Inspection on 07/01/08 for Folkestone Nursing Home

This inspection was carried out on 7th January 2008.

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

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

Other inspections for this house

Folkestone Nursing Home 02/05/08

Folkestone Nursing Home 16/07/07

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

CARE HOMES FOR OLDER PEOPLE Folkestone Nursing Home 25 Folkestone Road East Ham London E6 6BX Lead Inspector Sarah Greaves Unannounced Inspection 13:00 7 & 17 January 2008 th th 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 Folkestone Nursing Home DS0000068609.V357899.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. Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Folkestone Nursing Home Address 25 Folkestone Road East Ham London E6 6BX 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) 020 8548 4310 020 8472 5076 info@folkestonenursinghome.co.uk Folkestone Nursing Home Edna Pearlina Kumi Care Home 43 Category(ies) of Dementia (13), Old age, not falling within any registration, with number other category (43) of places Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE (maximum number of places: 13) The maximum number of service users who can be accommodated is: 43 16th July 2007 Date of last inspection Brief Description of the Service: Folkestone Nursing Home is a 43- bedded care home for older people. The service provides general nursing care, general residential care, residential care for people with dementia and nursing care for people with dementia. The care home occupies a three storey purpose built premises in a residential street. There are also four bedrooms on the basement floor. The building has a lift. Folkestone Nursing Home can be accessed by bus and there are car parking spaces for visitors. Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that people who use the service experience poor quality outcomes. This was the second unannounced key inspection of this service since the care home was registered in January 2007. Newham Safeguarding Adults Team received issues of concern regarding the service during the week prior to this inspection, from a whistle-blower. This inspection was conducted to check upon this information (including concerns about recruitment practices, missing staffing rotas and a lack of staff) and to monitor the service’s compliance with the eight requirements and three recommendations issued in the previous report. The inspection took place over two visits on the 7th and 17th of January. Subsequent information related to staffing hours was requested by Newham Safeguarding Adults, which has been used as evidence for this report due to some required documents (staffing rotas) not being available during the inspections. The inspector gathered information by speaking to residents, a visitor and staff; discussions also took place with the registered manager, the proprietor, the chef, activities organiser, and nursing and care staff. The inspector read three care plans and looked at four staff recruitment files. Medication administration records were viewed and the inspector spoke to staff nurses regarding medication practices. The Commission for Social Care Inspection will be requesting an improvement plan from the service. Failure to address the requirements in this report will result in enforcement action. What the service does well: The service has small units (13 bedrooms on the ground, first and second floor, which enables residents to experience a more homely environment. As a relatively newly opened service, the building is well maintained. Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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 Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Folkestone Nursing Home DS0000068609.V357899.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 Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is adequate. Prospective residents (and their representatives) do not presently receive comprehensively produced information about the service to enable people to make informed choices. Although the needs of new residents were assessed by their placing authorities prior to admission, the service needs to demonstrate that this information is used as the basis for the further assessments needed to provide suitable, individualised care. EVIDENCE: A requirement was issued in the previous inspection report for the registered manager to ensure that the Service User Guide was amended, so that prospective residents and their representatives have accurate information about the service. At the previous inspection, the inspector was provided with copies of the Statement of Purpose and the Service Users Guide. It was noted that there was a typing error regarding the registered manager’s qualifications. Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 10 The Service User Guide stated that ‘every person will get a nurse who will look after him or her’; the inspector was not clear how that statement applied to people admitted for residential (non-nursing) care. The inspector had noted a statement regarding confidentiality that did not advise prospective residents that there might be circumstances in which it would be necessary to breach an individual’s confidentiality in order to safeguard their welfare. At this inspection, the registered manager stated that no actions had been taken to address this requirement. The inspector read three care plans on the first day of the inspection, including one care plan for a person placed for a fortnight of respite care. It was noted that the placing authority had provided an assessment, which identified specific medical, social and mental health concerns. The care plan did not contain any evidence to indicate that the service had conducted its own assessment or sought further information in order to fully investigate and meet the complex needs of this individual. A recommendation was issued in the previous inspection report for the service to more rigorously promote the entitlement of residents to view the care home prior to moving in. At the last inspection there were nine residents and four of these people were stated to be placed for residential care. The inspector noted that at this inspection only one person out of forty residents was placed for residential care and the service has now registered with the Commission for Social Care Inspection to accept people with dementia. This recommendation has been deleted taking into account that some prospective residents would be too frail to visit the home or they might not wish to; however, the service should actively encourage these visits and record why a visit did not occur as part of the admissions process. Standard 6 was not applicable for assessment, as the service does not offer intermediate care. Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The care plans and observations noted at this inspection demonstrated that the service was failing to competently identify and address the holistic health care needs of the residents, including their need to receive safely managed and administered medications. EVIDENCE: The inspector read three care plans on the first day of this inspection. Care Plan 1: The resident was admitted in November 2007. The following blank documents were found in the care plan file; skin risk assessment, medical profile, allergy form, personal items and clothing inventory, diet/nutrition profile, communication profile, continence assessment, breathing profile, body chart, an ‘About Me’ document for life history and a social activities form. Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 12 Through reading the assessment from social services, the inspector found that this person was primarily admitted to the care home due to dementia, hence the particular importance of completing the communication profile, ‘About Me’ and the social activities form. The resident was known to be incontinent (lack of continence assessment noted) and was prescribed respiratory inhalers (lack of breathing assessment noted). There was a care plan regarding prevention of pressure sores that had one written entry in November 2007, which stated that the resident had a sore but not broken sacral area. The inspector considered this information to be too sparse, as it did not evidence monitoring by a registered nurse in order to determine if the findings should be formally classified as a pressure sore. Photographs had been taken and specialist advice was sought. Care Plan 2: A Waterlow risk assessment (to identify risk of pressure sores) was undertaken in August 2007. This risk assessment had not been updated since it was first completed, although it should be reviewed every month. The medical profile for the resident was not completed and there was a blank personal effects and clothing inventory. Care plans for activities of daily living (for example, eating and drinking, and communication) had been established in August 2007 and reviewed in October and December, although the National Minimum Standards for Care Homes for Older People state that the care plan objectives should be reviewed at least once a month. The resident was noted to have a sacral area pressure sore that was identified in September 2007 although photographs were not taken until the end of November 2007. The inspector found that there was only one entry in the care plan for prevention of pressure sores in November 2007, in which a registered nurse recorded that the resident had ‘1st degree pressure sores’. The inspector was unclear as to the meaning of this statement as it employed a clinical classification applied to burns as opposed to pressure sores. Care Plan 3: This care plan was for a resident admitted to the service nine days earlier for respite care. No assessment had been completed by the service; the only information compiled about the resident by care staff was an admission form. The home had used pre-written, photocopied care plan templates for elimination, communication and breathing. The resident’s first name had been inserted in to blank spaces within the template. The inspector noted that there was significant information about the resident supplied by the placing authority (alcohol dependency, dementia and challenging behaviour when not supplied with alcohol); however, there was no attempt to individualise the templates to reflect the specific needs of this resident. A recommendation was issued in the previous inspection report for the service to use a recognised system to determine whether a person is a healthy weight. The recommendation presented the Body Mass Index system as a possible tool, although any other system (for example, demi-span measurements) could be used, providing that the service ensured that staff were trained and appropriate documentation was maintained. The registered manager stated Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 13 that the service was now using the Body Mass Index system but evidence of this was not found in the three care plans viewed by the inspector. This recommendation has been deleted and has been replaced by a requirement. A requirement was issued in the previous inspection report for the registered manager to ensure that needs of residents to access external health care are very actively pursued, so that the health and welfare of people is promoted. The previous inspection report cited that a resident with an evident need for podiatry care had not been referred to a podiatrist, as the registered manager had stated that she did not know how to access this support for residents from outside the borough. The inspector was informed at this inspection that the registered manager had contacted Newham Primary Care Trust (PCT) and was informed that NHS podiatry care was provided only to residents with a diagnosis of diabetes. The registered manager had arranged for the service to be visited by a private podiatrist that residents would need to pay for themselves. At this inspection, a resident informed the inspector that they needed cream to be applied to both legs. The inspector noted that this person had oedematous legs, with red patches, and dry and flaking skin. The registered nurse on duty reported that no actions were taken on the basis that the individual (admitted for respite care) had not been prescribed a cream to take into the care home. This lack of attention demonstrated that staff do not responsibly address evident health care needs through appropriate measures (such as informing the General Practitioner, who would determine whether a cream could be prescribed). The inspector looked at the service’s records for falls and accidents, which was commenced in May 2007. It was noted that the average number of falls was between one and three each month, although this number had increased to eight falls in October 2007. There was no evidence to indicate that the registered manager had undertaken any analysis of this information, particularly regarding the significant increase in October. The inspector was concerned to find an entry in which a staff nurse recorded that she had asked the resident if they wanted to go into hospital, rather than recording their own clinical judgement. It was noted that the service did not consistently record residents’ blood pressure, pulse, temperature and