Inspection on 02/10/08 for Firlawn House Nursing Home

This inspection was carried out on 2nd October 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Firlawn House Nursing Home 05/10/06

Firlawn House Nursing Home 13/12/05

Firlawn House Nursing Home 24/05/05

Firlawn House Nursing Home 12/10/04

Firlawn House Nursing Home 21/04/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Firlawn House Nursing Home The Street Holt Trowbridge Wiltshire BA14 6QH     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Susie Stratton     Date: 0 3 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 37 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Firlawn House Nursing Home The Street Holt Trowbridge Wiltshire BA14 6QH 01225783333 01225783478 enquiries@firlawn.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Firlawn Nursing Home Limited care home 38 Number of places (if applicable): Under 65 Over 65 38 0 old age, not falling within any other category physical disability Additional conditions: 0 2 No more than 2 physically disabled service users at any one time. The minimum staffing levels set out in the notice of decision dated 4th January 2005 must be met at all times. Date of last inspection Brief description of the care home Firlawn Nursing Home is registered to provide nursing care for 38 older people. The home consists of two buildings on one site with a large garden between the two homes. The older house at the front of the site provides accommodation for 14 residents and the other house, which is to the rear of the site is a purpose built home which provides accommodation for 24 residents. All rooms are single many of which have an en-suite facility. Both homes have a dining room and communal lounge. The home is located in the village of Holt, which is, a few miles north of Trowbridge and 3 miles south of Melksham in Wiltshire. Firlawn is privately owned. The Manager is Mrs Penny Jarvis, she leads a team of nursing, care and ancillary staff. The fee range is Care Homes for Older People Page 4 of 37 Brief description of the care home 775 pounds to 930 pounds per week. The service users guide is given to all people during the admission process and a copy is available in both of the entrance areas. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The judgements contained in this report have been made from evidence gathered during the inspection, which included visits to the service and takes into account the views and experiences of people using the service. As part of the inspection, 20 questionnaires were sent out and six were returned. Comments made by the people in the questionnaires and to us during the inspection process have been included when drawing up the report. As part of this inspection, the homes file was reviewed and information provided since the previous inspection considered. We also received an annual quality assurance assessment from the home. This was their own assessment of how they are performing. It also gave us information about what has happened during the last year. We looked at the quality assurance Care Homes for Older People Page 6 of 37 assessment, the survey and reviewed all the other information that we have received about the home since the last inspection. This helped us to decide what we should focus on during the visit to the home. As Firlawn is a larger registration, the site visits took place over two days. The first site visit was on Thursday 2nd October 2008, between 11:00am and 5:00pm. The second site visit took place on Friday 3rd October, 2008 between 8:45am and 2:00pm. The Manager, Penny Jarvis was on duty during the inspection. Mrs Jarvis was available for the feedback at the end of the visits. During the site visit, we met with eight residents, two visitors and observed care for five residents for whom communication was difficult. We toured all of the home and observed care provided at different times of day. We reviewed care provision and documentation in detail for six residents and reviewed certain aspects of care and documentation for a further three residents, across all parts of the home. As well as meeting with residents, we met with one of the providers, four registered nurses, four carers, the activities coordinator, the chef, the maintenance man and the laundress. We observed two lunch-time meals and an activities group. We reviewed systems for storage of medicines and observed two medicines administration rounds. A range of records were reviewed, including staff training records, staff employment records, accident records and complaints records. What the care home does well: What has improved since the last inspection? What they could do better: At this inspection, 11 requirements and 17 good practice recommendations were identified. Improvements are needed in documentation relating to nursing and care. Where the care of frail people is being monitored, these records must be accurately completed at the time care is given and be reviewed regularly. Where a resident needs an intervention relating to an acute medical condition, a record must always be made of what actions were taken by staff. As urinary catheters can be a major factor in urinary tract infections, the reasons for their use must always be documented and the residents need for the appliance be regularly monitored. When staff are drawing up care plans measurable wording should be used and generalistic words like regularly Care Homes for Older People Page 8 of 37 or fairly high be avoided. Care plans relating to prevention of pressure damage, mental health care needs and the use of medication which affects daily lives, should be further developed. Work needs to be progressed in certain areas of medicines management. Registered nurses need to complete medicines administration records when the resident has taken their drugs, to provide evidence that the resident has taken their prescribed medication. The medicines trolley must always be secured, to prevent risk to residents. Strips of tablets must not be removed from their