooms, but very clinical. This impression was created by lino on many floors, hospital beds, and shabby and chipped furniture. Mr Butcher said that he plans to upgrade this unit in the near future. The home’s policy is to give couples two bedrooms: even if the couple elects to share a bedroom, this gives them a second room to use as a private lounge. Although none of the bedrooms in the care wing have ensuite facilities, most other bedrooms do. Since the last inspection, former staff accommodation has been converted into four new rooms for residents: these are attractive, sizeable bedrooms with ensuite bathrooms. The home has sufficient toilet, washing and bathing facilities, although several of the toilets on the ground floor do not have a wash hand basin. These facilities are all in reasonable condition and are fitted with suitable patient hoists. Hot water temperature regulators have been fitted to all hot water outlets to which residents have access, and these are routinely tested. Radiators are fitted with low surface temperature covers. Windows are restricted. Some residents were having their hair done in the lounge where activities were taking place. Some people may feel uncomfortable about this, and one activity may detract from the other going on in the same room. There are a large number of residents at this home and two visiting hairdressers, so it would be worth considering providing proper hairdressing facilities. Residents in the main home said that the cleaning staff are very good and keep it spotless. Hazardous cleaning chemicals were generally safely stored, with the exception of a hand-marked bottle of air freshener in the hallway, which smelled and looked like Dettol. Staff removed this as soon as inspectors drew to their attention. Since the last inspection, the home has acquired an industrial dishwasher, so staff no longer need to wash up by hand and the risk of cross-infection is reduced. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 24 It was a requirement at the last inspection that communal toiletries are not used. Some toiletries may increase the risk of cross-infection but even if this is not a risk, communal toiletries are not consistent with the homes aim to promote residents dignity and individuality. Steps were taken at the last inspection to stop this practice and introduce a better system, but the presence of a number of communal toiletries around the home at this visit showed that practice has slipped again. Several bathrooms contained communal tubs of barrier creams, some of which were past their expiry date. A senior member of staff removed the communal toiletries on the first day of this inspection and had begun setting up individual baskets of toiletries in each residents room by the second day of the inspection. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 25 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents are well protected by good staffing levels and a much improved programme of staff training. However, not all police checks are being carried out in good time, and this leaves a significant gap in residents protection. EVIDENCE: Staff rotas show that eight care staff are now on duty in the mornings, five in the afternoons, and three waking staff are on duty each night. Night staff take it in turns to have a two-hour break during their shift but are still on call in case there is an emergency. There are one or two senior staff on each shift. An early evening shift has been introduced to provide extra support at teatime. A cook and kitchen assistant are on duty each day, supported by two people doing the washing-up. Between two and three dining assistants are on duty each day, and a kitchen assistant is available for support at teatime. No cleaners are on duty on Saturdays and one person comes in on Sundays but between four and six cleaners are on duty the other days of the week. A member of staff covers laundry duties five days each week. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 26 The home has a standard information pack covering staff recruitment. This includes a recruitment checklist, an interview form, a Criminal Records Bureau form, reference requests, terms and conditions of employment, and a standard letter confirming appointment. The inspector checked three staff files. These included application forms, contracts, confirmations of satisfactory PoVA Firstand Criminal Records Bureau- checks, and copies of qualification certificates. All three staff had started work prior to a satisfactory PoVA First check being received by the home. In one persons case, they had started work over two months before this check was received. While the homes staff said that new staff work alongside a mentor at all times this does not necessarily ensure residents are protected. And it is unlikely that the person who started work two months before their PoVA First check was accompanied by a mentor for this whole period. Staff must not work in the home until a satisfactory criminal record check has been received. Each new staff member goes through a basic induction with the homes staff, then does a more in-depth induction training with an external agency. Handovers are used to allocate tasks, and staff in the main home are much clearer about what each tasks each person should be covering on their shift. Few staff were visible on the extra care unit. Although more came over to help with tasks such as toileting, there was minimal supervision of residents in the lounge and ground floor bedrooms. The person in the lounge who was calling out and distressed became settled as soon as someone started to talk to her. These interactions were very short lived, and she reverted to being unsettled as soon as staff left. Observations and residents comments indicated that staff are very good at dealing with more able residents. However, observation indicated that staff do not have specialist skills to care for people with dementia or mental health needs. Communication was poor, outpacing, ignoring or infantilizing residents. Each staff member is having an initial one-to-one appraisal with the deputy manager and then it is planned to start a regular schedule of supervision sessions. Each person is going to have a list of personal objectives following their appraisal, which will then be reviewed at supervision. Three of the senior staff have done supervision training and will be doing a presentation to the rest of the team on supervision in September. The deputy manager will be supervising senior staff, who in turn will supervise care staff. Staff who had already had their appraisal felt really positive about this: one person commented that supervision in the past has been about the job but that this session was about her, how well she is doing, and what she needs to develop her skills more fully. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 27 A good schedule of in-house training has been set up, and other relevant subjects. Some of the seniors have already completed several distance learning courses, and staff comments indicated that they had found these interesting and useful. Most staff had very detailed manual handling training in February this year by the deputy manager, who is qualified to give this training. More manual handling training has been booked for July. The deputy manager is also doing a lot of informal training and discussions at staff meetings, and staff felt this really helps develop their understanding. However, the training records do not actually show at present that each staff member is getting the minimum three days training per year. The inspectors suggested that attendance lists for team discussions and training sessions are kept for transfer to individual training records. The deputy manager plans to get all staff to do a distance learning course on abuse awareness. The inspector advised that all staff need more immediate training on safeguarding adults in the interim. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 28 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, 32, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and has a friendly atmosphere, benefiting all those associated with it. Staff are well supported. Recording systems are well used and effective. Health and safety is generally promoted at a few issues need to be addressed. EVIDENCE: The registered manager has owned and run the home for many years. A consultant has been employed for approximately a year, who works in the home as his deputy. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 29 In previous years, many people have been highly satisfied with the service and ethos at Earlfield Lodge, but there have been failings in this area for other people. Several comments were made to inspectors during the recent visits, which indicated that the home’s atmosphere and standards have further improved in the last year. Staff felt that their ideas are welcome and that the deputy manager has done a lot to make people feel part of a real team. Staff are even happier, and work is allocated better. More training is also being made regularly available to staff. Overall, communication has improved. However, several residents gave examples of poor communication between staff regarding meals, which had led to them missing meals or being served dishes they dislike. As examples, one person said that one of the cooks cuts the meat up before her plate is put in front of her but that other cooks do not. A person with sight problems said that some but not all staff think to tell her what is on her plate. Two other people had missed a meal or been served a meal very late after they had reminded staff. It may help resolve this problem if dining room and catering staff also have access to the homes communications book. The home only holds residents money for safekeeping if there is no one else able to do this. Cash and record totals are kept separately. Records are very basic but clear. Both cash amounts exceeded the amounts shown in the records: Mr Butcher explained that he always rounds these sums up, as he dislikes coppers. The records checked in depth confirmed other evidence that the home tends to pay for many of the extras on residents behalf. All staff have now had an appraisal and the regular round of two-monthly supervision sessions is beginning. All health and safety contractor information is now being kept on one file for ease of auditing. This is a great improvement on the system seen at the last inspection, when it was difficult to track down all relevant documents. The information seen at todays inspection showed that the fire system, call bells, passenger lifts, wheelchairs and hoists are all been checked with the required frequency. Inspectors noted a number of minor but potentially significant health and safety issues: • The placing of call bell cables may pose a trip hazard. • Although extension leads had been placed within residents reach in many of the rooms in the main home, none of the call bell panels in the extra care wing bedrooms were fitted with extension cords. It was not clear how these residents would summon help if required. • Mats on lino floors in the extra care wing - particularly the one with a torn edge - present a trip hazard. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 30 • • • Some of the liquid soap dispensers in the extra care wing were grubby, communal toiletries were in bathrooms, as were bars of soap rather than liquid soap in dispensers. Open bins, rather than foot-operated bins were in use in toilets. The shower head in the Parker bathroom was dirty, as was the bath rack and soap dish. The inspector reminded the deputy manager to ensure that all staff covering daytime duties have fire refresher training at least every six months, and staff covering nights time duties have fire training at least three monthly. Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X 3 X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? 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.(1) & 5.(1) Requirement Timescale for action 09/09/07 2. OP3 14.(1) (a), (b) & (d) 3. OP7 15.(1) & (2) 4. OP7 13.(4) & (7) The Statement of Purpose and Service Users Guide need to be kept up-to-date so that prospective residents have the information they need to make an informed choice about where to live. An assessment must be carried 09/07/07 out on prospective residents so that the home is reasonably sure it will be able to meet their needs. This needs to be confirmed to the prospective resident in writing. Care plans must show what 09/08/07 needs to be done, when, and by whom to meet residents needs. This guidance need to be put into practice and a record kept of its implementation. This will help to ensure that residents needs are properly documented and met. Areas of specific risk must be 16/07/07 assessed. Consent must be obtained for the use of bedrails. This requirement was first made on 21/12/05.
DS0000008040.V337582.R01.S.doc Version 5.2 Earlfield Lodge Page 33 5. OP9 13.(2) To protect residents health, the home must ensure that: • All medicines are administered as prescribed by the doctor. • Care staff do not make changes to the contents of the labelled medication boxes provided by the pharmacy. • Staff administering medicines are able to confirm the dose with the medicine label. • Clear information is available for the use of medicines prescribed, When required, so that they are given appropriately. 09/07/07 6. OP9 13.(2) 7. OP26 13.(3) To improve the recording of how 09/07/07 medications have been handled, the home must ensure that: • Records clearly show which medicines have been administered at any time. • The amount of medication received into the home is recorded, with the date of receipt. Suitable arrangements must be 16/07/07 made to prevent infection, toxic conditions and the spread of infection at the care home. This is with regard to the use of communal creams and toiletries. This requirement was first made at the inspection of 29/08/06. The registered person must ensure that the home is conducted in a way which respects the privacy and dignity of service users. This refers to the practice of displaying confidential
DS0000008040.V337582.R01.S.doc 8. OP10 12 09/07/07 Earlfield Lodge Version 5.2 Page 34 information about a resident’s continence on a notice in one of the bedrooms. This requirement was first made at the inspection of 29/08/06. Staff must have abuse awareness training. This requirement was first made at the inspection of 29/08/06. Staff must not work in the home until a satisfactory criminal record check has been received. All parts of the home to which service users have access must be kept free from hazards as far as reasonably practicable. This is with reference to the placing of- and access to- call bell extension cords, mats on lino floors in the extra care wing, grubby bathroom accessories, communal toiletries and open bins in toilets. 9. OP18 13 09/09/07 10. 11. OP29 OP38 19.(1) 13.(4)(a) 09/07/07 09/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Fridge temperatures should be recorded in degrees Centigrade, so that staff can easily see that they are in the safe range of 2 to 8. Proper facilities should be provided for keeping meals at the right temperature. The home should consider providing proper hairdressing facilities so that residents are able to have their hair done in more suitable surroundings. 2. 3. OP15 OP21 Earlfield Lodge DS0000008040.V337582.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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
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