respirations following a fall, which indicated that registered nurses were not consistently assessing for potential underlying causes. The registered manager stated Newham PCT was now collecting and analysing the information regarding falls every month, which had started in January 2008. A requirement was issued in the previous inspection report for the registered manager to ensure that correct procedures are followed if a resident’s medication label has been written on by an unknown source. It was noted at Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 14 the previous inspection that the care home received a new resident from another service without a discharge letter and with biro pen alterations to a medication label. The registered manager did not have a comprehensive list of the person’s medication needs, had not contacted the other service to query the absence of a discharge letter and could not explain who had made the biro pen alteration. On the first day of this inspection, the inspector found a prescribed medication (nasal cream) placed in a prominent position in the bedroom of a resident admitted to the service primarily for care needs due to dementia. A relative of the individual stated that other residents with dementia frequently wandered into the bedroom. The nasal cream pharmacy label did not have any instructions for administering other than to give ‘as directed by the physician’. The inspector checked on the medication administration record and found that there were no instructions regarding frequency and period of dosage. Two prescribed medications with instructions for disposal twenty-eight days after opening did not have the date of opening and date for disposal recorded. An expired prescribed cream was found in the bedroom of another resident. On the second day of the inspection, a prescribed cream was found in a resident’s bedroom but part of the label was removed so it could not be determined if the cream belonged to the resident or if there was a risk of cross-infection from it belonging to another resident. It was noted that a comprehensive risk assessment was not in place for a resident that selfmedicated with respiratory inhalers and a care worker was observed to leave two containers of prescribed thickening granules in prominent positions in the lounge (on the dining table and on the window sill). A recommendation was issued in the previous inspection report for the registered manager to provide an up-to-date British National Formulary (BNF) medication guide, as the BNF was dated March 2003. The previous inspection report stated that care homes with nursing should update their copies of the BNF annually. At this inspection, the registered manager stated that a new BNF had been ordered from the care home’s pharmacy service following the inspector’s advice in July 2007; however, the most recent BNF has been widely available since September 2007. The inspector considered that an unacceptable risk was being placed upon the safety of the residents through staff using an outdated medication guide that would not provide updated information regarding some currently prescribed medications. This recommendation has been repeated with a date for completion (29/02/08). A requirement was issued in the previous inspection report for the registered manager to ensure that the ‘end of life’ information has been attained through a multi-professional approach, including liaison with residents’ doctors, so that people receive appropriate medical and health care to meet their individual palliative care needs. The registered manager stated that she was awaiting training for staff regarding ‘end of life’ care from Newham PCT Continuing Care Nurses. The inspector spoke to the manager of this team, who confirmed that Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 15 an initial meeting was conducted on 03/01/08 and guidance would be provided to staff regarding ‘end of life’ care. The service must note that the role of the Continuing Care Team is to provide services with guidance to commence ‘end of life’ care; the registered manager needs to access additional training for staff in order to continually develop initial knowledge and skills. This requirement will be repeated in this inspection report with a new date for completion. Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 16 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 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service needs to provide a varied and carefully considered activities and entertainments programme that enables residents to enjoy fulfilling and meaningful activity within the care home and in the local community. Although the service welcomed visits from the relatives and friends of the residents, opportunities for contacts with other people in the community should be sought. The food service did not demonstrate that residents are provided with a balanced and nutritious diet. EVIDENCE: The inspector discussed activities (including access to community resources) with the registered manager and the activities organiser. The activities organiser was employed for sixteen hours each week, working from 10am to 2pm on a Monday, Tuesday, Wednesday and Thursday. It was noted that the activities organiser had not previously worked in social care and did not have any prior experience of organising activities. The inspector requested to look at Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 17 the activities records and was informed that records were not kept, such as information about which activities have taken place on a particular day and what arrangements were in place to support people that preferred one-to-one pursuits rather than group activities. The inspector was informed that some residents had declined to take part in activities; however, the activities organiser was unaware of the need to maintain records to demonstrate what actions had been taken to offer these residents regular social stimulation, such as a daily chat. The inspector found that residents had not been offered opportunities to visit local facilities, such as pub lunches, shopping trips and entertainments. The activities organiser had not developed links with any community resources, for example, dial-a-ride transport, or voluntary sector bingo and social clubs that residents could attend. The inspector was concerned to be told by the activities organiser that arrangements were not being made for residents to go out into the community because it was wintertime. It was noted that the activities organiser had not received any supervision since her appointment in August and there was no evidence of appropriate training