original containers, to ensure that medicines are being correctly given to the person they are prescribed for. Where a resident wishes to partially self-medicate, a risk assessment and care plan must always be completed. Some work needs to be progressed on prevention of spread of infection and supply of equipment. The policy and procedure prevention of spread of infection needs to include a policy on the disinfecting of sanitary equipment such as commode buckets as the home only has one washer disinfector across the two buildings. The policy also needs to consider the cleaning of mop heads, as these can also be a source of cross infection. Where residents are assessed as being at high risk of pressure damage, appropriate pressure relieving equipment needs to be provided for their chairs, as risk of pressure damage does not decrease when a person is sitting out of bed. In order to reduce risks to people presented by bed safety rails, variable height beds which can go down to the floor should be provided. Information given to residents needs to include the summary of the most recent inspection report and some areas could also be expanded, to fully inform people of the services offered by the home. Quality audit could be improved by developing a record of informal complaints and concerns and regular reviews of accidents, to identify any trends. The introduction of an interview assessment tool for prospective staff would improve identification of prospective member of staffs strengths and weaknesses. Systems for management of residents moneys and valuables need to be further developed, including a full audit trail of items handed in, provision of relevant equipment and modernisation of record keeping. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 37 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective new residents will be given a range of information to inform them of how the home can meet their needs and will have a full assessment, so that they and their supporters can be fully assured that the home can meet their nursing and care needs. Evidence: All residents and their supporters are given a copy of the service users guide prior to, or at admission to the home. The guide includes a wide range of information about services offered. All of the people who responded to this section of the questionnaire reported that they had had enough information about the home to decide if it was the right place for them. Some parts of the guide could benefit from further development. It is advisable that the part of the service users guide relating to staffing is expanded, to inform people of the numbers and skill mix of different staff on duty on different shifts and in the Care Homes for Older People Page 11 of 37 Evidence: different parts of the home. It is also recommended that the homes expertise in caring for different categories of residents, for example terminally ill or very frail people, be detailed in the guide. The manager reported that they give prospective residents and their supporters full information on the registered nursing contribution and methods of payment on admission. It is advisable that this information is given with the guide, to fully inform people of systems and methods of payment. A copy of the summary of the most recent inspection report is not provided in the guide, together with information on how the full report may be obtained as is required, although a copy of the report is available in the main entrance area. This is information is needed in the guide, so that all relevant persons can be informed of the homes response to the inspection process. During the inspection, we met with some people who had been admitted recently. Many of these people were too frail to recall much about the admission process. One person said that their legal representative had helped them to chose the home, another that they had visited the home before deciding on admission and another persons relative reported that they had visited the home on their relatives behalf. One person who reported that they had been admitted to the home recently reported, Its very nice here actually and another, so far, Im very happy here. All people have a full assessment of need prior to admission. This assessment can be used as a basis for care planning. Where further information is needed, for example from a specialist nurse, this was obtained in writing. Senior staff spoken with reported that they were fully involved in the decision-making process relating to admitting a new resident. Other staff said that they were informed of a prospective residents needs, so that they could plan for their admission. For example, the activities coordinator reported that the manager always informed her of what she had been able to ascertain about a prospective residents past life and that she could then use this as a basis for planning how she could meet the persons needs in the future. Care Homes for Older People Page 12 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents nursing are care needs are met by staff, however improved emphasis on documentation and specific areas of medicines management would further improve care practice. Evidence: Firlawn cares for elderly people, many of whom have complex nursing and care needs. Of the six persons who responded to this section of the questionnaire, three stated that they always and three that they usually received the care and support that they needed. One resident reported Im looked after very well, another the girls are very good at caring and another described Firlawn as a half way house between hospital and home. Carers appeared to take pleasure in talking to and being with residents. One carer was heard to compliment a resident on their appearance. All residents have assessment of nursing and care needs, including assessments of risk. Care plans are then drawn up, to direct staff on how individual residents needs are to be met or risk reduced. Some care plans are highly detailed and include a range Care Homes for Older