Inspection on 12/03/07 for Glenside Manor - Lime Tree Wing

This inspection was carried out on 12th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Glenside Manor - Lime Tree Wing 04/10/05

Glenside Manor - Lime Tree Wing 27/07/05

Glenside Manor - Lime Tree Wing 04/10/04

Glenside Manor - Lime Tree Wing 10/05/04

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

CARE HOMES FOR OLDER PEOPLE Glenside Manor - Lime Tree Wing South Newton Salisbury Wiltshire SP2 0QD Lead Inspector Susie Stratton Unannounced Inspection 12th March 2007 09:45 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 DS0000048135.V329306.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. DS0000048135.V329306.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenside Manor - Lime Tree Wing Address South Newton Salisbury Wiltshire SP2 0QD 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) 01722 742066 01722 744443 limetree@glensidemanor.co.uk Glenside Manor Healthcare Services Ltd Vacant Mr Andrew Norman Care Home 36 Category(ies) of Dementia (35), Dementia - over 65 years of age registration, with number (35), Mental disorder, excluding learning of places disability or dementia (35), Mental Disorder, excluding learning disability or dementia - over 65 years of age (35) DS0000048135.V329306.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users who may be accommodated at any one time is 36 The staffing levels set out in the Notice of Decision dated 12 August 2005 must be met at all times 4th October 2005 Date of last inspection Brief Description of the Service: Lime Tree Wing is a 36 bedded care home, which accommodates elderly persons and younger adults who need nursing care due to mental health needs, mainly dementia. On the day of the inspection, there were 33 persons resident in the home and one bed was reported to be booked. The home was purpose-built in the early 1990s. Accommodation is provided over two floors, with a range of different sitting and dining rooms available to service users. Lime Tree Wing is part of a group of homes, all on one campus owned by Glenside Manor Health Care Services Ltd. Mr Andrew Norman is the nominated responsible individual. He is supported by a senior management team. The registered manager’s post is currently vacant and an individual is being considered for the position, she leads a team of nursing and care staff. A multidisciplinary team, including physiotherapists, occupational therapists, psychologists, speech and language therapists and social worker work across the campus. One catering and laundry department supplies all the homes and a maintenance team works across the site. The group of homes is situated in the village of South Newton, on the A36, five miles north west of the city of Salisbury. A mainline train station is in Salisbury, the A36 is on a bus route and ample car parking space is available on site. The home has a service users’ guide, which is offered to all prospective service users supporters. The fees are £795 a week. Extra charges include hairdressing, chiropody and sundries, such as toiletries. DS0000048135.V329306.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the 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 this inspection, 20 questionnaires were sent out and 6 were returned. Comments made by residents and their relatives either in questionnaires or during the inspection, have been included when drawing up the report. The home also provided information requested by the CSCI prior to the inspection, relating to a wide range of matters, to inform the inspection. As Lime Tree Wing is a larger registration and is part of a campus which includes several registrations, the inspection took place over parts of three days. On Monday 12th March 2007 between 9:45am and 3:35pm, when the home itself was visited, on Wednesday 14th March 2007 between 9:45am and 1:45pm, when whole site services were reviewed and on Thursday 22nd March 2007, between 10:00am and 12:45pm when the Inspectors fed back and held discussions with the managers of the services. The first site visit was unannounced and took place at the same time as another Inspector visited another registration on the campus. The prospective manager was on duty for the visit to the home on 12th March 2007. During the site visits, the Inspector observed nursing and care for at least 16 different service users and met with two visitors. None of the service users were able to communicate more than a few words, so the Inspector concentrated on observing are and the service users’ responses to care provided. The Inspector reviewed care provision and documentation in detail for seven residents, two of whom had recently been admitted. The inspector also met with five staff directly involved in nursing and care, a catering assistant, two laundresses, a maintenance man, the training manager, the human resources manager and a finance manager. The inspector toured all the building and observed a lunch-time meal. Systems for administration of medicines and the clinical room was inspected. A range of records were reviewed, including staff training records, staff employment records, maintenance records and financial records. What the service does well: Lime Tree Wing provides nursing and care to service users with highly complex nursing and care needs due to dementia. There is a effective system in place to ensure that service users have their needs fully assessed prior to admission. Service users with dementia care needs can exhibit complex behaviours, however it was noted during the site visit that no service users showed any overt sounds of distress, such as noisy behaviours, distressed wandering DS0000048135.V329306.R01.S.doc Version 5.2 Page 6 behaviours or aggressive behaviours. Service users were observed to be relaxed and able to move freely, if that is what they preferred to do. Service users could be in a range of lounges and it was observed that there was always at least one