and mentorship being offered, for example, membership of the National Association for Providers of Activities for Older People or time spent observing activities at a day centre or residential setting. The inspector was informed that the service had arranged a Christmas party for residents and their visitors but there was no external entertainment booked as this had been left until too late. The inspector asked whether the service addressed this shortfall by organising a New Year/ January entertainment, but no arrangements had been considered. It was noted that the service had purchased some equipment for activities, such as arts and crafts, bingo, dominos, cards and board games. The inspector noted that some equipment was clearly indicated for use by children; the registered manager acknowledged that the service had not investigated manufacturers that supply specialist leisure and socially therapeutic equipment to services for older people, which would better promote the residents’ entitlement to dignity and demonstrate a respect for their experiences and knowledge acquired in adulthood. The inspector met only one visitor during the course of the two days spent at the care home; this visitor stated that visiting hours were flexible and that they felt welcomed by staff. The service had not made any specific arrangements for visits by religious ministers, although the Service User Guide informed prospective residents that the service would support people who wished to be visited by a representative of their religion or attend worship in the community. However, the inspector found that the care plans did not consistently indicate individualised wishes regarding religious practices and as previously identified, residents were not accessing community facilities with staff support. A requirement was issued in the previous inspection report for the registered manager to ensure that the menu plans contained sufficient details to enable any person inspecting the record to determine if the nutritional needs of the Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 18 residents were being addressed. At this inspection, the inspector requested to look at the current menu plan on two of the units and was provided with menu plans for other weeks. It was noted that the menu plans stated one option for lunch and one option for the evening meal, with a statement informing residents that alternatives were available written below the menu plan. The inspector was unable to locate any residents on the ground or first floor that had chosen to have an alternative to the stated evening dish (fish fingers and baked beans). Residents spoken to by the inspector were unable to recall if they had been offered an alternative; this response was consistent with the needs of many older people that require residential and nursing care (people with dementia, short-term memory loss and/or cognitive impairment related to physical conditions). The registered manager was advised at this inspection that the current menu plans need to be kept on the units, with a large print daily menu card displayed on the dining table or another prominent place. The menu plans needed to state available choices, taking into account that some residents would not be able to think of alternatives without prompting The inspector noted on the first day of this inspection that residents were provided with tea that was poured from a pot that already contained milk, thus denying people the opportunity to choose how much milk to add to their cup of tea. The inspector spoke to the two care workers serving the tea; they stated that the tea was prepared this way in the main kitchen but they had not challenged this practice, even though they knew it was wrong. It was noted at the second day of this inspection that this practice had ceased. Residents were observed to be eating their supper at 4.40pm. The inspector considered this to be too early, taking into account that this was the final substantial meal of the day. This observation was reported to the registered manager, who stated that this meal was usually served at 5pm. No explanation was offered as to why the mealtime was changed or whether residents had been consulted. This practice was not observed at the second day of the inspection. On the second day of the inspection, the inspector found that the salt and pepper pots were empty in one of the communal lounges. Discussions with residents did not identify any concerns regarding the quality of the food. The menu plans indicated that residents could have choices of vegetables at lunch and some desserts included servings of fruit. The inspector checked the choices of foods available in the main kitchen, on the second day of this inspection. It was noted that the only fresh fruit available was bananas and there was a large supply of tinned foods (such as Irish stew and macaroni cheese); the cook stated that these foods would be used if a resident requested an alternative to foods listed on the menu; however, the inspector was shown a proposed menu for the forthcoming weeks on the first day of the inspection that clearly stated that Irish stew was an option at the evening meal. The inspector discussed with the chef, registered manager and proprietor the importance of providing freshly prepared meals as much as possible due to the ageing process affecting peoples appetites, hence the need for appetising meals rich in nutrients to prevent malnutrition. The inspector Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 19 enquired how the macaroni cheese would be served and was informed that it would be on toast with ham; it was pointed out that this meal should be provided with vegetables (for example, mushroom and /or tomato) so that it was nutritionally balanced. The service did not present any system to evidence that the menu plan was audited to ensure that it was healthily balanced (for example, a simple daily calculation of which foods provided calcium or fibre) and the chef confirmed that she had not attended any training regarding how to meet the dietary needs of older people within nursing homes. The menu did not indicate the availability of home baked cakes once or twice a week, as an alternative to the mid-afternoon biscuits. Folkestone Nursing Home DS0000068609.V357899.