People Page 13 of 37 Evidence: of matters relating to the resident. For example, one resident had a very clear care plan relating to their visual disability, directing staff on how care was to be provided in the light of this. Another person had a clear care plan about their communication difficulties and how staff were to support the resident. Other care plans would benefit from further development. Many of the care plans use non-measurable terminology such as regularly, fairly high or on emergency. Where, for example a person needs their positions changing to prevent risk of pressure damage, their care plan should state in measurable terms how often they need to have their position changed. If a resident has diabetes, their care plan should state their blood sugar levels in measurable terms and clearly state what actions are to be taken should their condition fall outside these parameters. Some individual instructions about meeting certain residents needs were placed in residents rooms. Where this is necessary, all such documents should be dated and signed by the person drawing up the document, to enable evaluation. Residents at risk of pressure damage did have care plans in place to direct staff on how their risk was to be reduced. Care provision included low airloss mattresses on residents beds where indicated. However all of the residents met with who were assessed as being at high risk of pressure damage had cushions which related to a medium risk of pressure damage on their chairs. The reasons why this was indicated for the person, for example that they only spent a very short time out of bed, needs to be documented as peoples risk of pressure damage is not reduced when sitting in a chair. Some of the residents experienced difficulties in swallowing. For these residents, thickening agent was used in their drinks to support safe swallowing. Staff spoken with all agreed how thick these residents needed their fluids to be, however this was not always reflected in their care plans and generally accepted terminology to describe how their drinks needed to be syrup, custard, jelly should be used. Care plans are reviewed on a monthly basis and up-dated as indicated. For example one residents manual handling needs had changed recently and their care plan had been up-dated in full to reflect this. Some up-dates are made in the evaluation itself, not in the care plan. For example one resident had had their urinary catheter removed and their continence needs were managed by other means, however this was documented in their evaluation, not their care plan and it could be complex for a person unfamiliar with the resident to identify this. The home uses monitoring charts to document how often people who are frail have their positions changed, what fluids they are given and what meals they have eaten. These charts are kept in one central place in each building. This has the effect that Care Homes for Older People Page 14 of 37 Evidence: staff do not complete these records at the time care was given. For two people, these charts were not available at the start of the inspection and were completed later in the day. If charts are not completed at the time care is given, there is a risk that records will not be accurate. If they are not accurate, they cannot be used to inform other staff about responses to care or needs for intervention. These charts need to be regularly reviewed, to ensure care is being given as directed. For example one persons care plan stated that, due to their degree of risk, they needed to be turned every three hours, this was not evidenced to be taking place by their monitoring records. For other residents, their charts showed that they had remained in one position throughout most of the inspection, for one person this was in excess of eight hours. Whilst staff reported that they had attended to residents and relieved pressure, for example whilst changing a pad, this was not documented and the home therefore cannot provide evidence that they had regularly changed a persons position. It was noted during the inspection, that a higher than would be anticipated proportion of residents have urinary catheters. Urinary catheters need to be avoided as much as possible, as they increase the risk of urine infections. In order for registered nurses to assess if a urinary catheter is in the best interests of the resident, the clinical indicator for their use must always be documented in their records. As would be anticipated in a care home where very elderly people are cared for, some residents had additional needs relating to mental health care. Where this occurred, it was clear that the manager and staff worked on the persons behalf to seek support from external health care professionals, such as the community psychiatric nurse. Staff spoken with were very aware of how different residents presented when they had mental health care needs and this was reflected in their daily records. One person had a device which alerts staff to when a person wanders, known as a pressure pad. Staff knew why this device was provided. Care planning needs improving in these areas, as not all residents with additional mental health care needs had care plans to direct staff on how to meet their mental health needs and others who did, did not have all interventions, such as the pressure pad or details in the daily record, documented. The home were prompt to call in external support when needed. For example on the day of the inspection, they had asked the GP to visit to review a person who had a problem with weight loss. Where a resident had a wound, the support of the tissue viability nurse was sought. Records showed that one person who had been admitted with a complex wound had improved to the extent that the wound was fully healed. It was noted that one person with a known diabetic condition had had an instability recently. It was clear that staff had contacted the persons GP to ensure review. On one of the occasions where the person had shown blood sugar levels well