member of staff either in or very close to each lounge, so service users were not left unobserved. Many of the service users experienced double incontinence and it is much to the credit of the home that despite this, no unpleasant odours were noted during the inspection. The home and laundry department have established effective systems to ensure that service users own clothes are returned to them. This is particularly important in a service where residents are unable to identify their own clothing. Service users are supported by staff who are trained to meet their needs and staff commented on the effective induction and supervision systems. The Glenside group offers a range of training to staff at all levels in the organisation. Service users’ relatives commented on the quality of service offered. One reported “Standard of nursing care is excellent. I am always observing the staff and the majority do more than they are employed to do”, another reported “the staff are very kind and caring, not only to the residents but the relatives as well.” another “excellent care” and another “cannot think of anyway to improve” What has improved since the last inspection? What they could do better: Sixteen requirements and sixteen good practice recommendations were identified at this inspection. One requirement and one recommendation had not been addressed since the previous inspection. Some issues related to care planning. Where a service user has an assessed need or treatment, for example is a diet or tablet controlled diabetic or is prescribed or is assessed as needing a topical application, a care plan must DS0000048135.V329306.R01.S.doc Version 5.2 Page 7 always been put in place to direct staff on how this need is to be addressed. Where service users are assessed as needing to be offered regular fluids or have their positions changed regularly, there must be evidence that this is taking place. This matter was identified at the previous inspection. Where a service user is assessed as being at risk of pressure damage, care plans should state how often that individual needs to have their position changed. Where service users need to be offered fluids to prevent risk of dehydration, the amount of fluids aimed for in 24 hours should be stated on their care plan and where their fluid intake is being measured, this should be totalled every 24 hours. Where service users are assessed as needing thickening agents to assist them in swallowing, their care plan should state how much thickening agent they need. Where care plans are up-dated following evaluation, all additions should be dated. Liquid paper should not be used when correcting errors in documentation. When performing evaluations of care, there should be evidence to show that cross-referencing has taken place to all relevant information relating to the service user. Provision of activities and systems for documenting activities provided should be reviewed. Other issues related to management of medication. The two medication errors noted during the inspection must be reported to the CSCI and systems must be put in place to ensure that where a service user is prescribed medication on an intermittent basis, that medicines are given to the service user as prescribed. Prescribed items such as lotions must only be used for the service user for whom they are prescribed and where the service user is no longer in the home, all such prescribed items must be disposed of. Where service users are prescribed a medication on an “as required” (prn) basis, a care plan must always be drawn up, to direct staff on the indicators for the use of such medication. Where a service user goes out of the home for a period of time and their supporter needs to be given medication for them to take, there must be clear guidelines and protocols drawn up relating to this, which fully supports all persons involved. Contact should be made with the clinical waste company who removes medicines, to ensure that all dropped/found/spat out/refused tablets are also taken for disposal as well as other medicines sent for disposal. Further issues related to the home environment and health and safety. A policy and procedure on equipment shared across the site needs to be put in place to ensure that adequate equipment is provided. This must conform to health and safety and infection control guidelines. Suitable cleaning implements must be provided to ensure that the areas between the washing machines can be cleaned and be free of dust and debris. Where safety rails are in use, a full written assessment of their need and suitability must be undertaken. Such assessments must be reviewed on a regular basis. An audit of all items used in service user care, such as bed screens and safety rail protectors, must take place and any deteriorated items disposed of. Such items must always be in a clean state and free of debris. The deteriorating flooring in en-suite bathrooms, particularly where flooring is lifting up and could present a tripping injury, must be replaced. This requirement is outstanding from inspection of 4th October 2004. Systems must be put in place to ensure that where service users share a room, that wash bowls are identified for each service user, to DS0000048135.V329306.R01.S.doc Version 5.2 Page 8 reduce the risk of communal use. If a service user needs to have their door held open for any reason, a device which has been approved by the fire office must be used. A disabled showering facility should be provided on the ground floor. There should be a review of the call bell system, to identify if the number of repeater buttons can be increased and the tone of the door bell altered to assist staff in promptly attending to service users. A larger supply of crockery and cutlery should be provided. Some matters related to management of the home and staff training. Where a complaint/concern has been dealt with locally, this should be supported by documentation, detailing how the matters were dealt with. A review of whether there needs to be more supervision of domestic staff or if there are enough domestic hours for the work to be performed should take place. Management training should be provided to all persons who are in charge of a shift of duty. Due to the higher risks at night, when there will be fewer staff on duty, staff who work on night duty should be provided with fire safety training four times a year. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000048135.V329306.R01.S.doc Version 5.2 Page 9 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 DS0000048135.V329306.R01.S.doc Version 5.2 Page 10 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): 3; Lime Tree does not provide intermediate care, so 6 is N/A Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. All service users have a very full and detailed pre-admission assessment of their nursing and care needs prior to admission. EVIDENCE: All prospective service users receive a full and detailed assessment of their nursing and care needs prior to admission. Where possible, written assessments are obtained from persons currently responsible for care. Assessments for admission to Lime tree Wing are performed by a registered nurse with appropriate qualifications. Where a service user is unable, or due to their condition refuses, to be involved in the assessment, this is documented, together with information on whom the assessment information was obtained from. The prospective manager reported that she had been involved in the process and hoped to become more involved when she had fully taken up her role. Assessments seen were detailed and included a wide DS0000048135.V329306.R01.S.doc Version 5.2 Page 11 range of relevant matters. For example one assessment included a very detailed assessment of the service user’s dietary needs, another documented how important an individual’s practice of religion was to them. One relative reported that they had been able to visit the home several times on their relatives behalf, to help them make up their mind about admission. Staff reported that they were given information both verbally and in a written form, to enable them to fully prepare for the admission of a new service user. DS0000048135.V329306.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users’ nursing and care needs are largely planned for, however this is not the case for all care needs. Frail service users could be put at risk by the incomplete documentation relating to meeting their complex needs. Service users are largely protected by the home’s system for managing medication, however deficits were noted in certain areas and these need attention, to ensure that service users and staff are fully protected. The home works hard with this complex group to ensure that they are treated with respect and their dignity up-held. EVIDENCE: All residents have regular assessments of their nursing and care needs, including manual handling, dietary assessments and assessment of risk of pressure damage. Where a nursing or care need or a risk is identified, a care plan is drawn up to direct staff on how to meet these needs. Staff spoken with were fully aware of service users’ care plans and care staff reported that they DS0000048135.V329306.R01.S.doc Version 5.2 Page 13 were able to inform senior staff if service users’ needs had changed, so that care plans could be reviewed and up-dated. Care plans are now evaluated every month and reflected what was observed and what nursing and care staff reported. One service user who found agreeing to care provision complex had a care plan about supporting their gradual involvement. Evaluations showed that the service user was slowly becoming more involved in their own basic care. On some occasions where care plans had been amended, this had been dated, however at other times they had not, and this should take place, so that all relevant persons can be made aware of when care plans have been changed. Some errors in documentation had been changed using liquid paper. As these records are legal documents, this should be avoided. Evaluations largely took into account all factors which could have affected the service user, but not in every case. The chiropodist had noted for one service user that they were showing signs of pressure damage. This had not been considered in the service user’s evaluation. For another service user, a record had been made of a cut to their hand, which needed dressing. No further note was made of how this wound had progressed in documentation. On discussion with the prospective manager, she was able to inform the Inspector of the situation in relation to both of these occurrences and she was advised that she should ensure that such matters are fully documented when evaluations take place. Service users generally had care plans relating to all matters which could affect them, however some gaps were observed. One service user had a very detailed care plan about the management of their diabetic condition, however two other service users with slightly less complex diabetic conditions did not. Care plans are needed for all such medical conditions, to fully inform staff of how such conditions are to be managed. Some service users had detailed care plans about topical applications, however others did not, although a range of topical applications were observed in their rooms. When a service user is prescribed or is assessed as needing a topical application, a care plan should always be drawn up to direct staff on when, where and how often the treatment is to be applied. Some service users were prescribed thickening agents, to support them in swallowing and this was briefly documented in their records. It was also clear that these agents were being used for service users, however it is advisable that, as different persons need liquids thickening to a different consistency to meet their clinical needs and individual preferences, the amount of thickening