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service needs to demonstrate more robust measures to listen to and protect residents, through demonstrating a more focused approach to investigating complaints and providing more effective guidance to staff. Although the service produced a satisfactory complaints procedure, the absence of the complaints records has prevented the service from demonstrating that this standard has been met. EVIDENCE: The service produced a satisfactorily written complaints procedure. Since the previous inspection, a complaint regarding the standard of care received by a respite care resident was referred to Newham Safeguarding Adults Team by the placing authority. The daughter of the resident had made the complaint. Concerns were noted by Newham Safeguarding Adults Team and by the Commission for Social Care Inspection regarding the service’s delay in providing its own investigation into the concerns and the inadequate standard of the service’s submitted findings. Newham Safeguarding Adults Team convened a meeting during the first week of this inspection, in order to discuss serious concerns regarding the service’s performance. This meeting identified Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 21 that there are safeguarding concerns regarding two other residents, which will be followed up by the Safeguarding Team. The inspector requested to see the service’s complaints book and was informed that is was missing. A requirement was issued in the previous inspection report for the registered manager to (1) ensure that amendments are made to the Adult Protection procedure in order to ensure that residents are protected and (2) ensure that staff are made fully aware that they can inform the Commission of any concerns related to the conduct of the home. The inspector noted that the registered manager had contacted the Newham Safeguarding Adults Team, as advised to do within the previous inspection report. The registered manager had sought guidance in order to ensure that the Adult Protection procedure was now a more comprehensible and accurate document and the Safeguarding Team had provided one training session for staff, with a second session scheduled soon afterwards. At this inspection, the inspector spoke to two care workers regarding their understanding of whistle blowing. One care worker stated that whistle blowing was calling 999 in the event of a fire and another care worker stated that it involved calling a colleague if there was an emergency in another room. It was noted at this inspection that limited evidence was produced to demonstrate that staff received a comprehensive induction programme and there was no evidence of formal one-to-one supervision. The registered manager was informed at this inspection that staff training must be discussed at supervision sessions, in order to evaluate if individuals need further training and support. The whistle blowing policy stated that staff could inform the Commission for Social Care Inspection if they had any concerns about the service; however, no contact details were provided. The whistle blowing policy did not advise of other organisations that staff could speak to, such as social services. Folkestone Nursing Home DS0000068609.V357899.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The entitlement of residents to be provided with a safe and odour free environment needs to be addressed. The service needs to demonstrate that the facilities for people with dementia reflect recognised good practice. EVIDENCE: Folkestone Nursing Home is a purpose built care home, which began accepting residents in June 2007. The service provides accommodation on four floors. There are four bedrooms on the lower ground floor that have limited natural light; these rooms are offered to people receiving respite care. There is accommodation on the ground, first and second floors for thirty-nine residents. The care home was pleasantly decorated with evidence of homely touches (for Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 23 example, paintings, plants and ornaments) in the communal areas. The inspector did not observe specific environmental additions to the unit for people with dementia, such as easily accessible items to engage people with occupational tasks and provide sensory stimulation, or pictures on doors to assist people to recognise their bedrooms and communal bathrooms. It was noted that a small office area had been established in the lounge on the ground floor, which detracted from the room’s purpose as a place for residents and their visitors to relax in. The inspector found that several care plans containing confidential and sensitive information were left on the desk in the lounge on the first day of this inspection. One of the communal bathrooms had a broken light left on a windowsill with screws sticking out. A panel had been removed from the ceiling and there were wires dangling out, and a plastic chair had been left directly underneath. The proprietor informed the inspector that the bathroom was being kept locked whilst repairs were being undertaken; however, the inspector and two care workers were able to walk into this room. The inspector observed on the first day of the inspection that sluice rooms were not locked; on this occasion, a bottle of cleansing and sanitising solution was found in the sluice, which was potentially harmful if picked up by a resident with dementia. It was noted on the second day of the inspection that the sluice rooms now had a notice asking staff to keep the door closed, but no locking system (such as key pad) had been applied. On this occasion, the inspector found a prescribed topical cream. It was noted in the last inspection report that an offensive odour was detected within the premises. The inspector noted an odour of urine in the ground floor lounge. The inspector spoke to a visiting professional (a member of the Newham PCT Continuing Care Team) who stated that she had noticed a strong smell of air freshener on previous visits and advised staff that a more gentle system for eradicating odours must be used in order to prevent any respiratory discomfort to residents. On the second day of this inspection, one of the bedrooms was noted to have a strong odour of urine, which was brought to the attention of the registered manager and the proprietor. Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 and 30 Quality in this outcome area is poor. This judgement has been made by using available evidence including a visit to this service. Residents do not receive care from staff that are suitably trained and safely recruited. More permanent staff of an appropriate calibre must be recruited in order to provide a stable service for residents. EVIDENCE: On the first day of this inspection, there were forty residents placed at the care home. The registered manager stated that four people were in hospital. The care home employed three staff nurses; this number excluded the registered manager and the deputy, who was on leave. The registered manager stated that she had two vacancies for staff nurses and eight vacancies for care staff. Although the service was now using agency staff to fill this significant number of vacancies, the inspector noted that during a two week period in November, two staff nurses worked between sixty and seventy-two hours each, per week. The rotas for the four months prior to this period were missing. The inspector noted that there was usually two staff nurses employed between 8am and 8pm, and five (occasionally six) care workers. The inspector was informed that the two staff nurses were in charge of one floors each and divided up the remaining floor; at the time of this inspection there was one resident in the Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 25 lower ground floor although this number could rise to four. The staffing arrangements appeared to be very unsatisfactory, taking into account that the needs of residents were not being met (comprehensive assessments of needs, individualised care planning, reviewing of care needs at least once a month, responding to health care problems and the safe management of medications). Purchasing authorities will need to consider if this service can meet the needs of individuals that have been assessed to require registered nursing care banded at the medium or high level, and people with dementia. The inspector was particularly concerned as to how a registered nurse allocated to work on two or three separate floors (including lower ground floor) could address the needs of people assessed to require the high level of registered nursing care, given that these individuals are stated to have unstable and unpredictable nursing needs that will require frequent intervention and assessment by a registered nurse throughout the twenty-four hour period. At present, the care home was employing one staff nurse and three care workers on night duty. The inspector noted that the salary scale for trained nurses and care workers was significantly lower than local standards. The proprietor must seriously consider the staffing terms and conditions required in order to attract and maintain staff with the appropriate experience, aptitude and qualifications to work with frail older people that have identified needs for nursing care and dementia care. The inspector noted on the second day of the inspection that the four bedrooms on the lower ground floor were unoccupied (there had been one resident placed for respite care in one of these rooms on the first day of the inspection). Following detailed discussion with the proprietor and the registered manager, the service proprietor stated that the service would not use these rooms until it could be determined, in consultation with relevant stakeholders, that issues of concern had been resolved. The inspector noted that a very limited amount of training had been delivered by the service. Staff had attended training regarding Safeguarding Adults, fire safety, gastrostomy (PEG) feeding, Control of Substances Hazardous to Health (COSHH) and use of hearing aids. The registered manager identified on the first day of the inspection that staff needed to attend training in diabetes, hypertension (high blood pressure), falls and end of life, but no service training plan or individual training plans had been drawn up. The inspector advised that the service should provide other training including infection control, food handling, diversity, pressure care, activities and the nutritional needs, taking into account that the registered manager needs to develop a detailed training plan that also reflects the identified health and social care needs of the residents, and the gaps in staff knowledge identified during supervision, team meetings, care plan auditing complaints investigations and other observations. The inspector found that although staff had undertaken moving and handling training within the past year in their previous employment, the service did not evidence that individual staff competency and knowledge to use the equipment Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 26 within the care home had been checked and there was no records to demonstrate that the registered manager had observed staff support the moving and handling needs of a resident with moderate to complex needs in order to check if they were safe or needed more training. The service employed thirteen care staff. None of the care staff had a National Vocational Qualification in Care (NVQ) level 2, although four staff were undertaking this training. On the second day of this inspection, the registered manager stated that five staff (laundry, domestic and catering) had been referred to a training organisation for their training needs to be assessed and applicable training offered; the inspector was shown the referral forms. The registered manager confirmed that all staff would be provided with moving and handling training, irrespective of whether they had received this training recently elsewhere. The service had received information from the Newham PCT nursing team regarding how to access an external audit of its provision of dementia care and subsequent staff training based upon the findings of the audit. A requirement was issued in the previous inspection report for the registered manager to demonstrate the safe recruitment of staff, including evidence of Protection of Vulnerable Adults (POVA) First checks, two references in each file and a documented exploration of any gaps in employment. This requirement was due to be met by 30/09/07. Four staff files were checked at this inspection. Staff File 1: Contract for employee signed on 13/08/07. POVA First check received on 14/09/07 and Criminal Record Bureau check received on 11/10/07. The inspector was unable to verify when this employee commenced work at the service as the staffing rotas for four months were missing. There was one reference only, which had not been verified by the service. The induction document had been signed by the employee but not by person conducting the induction, and it was not dated. There was no health information, such as evidence of inoculations. Staff File 2: Two references found, but neither had been verified by a telephone check in order to establish the authenticity and position of the referees. The person conducting the induction with the employee did not sign the induction document. The file did not contain any evidence of a POVA First check and Criminal Record Bureau check. The registered manager stated that these documents had been sent back to the Criminal Record Bureau as further evidence had been requested. There was correspondence in the staff file to indicate that this