outside Care Homes for Older People Page 15 of 37 Evidence: expected limits, whilst the actual blood sugar levels were documented, there were no records made by staff of what actions they had taken to ensure the persons safety. This must take place, so that staff can demonstrate that they have taken actions in the best interests of the resident in an emergency. During the inspection, we observed two medicines rounds. The registered nurse supported the residents in taking their medication and making sure that they did not feel rushed in taking their medication. The registered nurse spoken with showed a good level of knowledge about the medicines they were administering. The registered nurse performed the medicines administration round with care, checking the medicines administration record before administering the drug. However they signed for the medication before the resident had taken the medication. This is not regarded as good practice. The medicines administration record must not be completed until the registered nurse has observed the resident taking their medication. Additionally when we reviewed medicines administration records, we observed that there were some uncompleted records, including one for Insulin. Medicines records must always be fully completed, to provide evidence that the resident has been given their prescribed medication, or if they have not, why this is. On several occasions it was noted that the registered nurse did not lock the medicines trolley while she was with the resident. The medicines trolley must always be locked when the registered nurse is with a resident, due to the risk to other people of gaining access to a medicines trolley. One of the residents met with had chosen to administer their own medication. They had a full risk assessment and care plan about this, which was regularly reviewed. Two other residents were observed to have been left with their medication for them to take later. If a resident has chosen to do this, this is regarded as good practice, however neither of these residents had a risk assessment relating to this partial self-medication and it is indicated, to ensure that there are no risks for the resident or other residents in the home. Some of the residents were prescribed medication which will affect their daily lives, such as painkillers, aperients or mood altering drugs. Where such interventions are needed, care plans should be in place to advise on the interventions necessary and to enable evaluation of the residents response(s) to medication treatment. The home has a policy on homely medication, however it has not been reviewed recently and would benefit from further development, as it includes certain invasive treatments which are not expected to be included in homely medicines policies. The policy which is in place had not been agreed by the residents GPs and this is also Care Homes for Older People Page 16 of 37 Evidence: needed, to enable the use of homely medicines. The home has safe and secure storage systems for medication. All Controlled Drugs were stored in accordance with guidelines and full records maintained. All limited life medicines were dated on opening, so that they would not be used after their expiry date. Where a resident was prescribed Warfarin, staff were fully aware of its safe administration. One matter relating to contacting the residents GP about a prescription for Warfarin was fully dealt with on the day of the first site visit. Medicines cupboards were organised, with no over stocking. In one medicines trolley, there were two strips of different commonly prescribed tablets left in a container. This is not advisable as the home has a legal responsibility to ensure that all tablets are used only for the person for whom they are prescribed. Strips of tablets must therefore not be removed from their original containers. People reported that their privacy and dignity was respected by staff in the home. One visitor described how they appreciated the way that staff gently and tactfully changed their relatives clothes if indicated, for example after a meal, if they had inadvertently dropped food on themselves. Carers were observed to carefully explain to residents what they were doing. For example two carers carefully explained to a resident what they were going to do before lifting them using a hoist and another carer explained to a resident what they were going to do when lifting their feet of the pedals of a wheelchair. One resident reported that the carers knew what they liked to wear and that they were supported by the carers in this. Another resident reported they all help you if you need any care. Care Homes for Older People Page 17 of 37 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported in continuing to live their lives as they prefer, including an appreciation of their diverse preferences in some areas. Evidence: Firlawn employs an activities coordinator. This person is highly motivated in her role. She provides a range of activities, from large group, to small group and 1:1 activities. We observed an art group during one of the site visits. The activities person worked to encourage and support residents, who had a wide range of different skills and abilities. All of the residents were clearly enjoying participating in what they were doing, talking to each other and staff. Of the five people who responded to this section of the questionnaire, two reported that there were always, two usually and one sometimes activities arranged by the home that they could take part in. One resident reported, I go to some of the activities, the ones that I want to go to anyway. The activities coordinator reported that she tries to see all residents very soon after their admission to introduce herself and to find out what they liked to do. She would then support residents to join in, if that was what they wished to do. The activities person also reported that she was supported by staff, who informed her of any Care Homes for Older People Page 18 of 37 Evidence: changes that