agent needed should be documented in their care plans. Some of the service users were very frail and needed their positions changing regularly and to be given fluids and diet. For such frail service users, the home uses a frequent care chart, which documents changes of position, fluids given and other interventions. Some of these service users had care plans stating how often they needed their positions to be changed, but not all. This should take place for all service users, as different persons will need their positions changing at a different frequency, according to their risk assessment, individual needs and preferences. A review of frequent care records showed DS0000048135.V329306.R01.S.doc Version 5.2 Page 14 that service users had not had their positions changed at the frequency directed in their care plan or indicated by their condition. Additionally, fluids given showed periods when they had not been given fluids or had a low intake during the 24 hour period. This was discussed with the prospective manager, who reported that staff were meeting service users’ needs but that they did not always document the care given. She was advised that records needed to be fully completed, so that the home can demonstrate that they are meeting individual needs. It is also advised that where a service user needs support in taking in adequate fluids, the amount of fluid aimed at for that individual be documented on their care plan and their fluid intake chart be totalled every 24 hours, so that staff can assess if the service user’s individual needs have been met. Service users’ records show that the home are supported by local GPs. All service users have regular reviews of their conditions and are promptly referred when medical needs are identified. All staff spoken with reported on their close working relationships with the local GPs. Due to the multidisciplinary team on site, referrals can also be made to therapists when indicated. Where service users show more acute symptoms, such as development of a temperature, staff make regular observations and documented them until the situation was resolved. One service user was assessed as being at risk of choking. They had a very clear care plan, which directed staff on actions to take should an emergency situation arise. The home has a clinical room for the storage of all medicines and other clinical items. The room is due to be up-graded shortly. All medicines were safely stored and there was a full audit trail of drugs received into the home, given to service users and disposed of from the home. Discussions should be held with the clinical waste company responsible for removing drugs, as it appeared that they do not always remove loose tablets which have been refused, spat out, dropped or found. Such occurrences are common in a home specialising in dementia care and so arrangements are needed for the safe disposal of such tablets. A review of the medicines administration records showed that two medication errors had occurred during the past month. Both related to an intermittently prescribed Controlled Drug. These errors need to be reported to the CSCI and an investigation made, together with an action plan as to how such intermittent prescriptions are to be consistently administered by registered nurses. Several service users were prescribed medication on an “as required” (prn) basis. Some service users had clear care plans about when such medicines were to given, others did not. For example, one service user considered in detail was prescribed a pain-killer, however a review of their records did not indicate why they needed this drug, although a review of their medicines records showed that they were administered this drug at times. Such plans are needed for all service users, to ensure that all registered nurses are administering such drugs in a consistent manner. DS0000048135.V329306.R01.S.doc Version 5.2 Page 15 Several service users were prescribed topical applications and other items. During the inspection, it was noted that jars of such items were placed in rooms of service users with names other than that of the person in the room. One used jar of a topical application for a person no longer in the home was placed in a communal bathroom and a thickening agent prescribed for a person no longer in the home was in a kitchenette. Prescribed items are the property of the service user and must only be used for the person for whom they are prescribed. Where a service user has left the home, such items must be promptly disposed of. One service user went out of the home with a family member on a regular basis. The Glenside Group does have a policy and procedure for actions to take in relation to medication when this occurs. Due to the individual needs of the service user’s relative, the home were not able to follow this procedure and the home were taking other actions to meet the service user’s relative’s needs. This needs to be reviewed, as the actions taken were not in accordance with the company’s policy and may put the service user, relatives or staff at risk. The home cares for some service users with very complex dementia care needs, many of whom experience double incontinence. It is much to the credit of the staff in the home that there were no odours in any part of the home. Staff ensured that resident’s dignity was maintained at all times, even when the service user was unaware of their own behaviours, which could affect their dignity. Service users looked well presented, clearly wearing clothes which suited them and their individual preferences. For example, the Inspector spent time with one service user who clearly liked wearing bright colours and later talked to another who was smartly dressed in matching pastel clothing. Service users who spent most of their time in bed had clean hair and nails and attention had been paid to the cleanliness of areas such as skin creases. DS0000048135.V329306.