CARE HOMES FOR OLDER PEOPLE
Elstree Lawns Nursing Home Barnet Lane Elstree Hertfordshire WD6 3RD Lead Inspector
Alison Jessop Key Unannounced Inspection 30th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elstree Lawns Nursing Home DS0000019344.V330597.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. Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Elstree Lawns Nursing Home Address Barnet Lane Elstree Hertfordshire WD6 3RD 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) 0208 207 3255/3271 0208 207 1149 www.bupa.co.uk BUPA Care Homes (CFC Homes) Limited Manager post vacant Care Home 54 Category(ies) of Dementia - over 65 years of age (54), Mental registration, with number disorder, excluding learning disability or of places dementia (1) Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. This home may accommodate people (aged 50 or over) with a diagnosis of pre-senile dementia who require nursing care. This home may accommodate one (named) service user under the Mental Disorder category. The home manager must inform the CSCI when the (named) service user admitted under the Mental Disorder category is discharged. 19th September 2006 Date of last inspection Brief Description of the Service: Elstree Lawns Care Home is sited in a large, three-storey building, which has been converted and extended to provide nursing care for those over 50 who have a diagnosis of dementia. The top floor of the building is no longer used for accommodation. All bedrooms are for single occupancy and 29 have en-suite facilities. Each floor has its own lounge and dining area and there is a hairdressing room for the residents’ use. The home is reached at the end of a long, secluded driveway and there is ample parking available in front of the building. There are gardens and patio areas to the rear of the home and these have been modified for the safe use of the residents. The home is set back from a busy road and is near to the village of Elstree and the town of Borehamwood. Facilities for shopping and leisure are within a short drive and there is a nearby bus service. The current accommodation charges range from £550 to £900 (£1000 for respite) per week. A copy of the homes most recent inspection report, Service user Guide and Statement of purpose is displayed in the foyer of the home. Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced Key inspection was carried out over one day by two Regulatory Inspectors. The majority of time was spent with service users gaining feedback and observing care practice. Feedback was also gained from staff and the manager. Time was later spent in the office scrutinising records. A second inspector spent from 11 am until 13.00 in the sitting/dining room with very vulnerable service users to get an impression of what life was like in the home. This inspector made notes every five minutes on the state of being (mood) of the service users, their interaction with their surroundings and other people including staff and interaction with service users. The inspector noted the best interaction observed. Details of this observation are incorporated in the report. This was the third inspection of the year and the outcome of the inspection was poor. The Commission for Social Care Inspection are now considering enforcement action. What the service does well: What has improved since the last inspection?
Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 6 The home is currently undertaking a review of the care planning process. BUPA has commissioned a nurse from another home to review the care planning format and provide training to staff on how to record, maintain and utilise the information. Dr Graham Stokes the Head of Mental Health for BUPA visited the home and has recommended several ways in which the care of people who have dementia can be improved. More thought has been put into the activities programme, however further training on dementia care for staff would be beneficial. Finger foods have been provided however these are inaccessible to most service users. Staff were not observed encouraging service users to snack between meals. The dining room on the first floor has been redecorated and is now used solely for dining. Each service user now has the opportunity to sit at the table to eat if they wish to do so. The lounge on the first floor has also undergone refurbishment; the nurse’s station has been removed creating a more spacious homely environment. The small lounge has been transformed into a quiet area. The home looked clean and tidy throughout and no malodours were detected. What they could do better:
The service is unable to demonstrate up to date knowledge about dementia care and there is evidence that staff in the home treat residents in a way, which does not respect their privacy and dignity. The manager stated that the company may be implementing ‘safe holding techniques’ to be able to manage challenging behaviour, service users and staff may be at risk if inappropriate safe holding techniques are introduced. Routines around meal times are rigid and the emphasis on sitting for lunch is inappropriate for some service users. Service users on the first floor do not have free access to the open air, this may contribute to challenging behaviour. The outcomes from complaints and adult protection issues are poorly managed with issues not always satisfactorily resolved. The environment does not always meet the residents’ needs and does not have an on-going maintenance programme in place. The environment on the first floor is unsuitable for people who have dementia. Several of the bedrooms had no hot water.
Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 7 Although staff have attended mandatory training, very little evidence was observed that this has been put into practice, particularly dementia care and moving and handling. Quality audits carried out in the home are ineffective. Spot checks and quality monitoring systems do not provide evidence that practice reflects the homes policies and procedures. 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. Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. The home are then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. The home does not provide intermediate care. EVIDENCE: Each resident is provided with a statement of terms and conditions prior to moving to the home. Prospective residents are given the opportunity to spend time in the home. Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 10 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 poor. This judgement has been made using available evidence including a visit to this service. Evidence of updating information and changing actions appears on care plans. The service is unable to demonstrate any up to date knowledge about dementia care. There is evidence that staff in the home treat residents in a way, which does not respect their privacy and dignity. For example, resident’ personal appearance is unclean and some are left sitting in wheelchairs. Procedures relating to medication were satisfactory. EVIDENCE: Care plans were not fully inspected on this occasion as the home is currently undertaking a review of the care planning process. BUPA has commissioned a nurse from another home to review the care planning format and provide training to staff on how to record, maintain and utilise the information.
Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 11 Generally a lot of information in care plans was out of date or irrelevant to service users current needs. This is being replaced with easily accessible, current information. This standard will be fully assessed during the next inspection. Food intake was not recorded immediately following meals or snacks; therefore the accuracy of records must be questioned. Although good interaction from some staff, which was kind and caring was observed, some undignified and poor interaction was also observed. One member of staff was trying to force a service user to eat her lunch. The service user was clearly distressed however the member of staff continued to persist. Generally those being assisted to eat were being outpaced and one member of staff did not engage in conversation. The appearance of many of the residents was poor. Service users hair looked untidy and clothing looked creased and stained. One service user looked unshaven, his shirt was heavily stained, his hair and teeth un-brushed. The manager stated during feedback that they are introducing a key worker system, which should help to encourage staff to ensure that they assist service users to take pride in their appearance. Wardrobes were also untidy, with clothes being left on the wardrobe floor. Although moving and handling techniques observed were adequate, some poor moving and handling techniques were observed. For example service users were observed being led by staff who were walking backwards, also underarm lifts were observed. Hoisting techniques were carried out safely however a more dignified approach must be adopted by staff. Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 12 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. A programme of activities is available to service users, however this could be tailored more towards individual preferences. Service users are able to maintain contact with family and friends however contact with the local community is minimal. Routines around meal times are rigid and the emphasis on sitting for lunch is inappropriate for some service users. EVIDENCE: On the day of the inspection service users on the ground floor were observed listening to staff sing karaoke. The activity co-ordinator has explored new ways of involving service users in activities and has provided some stimulating items such as inflatable animals and soft toys. No evidence was seen that individual needs are met through the use of information gained from service users pen pictures. Service users living on the first floor do not have free access to the open air, this may contribute to the frustration demonstrated by some of the service users.
Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 13 Although some biscuits and fruit were seen on offered in the communal lounges, most service users were unable to access snacks and no encouragement or assistance from staff was observed making this a pointless gesture. Only service users that could ask for a biscuit or fruit were able to snack. The emphasis on getting service users who have dementia to sit and eat lunch is inappropriate for service users who cannot sit at the table throughout the lunch time period, therefore more suitable means of ensuring adequate calorific intake must be explored. Lunch served on the day was braised steak, potatoes, cauliflower cheese, cabbage, green beans and gravy. Service users said that the food was served hot. One service user said ‘it’s lovely, the meat is really tender.’ Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 14 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 poor. This judgement has been made using available evidence including a visit to this service. The outcomes from complaints and adult protection issues are poorly managed with issues not always satisfactorily resolved. Service users may be at risk if inappropriate safe holding techniques are introduced. EVIDENCE: An accident had occurred in the home where a service user had lost the end of her finger, which she had trapped in a door during the night. Adult Care Services were notified by the family of the accident and the service users family has since removed their relative from the home. Although the Commission for Social Care Inspection were notified in accordance with Regulation 37, and the accident was reported to the Health & Safety Commission, other than the door being adjusted no further investigation has been carried out by the home. Two complaints have been received since the previous inspection. One was from a relative about the lack of dental care. Although this complaint had been received poor dental care and personal hygiene was observed throughout the inspection. The second was from a relative that said that a resident was shouting for help and no one attending. The manager is currently investigating this.
Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 15 The manager stated that the company may be implementing ‘safe holding techniques’ to be able to manage challenging behaviour displayed by service users as the manager feels that de-escalation may be insufficient in certain circumstances. The risks were pointed out to the manager by the inspectors, however the manager felt that with training and policies and procedures in place this would be an appropriate practice. It is advised that the home look at ways in which to prevent challenging behaviour rather than contain it. Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 16 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 & 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment does not always meet the residents’ needs and does not have an on-going maintenance programme in place. A number of the fixtures and fittings need replacing and the décor requires upgrading. The environment on the first floor is unsuitable for people who have dementia. A lot of equipment in the home such as wheelchairs require repair or replacement as they are old and in a state of disrepair, this is a risk to the health and safety of service users and staff who operate such equipment. The home looked clean and tidy. EVIDENCE: The décor in the communal hallways is unsuitable for people who have dementia, the lighting is inadequate, and the décor on the walls and carpets
Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 17 could create confusion. The skirting boards are heavily scratched and look unsightly. There has been a leak onto the ground floor dining room wall, the wallpaper has been taken off and the area requires redecorating. The dining room on the first floor is now being used solely as a dining area. It is spacious and offers adequate seating for all service users should they require to sit at a table to eat their meal. The lounge on the first floor has undergone some refurbishment. The nurse’s station has been taken out creating a larger area for seating. The small lounge on this floor had been redecorated and was awaiting new carpet. This room will be used as a quiet lounge for service users to relax. Several of the bedrooms had no hot water, this was reported as being a regular problem to staff. Service users on the first floor do not have free access to the outdoors. Staff said that they take service users down to the garden when the weather is nice. It was questioned why service users do not go out throughout the year. This may be a major contributing factor to the frustration demonstrated by service users. Staff reported that most of the wheelchairs have flat tyres and the footplates are not working. This appears to be an on-going problem even though a regular audit of equipment was reported to be carried out. The home looked clean and tidy throughout, no malodours were detected and universal infection control procedures were observed. Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 18 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. Service users needs appear to be met by the numbers of staff. The home’s recruitment policies and practices increase service users safety. Although staff have attended mandatory training, very little evidence was observed that this has been put into practice, particularly dementia care and moving and handling. EVIDENCE: Staffing numbers appear adequate and the manager stated that the staffing skill mix at night is being reviewed which will include one extra nurse. Records pertaining to recruitment are satisfactory. A training plan has been introduced and most staff had received mandatory training. There was very little evidence that staff have attended dementia training as current practices have not been observed. Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 19 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. The manager has been in post for two years and has not registered with the Commission for Social Care Inspection. Therefore, their integrity cannot be guaranteed. Quality audits carried out in the home are ineffective. Spot checks and quality monitoring systems do not provide evidence that practice reflects the homes policies and procedures. EVIDENCE: The manager who has been in post for two years has not registered with the Commission for Social Care Inspection. An application has recently been received and an interview has been arranged. A manager has not been
Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 20 registered for this home since 2002, this raises concerns and will be investigated by the Commission for Social Care Inspection. Although quality audits are carried out these are ineffective. Monthly reports provided to the Commission for Social Care Inspection conflict with outcomes observed by inspectors. Where the home manages money on residents’ behalf a system is in place to record transactions and accounts for spending. The home has developed a health and safety policy that generally meets health and safety requirements and legislation. Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 2 X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 22 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 OP8 Regulation 12(1)(a)& 13(4)(c) Requirement Food and Fluid intake must be monitored and recorded. This requirement has been carried forward from reports dated 26/07/06 & 19/09/06. Staff must assist service users to maintain their personal and oral hygiene. Service users dignity must be respected at all times. • • • • Service users must not be outpaced. Service users must be treated with dignity whilst assisting them to eat Service users clothing must be treated with care Moving and handling techniques must be carried out in a dignified manner Timescale for action 20/03/07 2. 3. OP8 OP10 12(1)(a)& (4)(a) 12(4)(a) 20/03/07 20/03/07 4. OP12 16(2)(n) This requirement has been carried forward from inspection reports dated 26/07/06 & 19/09/06. A suitable, stimulating, recreational atmosphere must be provided to service users who
DS0000019344.V330597.R01.S.doc 20/03/07 Elstree Lawns Nursing Home Version 5.2 Page 23 5. OP15 12(1)(a) & 16(2)(i) 6. OP16 22(3) & (8) 7. OP18 13 (4)(b) &(c)&(6) 8. 9. 10. 11. 12. OP19 OP20 23(2)(j) 23(2)(o) 23(2)(c) 9(1) 24(1)(a)& (b) OP22 OP31 OP33 have dementia. Activities must be appropriate to individual needs taking current good practice in dementia care into consideration. Finger foods and fluids must be available to service users throughout the day. Foods must be accessible to service users and must be encouraged by staff. This requirement has been carried forward from inspection report 19/09/07. The registered person shall ensure that any complaint made is fully investigated. A copy of the investigation in relation to the service user whose finger was cut off in the door must be sent to CSCI. The registered person must investigate ways to prevent challenging behaviour rather than by introducing ‘safe holding’ techniques as a way to contain challenging behaviour. Hot water must be available in all bedrooms at all times. Service users must have access to safe, external grounds as and when required. All equipment used must be maintained and in good working order. The home must be managed by a person fit to do so at all times. An effective quality monitoring process must be implemented. 20/03/07 20/03/07 20/03/07 20/03/07 20/03/07 20/03/07 20/06/07 20/03/07 Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 24 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 OP19 Good Practice Recommendations It is recommended that improvements are made to the environment in order to create an appropriate environment to service users who have dementia. Elstree Lawns Nursing Home DS0000019344.V330597.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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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