she needed to know about in residents conditions. She showed a detailed knowledge of different residents and what they preferred to do. This was supported by clear records. For example one residents first language was not English and the activities coordinator reported on how she had worked with the persons family and gained information from them so as to see how she could support the person. The activities person was aware of the importance to some people of the practice of their religion and was able to demonstrate effective close working relationships with the local church. She was also aware that for some people, religion is not a key factor in their life and she respected this. For example one persons documentation showed that they were from a non-Christian religion but had not practiced their faith for an extended period. The activities person reported that they had verified this with the persons family and had ensured that their choice was respected. Visitors were observed being able to come and go as they wished. One visitor whose relative had been away from the home for a period and had now returned reported that they were very pleased to be back here. Staff spoken with at all levels reported on their good working relationship with relatives and other visitors and how many relatives were central to them finding out about residents and their past lives. Reviews of records showed that staff regularly contacted residents relatives about matters of importance relating to the resident. Residents reported that they could chose how they spent their lives. One person reported the girls, oh yes theyre good, they get me up when I tell them to, another person reported I decide when I get up and another reported that they did not go to the activities because they preferred to stay in their room and that staff respected this. Residents can bring in items of their own if they wish and some of the rooms were highly personal, reflecting the persons likes and preferences. Of the six people who responded to the questionnaire, two people reported that they always and four that they usually liked the meals in the home. One person commented the last few months we have been given a choice on Mon, Wed, Sat. I would like a wider choice but recently it is better. Residents commented on the meals. One person reported the foods good, yes its very good indeed, another the foods very good, I DO enjoy it, another Its good food, edible, varied, sometimes I cant eat all that they give me but no-one seems to mind that, however another person reported the foods very nice but theres not much of it, I could do with a bit more. We met with the chef and observed a lunchtime meal in both parts of the home. The chef confirmed that the residents do not have a choice of main meal every day but that they do have a choice of evening meals every day. If a resident did not like Care Homes for Older People Page 19 of 37 Evidence: something, she was happy to prepare a different meal for them and salads and omelets are available all the time. The chef reported that she regularly reviews menus and rotates different items. She generally designs the menus around her knowledge of what residents prefer to eat. She was advised that she might like to consider if the meals offered over the 24 hour period comply with current good practice guidelines on health eating for older people. She reported that she cooks all meals up from fresh ingredients. The chef showed a knowledge of specialist diets, including gluten free and diabetic diets. She also showed a detailed knowledge of residents individual likes and dislikes. For example she was aware that one resident did not like meat and reported on how she met this persons needs. The meal times were well organised, with residents sitting at the same table being served their meals at the same time. A choice of drinks was offered, including cranberry juice and residents could have sherry and wine or beer if that was what they wanted. Carers supported residents in eating their meals. Where a resident remained in bed to eat their meal, carers adjusted their bed to make sure that they were comfortable, before starting to assist them to eat. It was noted as good practice that carers sat with residents while they assisted them to eat, engaging them in conversation and observing if they were swallowing safely. Where a resident had difficulty in swallowing, carers assisted them to eat using a teaspoon, rather than a larger spoon and did not show any signs of trying to rush the person, supporting them and encouraging them whilst they ate. Care Homes for Older People Page 20 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be protected from abuse and have their complaints and concerns responded to. Evidence: The home has a complaints procedure, which is displayed and is available in the service users guide. All of the people who responded to this section of the questionnaire reported that they knew how to make a complaint. One person reported in their questionnaire the manager is very good and comes in most days & you can talk to her. Residents spoken with also reported that they knew how to raise issues. One person said Id talk to one of the girls if I was not happy, another Id tell Penny [the manager] whatever is the matter and another Id tell the girls on duty or Penny. We have received one complaint since the last inspection. This was handed back to the owner who investigated it in accordance with their own procedures. The home does not maintain a log of informal concerns and complaints made by people. Mrs Jarvis reported that such matters are generally dealt with by the member of staff involved and resolved at the time. It was discussed that such verbal concerns should be logged so that, as part of her quality of service reviews, she can make herself aware of the issues being raised and can ensure that all staff respond in a consistent manner. Care Homes for Older People Page 21 of 37 Evidence: The home has a safeguarding adults policy and all staff spoken