information was accurate. Staff File 3: The contract was signed on 20/09/07; however, the POVA First check was received on 22/11/07 and the CRB check was obtained on Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 27 29/11/07. There were no references in the file; the registered manager stated that the references had been handed back to the employee (a staff nurse) so that they could ask the referees to stamp the references. One of the references was stated to be from a staff nurse at another care home. The inspector contacted the care home and was informed that this establishment only permitted the manager or deputy to issue references regarding current or former employees. Via reading the employee’s application form, the inspector could not find evidence to demonstrate the professional relationship between the employee and the referee; the registered manager was unable to offer any information regarding this query. There was no detailed health information. Staff File 4: There was no evidence of induction or health information. The POVA First check was obtained on 01/10/07 and the CRB was obtained on 05/10/07. There was no contract and the inspector could not ascertain the start date of the employee due to the missing staff rotas. There were two references although one of the referees had not completed the query regarding how long they had known the applicant. There was no evidence to indicate that the service had contacted the referees to check the authenticity of the references. Folkestone Nursing Home DS0000068609.V357899.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): 31,33,35,36 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents were not benefiting from a well managed, experienced and knowledge –based service that demonstrably responded to their needs and best interests. Financial record keeping was satisfactory but improvements are needed in order to provide a safe environment. EVIDENCE: The registered manager has been in post since the home was registered. This is her first position as a registered manager, having worked as a deputy at other care homes for older people. She is a registered general nurse and is undertaking the Registered Manager’s Award. The issues of concern raised in Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 29 this report have identified that the expectations of the role and responsibilities of a registered manager have not been met, including the service’s failure to meet six out of the eight requirements in the previous inspection report. During the inspection, the inspector found evidence of residents having been admitted to hospital through reading care plans. Although some notifications had been received from the service, this evidence demonstrated that the Commission for Social Care Inspection has not received notification of all events detailed in Regulation 37 of the Care Homes for Older People Regulations. It is acknowledged that the registered manager required specific support and guidance from the proprietor, taking into account the unique problems that new services encounter, which was not provided. The registered manager was unable to produce any written evidence to demonstrate that she had received managerial and clinical guidance regarding how to manage a care service for older people from an external supervisor, which was essential for a new manager unable to access this support from within their own organisation (the proprietor had no prior experience of care services). The registered manager confirmed at the second inspection visit that she has resigned and will remain in post until a new manager is appointed; advertisements have been placed in national and local publications. The inspector spoke to the proprietor regarding his knowledge of the needs of the residents; (for example, the role of statutory social workers for people living in care services) the proprietor was unable to provide any relevant responses. The proprietor was attempting to engage an independent nursing home adviser at the time of the second day of this inspection, which has subsequently been achieved. The service had been receiving residents for less than nine months; therefore the inspector did not anticipate the production of an annual quality assurance report, with the views of residents, their representatives (if applicable) and community stakeholders (for example, General Practitioners, social workers, PCT nurses and other visiting professionals). However, the service has failed to demonstrate that the views of residents (and their representatives) are sought for the production of individualised care plans and no evidence was produced that the service has been using a professional quality assurance system to internally audit and review its own practices. The inspector asked the proprietor for copies of the statutory unannounced ‘person-in-charge’ visits, as required by Regulation 26 of the Care Homes for Older People Regulations. The proprietor stated that he had undertaken only one of these visits but the report was not being stored within the care home. This report has not been made available to the Commission for Social Care Inspection. The previous inspection report identified that the proprietor would need to employ a person with an appropriate background in care services to accompany him on these visits; however, no arrangements had been made at the time of this inspection. The inspector looked at a randomly selected sample of residents’ financial records, which were found to be satisfactorily maintained. These records contained records of expenditure and receipts; personal spending monies counted by the inspector were in accordance to the service’s own accounting. Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 30 Via discussion with the registered manager, it was noted that the service was experiencing problems with receiving sufficient personal spending allowance for approximately one third of the residents. In some cases this was identified to be due to families that did not respond to requests for money to pay for hairdressing, toiletries and podiatry, and in other cases there were obstacles in liaising with local authorities. The registered manager was advised to contact a local authority during the course of the inspection on behalf of a resident that had not received their personal allowance since moving into the service (July 2007) and this contact appeared to generate useful advice to resolve the issue. The inspector was concerned that the difficulties of the service to access residents’ finances would significantly impact upon the quality of an individual’s well-being and the home were advised to rigorously pursue this issue with the relevant placing authorities. The registered manager stated that the service had not implemented a programme of formal one-to-one supervision. The National Minimum Standards for Care Homes for Older People states that formal one-to-one supervision of staff needs to be delivered six times per year. The staff nurses had not been trained to provide supervision for care staff. Health and safety records were checked at the previous inspection in July 2007 and found to be satisfactory, apart from an expired certificate for the annual maintenance of the gas safety; therefore a requirement was issued in the previous inspection report for the service to demonstrate that the gas safety had been checked by a competent person. At this inspection the registered manager produced a gas safety certificate that had expired but the service believed that the engineer had recorded the wrong date. This requirement has been repeated and the service were advised to seek a new certificate to demonstrate the current safety of the gas system. It was noted the catering staff did not consistently maintain appropriate practices for food safety in the main kitchen. The inspector found two opened food items that had not been labelled with the date of opening and date for disposal. Folkestone Nursing Home DS0000068609.V357899.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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 1 X 2 Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 32 Yes 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 5 Requirement The registered person must ensure that the Service User Guide is amended as detailed in this report, so that residents and their representatives have accurate information about the service. This is a repeated requirement. The registered person must ensure that the needs of residents to access external health care are very actively pursued, so that the health and welfare of people is promoted. This is a repeated requirement.. The registered person must ensure that correct procedures are followed if a resident’s medication label has been written on by an unknown source, in order to ensure that residents’ medication needs are safely met. This is a repeated requirement. Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 33 Timescale for action 30/04/08 2. OP8 12(1) (a) 30/04/08 3. OP9 13 (2) 30/04/08 4. OP11 15 5. OP15 17(2) 6. OP38 13 (4) 7. OP7 15 8. OP9 13 (2) The registered person must ensure that the ‘end of life’ information within the care plans has been attained through a multi professional approach, including liaison with residents’ doctors, so that people receive appropriate medical and health care to meet their individualised needs. This is a repeated requirement. The registered person must ensure that the menu plans contain sufficient detail to enable any person inspecting the record to determine if the nutritional needs of residents are being addressed. This is a repeated requirement. The registered person must ensure that the home has a current gas safety check, so that residents and all other persons that enter the premises are provided with a safe environment. This is a repeated requirement. The registered person must ensure that the needs of residents are appropriately assessed, planned for, monitored and reviewed in the individual care plans. The care plans must evidence the use of recognised clinical tools for managing the nutritional needs of older people. The registered person must ensure the safe arrangements are made for the storage of prescribed medications, topical creams and locations, and any other prescribed items (such as thickening granules) that could potentially harm another DS0000068609.V357899.R01.S.doc 30/04/08 30/04/08 31/03/08 30/04/08 15/03/08 Folkestone Nursing Home Version 5.2 Page 34 9. OP12 12 (1) 10. OP16 22 11. OP19 13(4) (c) 12. 13. OP26 OP27 16 (2) (k) 18 14. OP29 19 15. OP30 18 16. OP31 8 resident. The registered person must ensure that residents are provided with a programme of activities that provides quality and choice, and meets the needs of people with individualised interests and people with dementia. The registered person must ensure that the service maintains a copy of all complaints received, with detailed information regarding how the complaints were managed. The registered person must ensure that a safe and lockable system is installed on the sluice rooms’ doors. The registered person must ensure that the premises are kept free from offensive odours. The registered person must ensure that the home is staffed by sufficient permanent staff, with the appropriate skills and experience for their positions. The registered person must ensure that references are carefully verified and health information for prospective employees must be obtained prior to employment. The registered person must ensure that the service produces a training programme for all staff. Training must be provided to the chef and the activities organiser as detailed in this report. The registered person must ensure that a new manager is appointed, with appropriate experience and skills to meet the needs of the residents (people with general nursing and residential care needs, and DS0000068609.V357899.R01.S.doc 30/06/08 30/04/08 31/03/08 15/03/08 30/06/08 15/03/08 31/03/08 31/03/08 Folkestone Nursing Home Version 5.2 Page 35 17. OP31 37 18. OP33 26 19. OP36 13 (4) (c) people with dementia requiring nursing and residential care). The registered person must 15/03/08 ensure that the service complies with the specifications of Regulation 37. The registered person must 29/02/08 ensure that an unannounced monthly inspection visit is conducted by the registered provider; one copy must be maintained on the premises and another copy must be sent to the Commission for Social Care Inspection. These reports must demonstrate that records (including care plans) have been audited. The registered person must 15/03/08 ensure that opened, packaged food items are marked with the date of opening and when the items should be disposed of. 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 The home should provide staff with current issues of the British National Formulary medication guidance book. This is a repeated recommendation to be met by 15/03/08. The home should amend the whistle-blowing policy in order for it to contain contact details for the Commission for Social Care Inspection and the local Social Services. 2. OP18 Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Folkestone Nursing Home DS0000068609.V357899.R01.S.doc Version 5.2 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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