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, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are provided to support service users’ needs. Religious observance was supported. Family and friends are seen as important to provision of care. Staff work hard to encourage service user choice. Meals are attractively presented and staff are available to support frail service users at mealtimes. EVIDENCE: The home employs an activities coordinator Monday to Friday. The activities coordinator was on annual leave during the week of the inspection, so the Inspector could not discuss her role with her. The prospective manager reported that the activities coordinator leads a range of activities in a flexible manner, to meet the needs of service users. Some relatives felt that there was not enough emphasis in this area. One reported “there is not enough one to one” another “More interaction required” another “there is an obvious lack of activities”. During the inspection, it was observed that at least one member of staff was always with service users in each of the lounges. The staff in the lounges spent their time in individual one-to-one interactions with service users. One relative reported on how much service users clearly enjoyed it DS0000048135.V329306.R01.S.doc Version 5.2 Page 17 when one of the staff brought their dog in. Activities performed by the activities coordinator are documented but nursing and care staff do not document the one-to-one activities that they perform in activities records, so other persons would not be aware of the extent of their involvement in such activities. It was noted as good practice that service users’ religious and spiritual needs were documented in their records, together with information on when they last participated, for example in Holy Communion. Relatives are free to come and go as they wish. The prospective manager and staff spoken with stressed how important developing effective relationships with family members was in providing appropriate care and support to the service user. Several relatives commented that the home “always” gave them enough information to help them to make decisions on their relative’s behalf. Staff work hard to ensure that service users can exercise control over their own lives, as much as they are able to. Two members of staff were observed to assist a service user who had a communication problems with moving. They both took time to explain several times what they were going to do, how they would help them and make them safe and encouraging the service user in being involved in what was happening. Despite some complex behaviours exhibited by service users, many of the service users’ rooms were highly individual in appearance, reflecting the service user’s likes and preferences. Service users were able to walk as they liked along the corridors of the home and not requested just to sit quietly, as can happen in some dementia care units. The inspection started at 9:45am and it was noted as good practice that some service users were still eating their breakfast, as staff reported they did not want to get up early and preferred to have breakfast after they had got out of bed. One service user was observed to ask for some porridge in the midmorning and a member of staff went to get it for them. Staff work hard to offer service users a choice of meals at meal-times, observing for different behaviours and using knowledge of the service user, to ensure that they were given the meal that they preferred. Menus across the site have been reviewed recently. One person did inform the CSCI that they would like “proper puddings” and fewer “mousses”, another comment received that there were “too many sausages”. One person reported that the food was “good”. One service user was observed to be given a meal and clap their hands happily as they were being assisted to eat, giving all appearance of really enjoying what they were being given to eat. Service users can eat in the main dining room or in one of the smaller sitting rooms or in their own room. Meals are individually plated and liquidised diets are attractively presented. Staff remain with service users, observing and supporting them at mealtimes. Many of the service users needed assistance to eat their meals, either by verbal prompting or actual assistance. Where staff did this, they were observed to sit with the resident, chatting and supporting DS0000048135.V329306.R01.S.doc Version 5.2 Page 18 them. The home uses domestic-style crockery and cutlery as much as possible, however where aids to eating are required, these were provided. Discussions with several staff indicated that the amount of crockery and cutlery needed to be increased, as some items needed to be washed up several times during the day. DS0000048135.V329306.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the home’s complaints procedure, which works in practice. Staff are fully aware of their responsibilities for protecting vulnerable adults from abuse. EVIDENCE: The Glenside Group has a complaints policy, which includes all registrations on site. Five relatives who responded to the in questionnaire reported that they knew how to make a complaint and four reported that the home always and one usually, responded appropriately. One relative reported “I have never needed to make a complaint”. Another relative reported that they “kept in touch” with the prospective manager whenever any matters concerned them. Another relative reported “I have had issues recently but have resolved them on site.” Each home keeps its own complaints file, on which compliments and verbal concerns, as well as written complaints are documented. The acting manager and staff spoken with were aware of the operation of this procedure. One complaint had been received by the CSCI since the previous inspection. A review of the home’s records including staff employment records showed that it was fully investigated, including appropriate follow-up with relevant persons to improve