with showed an awareness of the importance of protecting vulnerable adults from abuse, this included non-direct care staff such as the activities coordinator. Training records showed that all staff have received training in this area. The home has made one referral under the local procedure on behalf of a vulnerable person, to ensure their safety. There have also been two other referrals made about the home under the local procedure. In both cases the home worked will with external agencies and no matters for action were identified. Care Homes for Older People Page 22 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be generally supported by an environment which is well maintained and clean. A few areas relating to prevention of spread of infection would benefit from more emphasis. Evidence: Firlawn comprises two buildings, one smaller older building at the front of the site and one larger purpose-built building to the rear. There is a pleasant garden area, which is fully wheelchair accessible, between the two houses. Both houses have their own communal rooms, including a sitting and dining room. These communal rooms have pleasant views, looking out either over the garden area or the fields behind the home. Management have worked hard to make the atmosphere of both buildings pleasant, including art work and paintings in corridor and stair wells, which greatly reduce any institutional appearance. All of the home was well maintained and there is a system for developing action plans to improve and up-grade the home environment. There is a written log of matters requiring maintenance and the maintenance man said that staff were very good at ensuring that small repairs were promptly reported to him. He reported that he was able to do nearly all small jobs himself but was also able to contract external contractors himself when necessary. During the past year, works have taken place to Care Homes for Older People Page 23 of 37 Evidence: both buildings, including overhauling of the roof and rebuilding of the gable end in the house at the front of the site. Plans for the next year include provision of wet rooms and a new kitchen in the house at the front of the site. The home has aids to support people with a disability. This includes hoists to aid manual handling and pressure relieving equipment. A few of the cushions to reduce medium risk of pressure damage were becoming old and loosing their surface. As such they could not be wiped down effectively and should be replaced. As noted in Standard 8 above, there were no low airloss chair cushions provided,and this needs to be considered for people at high risk of pressure damage. Not all people with complex manual handling needs were cared for in variable height beds. Mrs Jarvis reported that this had been identified as an issue and that the providers were progressively purchasing variable height beds, with the aim that by the end of the financial year, all people with complex manual handling needs would be cared for in a variable height bed. None of the beds purchased so far will lower to the floor, and this is recommended to reduce the needed for use of safety rails. Current good practice guidelines are that to reduce the risk to people associated with safety rails, residents who need such protection should be cared for in beds which lower to the floor, with crash mats if needed. The home was clean throughout. Of the people who responded to the questionnaire, four reported that the home was always and two usually fresh and clean. Cleaners were observed working, they took care to clean behind and under objects. The laundry was clean throughout, including the areas behind the washers and dryers. The laundress was very aware of the importance of her role in the prevention of spread of infection. She reported that staff consistently separated infected and potentially infected laundry and placed them in the correct bags. The home clearly has systems to ensure that residents own clothes are named and returned to them, as there were very few un-named clothes for a home of this size. The home does not have a policy and procedure on the cleaning of sanitary items such as urinals and commode buckets, to ensure that they are regularly disinfected, to prevent risks of cross infection. The home also needs to develop a policy and procedure for the cleaning of mop-heads for high risk areas, such as dirty utility rooms. Mop-heads can present a risk to cross infection and so need to be regularly cleaned/replaced and not left wet. Antibacterial hand sprays are available in the home for visitors to use. Staff were observed to wash their hands and use gloves and aprons when indicated. All staff spoken with showed a good knowledge of the importance of prevention of spread of infection in their roles. Registered nurses reported that they had a good supply of Care Homes for Older People Page 24 of 37 Evidence: sterile gloves for performing aseptic procedure. Care Homes for Older People Page 25 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported by numbers and skill mix of staff who have been safely recruited and are trained in their roles. Evidence: As Firlawn consists of two separate buildings, there are two teams of staff, each led by a registered nurse, for each building. However staff will also work flexibly in both houses. As well as nursing and care staff, there are catering and cleaning staff and a maintenance man and activities coordinator employed. Mrs Jarvis reported in her annual quality assessment that, following consultation with staff, they have changed shift times to enable more efficient working. Staff spoken with felt that there were enough staff in post to perform their roles. Of the four people who responded to this section of the questionnaire, two reported that there were always and two usually staff available when they needed them. One person reported sometimes not enough cover at weekends and another On the whole yes. Residents also commented to us on staffing. One person reported Oh yes, they always answer the bell, another I press a button and I get a response from one of them to get what I need being done another staff are not always prompt at 8:00ish and at lunch-time, but they are at other times and another person described the night staff as being very good when they called them. Care Homes for Older People Page 26 of 37 Evidence: We reviewed the files of three people who had recently been employed and one other person. Files showed that all people had police checks, two satisfactory references, provided an employment history and completed a health status questionnaire. All staff are given a job description and a contract. Where a member of staff had been employed from aboard, there is evidence that they are able to work. One small discrepancy in documentation was identified during the inspection and addressed at the time of the visit. Mrs Jarvis reported that all staff are interviewed for their role. She was advised that she should use an interview assessment tool so that the persons strengths and weaknesses can be identified. The home employs a training manager. This person runs the induction programme, as well as being involved in and facilitating other training. A new member of staff was on their first day of induction during the visit. The induction complies in full with guidelines. The training manager reported that all new staff shadow an experienced member of staff before fully taking up their duties. The amount of time spent shadowing is flexible, according to the persons past experience and how they progress. All staff, not just carers, receive an induction, irrespective of their role. Once carers have completed their probationary period, National Vocational Qualifications are supported. The home is introducing a computerised training recording system, so that people who need to attend mandatory training can be identified promptly. Other training is also provided for staff, this has included areas such as palliative care. Plans are being made to train staff in their responsibilities under the Mental Incapacity Act during the next year. The training manager reported that where training needs are identified during supervision on an individual or group basis, she is able to act to ensure that relevant training takes place. It was reported that external training is often cascaded to other staff, so that all staff are made aware of a wider range of matters. Some residents use appliances which can be put in place by care assistants, such as colostomy bags. It was discussed with the training manager that records should be maintained of training for carers in such areas, so that the home can provide full evidence that carers who provide such care have been trained. Care Homes for Older People Page 27 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported by the management practices in the home, which include audit of the quality of service provision and adherence to the principals of health and safety. Evidence: Firlawn is managed by an experienced manager and registered nurse. Mrs Jarvis reported in her annual quality assessment that she has gradually delegated a range of roles to the registered nurses during the past year, which has worked well and given them a greater job satisfaction. People spoken to reported that they could speak to Mrs Jarvis when they needed. Mrs Jarvis runs regular meetings for different groups of staff. Minutes of meetings indicated that they were a two-way process and that staff felt able to contribute, if they needed to. Mrs Jarvis completed an full annual quality assessment, to inform this inspection. She meets frequently with the provider, who visits the home regularly and completes a Care Homes for Older People Page 28 of 37 Evidence: monthly report of her findings. During meetings with the provider, they reported that they discuss changes needed and develop action plans to progress matters which need to be addressed. It was discussed with Mrs Jarvis that as part of the homes internal quality audit, she should perform regular audit of accidents, to identify any trends, such as time of day, area of the home and any equipment involved. During the inspection, we reviewed systems for management of residents moneys and valuables. Records of moneys in and out are satisfactory, but would benefit from modernisation, including a computerised financial system for residents moneys, which will facilitate regular audit. It was discussed that as some items are handed in at the weekend, a weekend safe needs to be provided, rather than securing items in clinical areas. Where items are handed in, a full written audit trail, including dates and signatures, needs to be commenced at that time. It was also recommended that systems be put in place to remove responsibility for storage of such items from clinical areas. Training records showed that all staff are regularly trained in mandatory areas, such as fire safety, manual handling and first aid. Discussions with staff and observations of practice showed that they used this training in practice. There are full systems to ensure that equipment and services are regularly maintained, in accordance with good practice guidelines. Accident records are clear and include full details of the circumstances of the accident. Care Homes for Older People Page 29 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 30 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 5 A copy of the summary of 01/12/2008 the most recent inspection report must be included in the service users guide, together with information on how the full report can be obtained. Prospective residents and their supporters need to be informed of the homes response to the inspection process. 2 7 15 Where nursing and care 28/11/2008 provision is being monitored using a chart, records must be accurately completed at the time care is given. These records must be monitored to ensure that care is given in accordance with directives in care plans. Records must state the actual care given. If monitoring charts are not completed at time care is given, they may not be accurate. To ensure that the Care Homes for Older People Page 31 of 37 resident receive the care that they need, such charts need to be monitored. Charts must state the actual care given to provide evidence that care has been given in accordance with care plans. 