performance. One matter brought up by the relative of a service DS0000048135.V329306.R01.S.doc Version 5.2 Page 20 user recently was documented on the home’s complaints file. The manager was able to inform the Inspector of actions taken to address the matter and that it was addressed informally. However, she had not documented how she had addressed the matter on the file, including response from the complainant and she should do this, as with the passage of time, such details may not be recalled, unless they are documented. The home cares for service users with complex nursing and care needs relating to dementia. All service users have care plans drawn up relating to their individual vulnerability and risk. These are regularly reviewed. Staff at all levels were very aware of their responsibilities for safeguarding adults across a range of areas, relating to the service user both as an individual and generally. Training in safeguarding adults involved taught sessions, discussions and question and answer sessions. This training is offered regularly by the training department and all staff are required to attend annual up-dates. DS0000048135.V329306.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home environment is largely well maintained, apart from one area, which has not been addressed for an extended period of time. A range of communal areas are provided. Sufficient wcs and washing facilities are provided, although the home could benefit from the provision of a disabled shower. A range of equipment is provided, but consideration needs to be given to health and safety and risk of cross infection, where equipment is used across site. Attention is needed to the replacement of some deteriorated equipment and to ensuring that all equipment is fully cleaned. While there are systems in place to prevent spread of infection, service users could be put at risk by the lack of systems to prevent communal use of some items and ineffective removal of dust in parts of the laundry. DS0000048135.V329306.R01.S.doc Version 5.2 Page 22 EVIDENCE: Lime Tree Wing is a two story building, with a passenger lift in between. Some areas have been redecorated and some new bedroom furniture and curtains have been provided since the last inspection. A new washer disinfector has been provided for sanitary items. The appearance of the entrance areas on the ground floor as improved. Less attention has been paid to other areas of the home. The home have been required to replace the deteriorated flooring to ensuites since 4th October 2004 and an action plan detailing when this would take place had been submitted to the CSCI to comply with this. By this inspection, some en-suite floors had been replaced on the ground floor, however the home had not completed much of the work in accordance with their action plan and had not informed the CSCI of why this was. This is of concern, as many of the ensuites show very stained and deteriorated flooring. Some flooring was coming up from the undersurface, meaning that ensuite rooms were becoming difficult to clean and liquids may penetrate under the flooring. At least two ensuite rooms exhibited stale odours, presumably due to this. Raised flooring can present a risk of tripping injury to this vulnerable group and to staff. This was discussed with the managers and they agreed to replace all flooring which could present a risk to service users and staff within three months and all other flooring by 21st December 2007. Service users can spend their time in one of the range of sitting areas. There is a large lounge on the ground floor, which opens out into a dining room. There are also two smaller sitting rooms, one on each floor. One carer reported how much some very frail service users, who lived on the first floor, liked the small sitting room there, as it was light, not too big and meant that they did not have to go down in the lift to a larger room, which could alarm them and provide them with too much stimulation. In warm weather, service users have access to an enclosed patio area. A wide range of equipment is provided to support service users, including variable height beds, a range of pressure relieving equipment and different hoists, to suit different service users’ manual handling needs. A range of specialist chairs to meet the needs of service users with complex seating needs were available. Service users who used such chairs looked very comfortable. All service users have new commodes in their rooms. Some staff reported that the door bell sounded in tone too like the service users’ call bells and so could become confused. This could delay response. They also felt that an increased number of repeater lights would help, so that they could ensure that they were able to respond promptly when a service user, colleague or relative used a call bell. A weighing scales suitable for wheelchair users was provided, however this was also used by other homes on site. Discussions with the maintenance department also indicated that while industrial carpet cleaners were available, there were not enough for each registration. Joint use of equipment across the DS0000048135.V329306.R01.S.doc Version 5.2 Page 23 campus needs to be reviewed, as while it is appreciated that sharing of equipment between units may be necessary, such sharing may also involve a range of risks to health and safety and prevention of spread of infection. These need to be fully considered. The home provides a range of bedrooms, many of which are single, but some double rooms are also provided. Where service users share rooms, two wash bowls are provided, these gave the appearance of having been named in the past, however the names have now come off and as all bowls seen were of a similar colour, there need to be systems developed to prevent communal use of such items, as this could present a risk of cross infection. Screens are provided in double rooms, to ensure privacy for service users. Most of the screens inspected