3 8 17 Where a resident needs an intervention relating to an acute medical condition, records must always be made of actions taken by staff. Where a resident has an acute medical episode, a record of actions taken by staff to ensure their safety and stability must always be made, so that management can ensure that appropriate action(s) took place. 4 8 14 The clinical indicator for use of a urinary catheter must always be documented. Urinary catheters are invasive devises and can cause increased risks of infection to a resident. Therefore the reason(s) for their use need to be documented, so that registered nurses can assess if the resident continues to need the appliance. 5 9 13 Strips of tablets must not be 28/11/2008 taken out of their original container. The home has a responsibility to ensure that 28/11/2008 21/11/2008 Care Homes for Older People Page 32 of 37 prescribed medication is only given to the person for whom they were prescribed and in accordance with their doctors instructions. therefore tablets must always be kept in the container they were dispensed in, which will give the persons name and instructions relating to dosage and frequency of administration. 6 9 13 Where a resident has chosen 28/11/2008 to partially self-medicate, a risk assessment and care plan must always be drawn up about this. Where a resident wishes to self-medicate, even if only partially, this is to be supported. As Firlawn cares for frail people, some of whom may have additional mental health care needs, a risk assessment and care plan about self-medication must always be drawn up. Risk assessments need to take into account risks to other residents as well as the resident themself. 7 9 13 The medicines trolley must always be locked when the registered nurse not with the trolley. If medicines trolleys are not fully secured, there is a risk to residents and their visitors. 21/11/2008 Care Homes for Older People Page 33 of 37 8 22 23 Where residents are assessed as being at high risk of pressure damage, chair cushions consistent with this degree of assessed risk must be provided, unless otherwise indicated by the residents care plan. Residents risks of pressure damage do not decrease when they are sitting out of bed. Therefore equipment which is consistent with that risk must always be provided, unless the reasons for them not needing such equipment is indicated in their care plan. 31/12/2008 9 26 13 A policy and procedure, 21/11/2008 which conforms to the principals of the prevention of spread of infection, on the regular disinfection of sanitary items and mop heads must be developed. Systems must then be put in place to ensure that staff comply with this procedure. Sanitary items such as commode buckets and mop heads can present a risk to cross infection. therefore systems must be put in place, which conform to the principals of prevention of spread of infection to ensure that they are regularly cleansed and disinfected. Staff handling such items must be trained to follow the Care Homes for Older People Page 34 of 37 procedure to prevent risk to residents and themselves. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The service users guide should be expanded to detail the numbers and skill mix of staff on duty in different areas of the home, the homes skills base in caring for people with complex nursing needs and include information on the registered nursing contribution. Care plans relating to mental health needs should be further developed and include any aids provided to the resident. Where equipment is provided which is not consistent with a residents assessed risk of pressure damage, their care plan should always state why this is in the persons best interests. Where plans of care are changed on evaluation, this should be clearly shown in the care plan itself, to fully inform all relevant persons. Care plans relating to nursing and care needs should include measurable terminology. Wording such as regularly or fairly high should be avoided. Care plans relating thickening agent should state clearly how thick drinks need to be. Where signs directing care are placed in residents rooms, they should be dated and signed by the person who draws up the documentation. The policy and procedure on homely medicines should be revised to comply with current guidelines and agreed with the residents GPs Where residents are prescribed drugs which can affect their daily lives such as painkillers, aperients or mood-altering drugs, care plans should be drawn up so that the effectiveness of such treatment can be evaluated. A record should be made of informal concerns and complaints, so that management can identify any common themes and ensure that all staff respond in a consistent manner. 2 7 3 7 4 7 5 7 6 7 7 9 8 9 9 16 Care Homes for Older People Page 35 of 37 10 11 22 22 Profiling beds which will go down to the floor should be purchased, to reduce the use of safety rails. Pressure relieving cushions should be audited and any which no longer have intact, wipable surfaces, be disposed of. An interview assessment tool should be used to assess the strengths and weaknesses of prospective members of staff. A record of training of carers in extended roles, such as use of appliances, should be maintained. Regular audit of accidents should take place, to identify any trends. A safe should be provided away from clinical areas, for items handed in at the weekends. Systems for handling residents moneys should be modernised, to include computerised record-keeping and invoicing systems, to facilitate audit. 12 13 14 15 16 29 30 33 35 35 Care Homes for Older People Page 36 of 37 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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