showed some degree of deterioration, some showed old staining, others needed through cleaning, as they had evidence of dried-on debris. Where service users needed safety rails, these were provided with protectors to prevent damage to service users’ limbs. As for the screens, some were old, with deteriorated surfaces, others showed dried-on debris. A range of wheelchairs are provided for service users. There did not appear to be a system for regular cleaning of wheelchairs and most examined showed evidence of debris such as dried-on food. This was echoed by a relative who responded in a questionnaire to state “the state of the wheelchairs for the residents’ use leaves a lot to be desired.” An audit of all equipment used in nursing and care needs to take place and any old, deteriorated items disposed of and replaced. There needs to be a cleaning monitoring system to ensure that all items used in nursing and care are clean and debris-free. Nearly all rooms have an ensuite facility, including a bath. Disabled wcs are available close to sitting rooms. On the ground floor an unused bathroom has been converted into a large disabled wc. Staff reported that this helped service users who needed hoisting, to use a wc. There is one assisted bathroom in the home, it is on the first floor. Staff reported that service users on the ground floor who needed this bath had to come up to the first floor to have a bath. This is not ideal and it was reported that it could confuse some residents. Many registrations for persons with dementia now have disabled showers provided, as many younger service users are more used to showers than baths. It is advised that the home considers putting one in on the ground floor. The home has systems to prevent the spread of infection. All potentially infected waste and laundry was handled in accordance with this policy. Registered nurses reported that dressings were performed using aseptic procedure and that they had a full supply of sterile gloves. As noted in Standard 9 above, a range of jars of topical creams labelled with the name of a person other than the person in the room, were noted in ensuite facilities. Additionally two jars of used topical creams were observed in the bathroom, one of which was for a person no longer in the home. A range of other creams with no name on them were also observed in rooms. Communal use of topical DS0000048135.V329306.R01.S.doc Version 5.2 Page 24 applications is a major risk to cross infection, so all jars of topical cream must be labelled with the service user’s name and used only for that service user. Jars of topical cream must not be left in communal areas, due to the risk presented. The laundry provides a service across the whole site. It is provided in a separate building at the back of the site. The laundresses reported that clothing nearly always comes down to them properly named, so losses of service users’ clothing was not a common occurrence. This was supported by an inspection of the storage facilities in the laundry. In such a number of registrations as are on the Glenside campus, this shows good practice and staff are to be commended for their effective systems to ensure that service users’ clothing is returned to them. There are procedures for the management of infected and potentially infected laundry, which laundresses report staff keep to. The washing machines and dryers are regularly serviced. The area behind the machines was clean and dust-free. One of the laundresses reported on how they were small enough to climb behind the machines to clean the area. The area between the washing machines showed significant deposits of dust. The laundresses reported that this was because they did not have any implements to clean these narrow areas. Deposits of dust in a laundry present a significant risk to cross infection, as micro organisms can live in dust in the warm, dry atmosphere of a laundry for extended periods of time. Correct implements need to be provided to enable full cleaning between the machines. DS0000048135.V329306.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs can be met by the numbers and skill mix of staff. Training is supported for all staff, to ensure that they are competent to perform their role. The Glenside Group’s recruitment procedures protect service users. EVIDENCE: Lime Tree Wing is meant to meet minimum staffing levels as set out by the CSCI in a Staffing Notice. At the previous inspection, they were not meeting these levels for the afternoon shifts, however they were again doing this again by this inspection. Staff reported that the home generally met or exceeded the minimum levels of staffing. They reported that on the few occasions that they did not, this related to unplanned sickness. However two relatives felt that there were not enough staff. A review of the home’s roster showed that there is a low turnover in staffing. Some of the staff have worked in the home or the Group for many years. Many staff were very loyal and were prepared to cover for unplanned absences. Agency staff are not used. As well as nursing and care staff, the home are supported by central staff services, including maintenance, catering, laundry and therapy staff, as well as site management, administration and training. The home has two domestic staff, who work opposite each other. DS0000048135.V329306.R01.S.doc Version 5.2 Page 26 Given the size of the home and the issues identified in Standard 26 above, a review of whether there is enough domestic support to ensure full cleanliness of equipment and services is indicated. The Glenside Group has a training department, which is managed by a qualified trainer. All staff, at all levels, undergo a standard induction programme when they take up their posts. This includes all relevant areas such as manual handling, health and safety, fire safety and infection control. Newly employed staff are issued with a standard induction booklet, which they and their trainer/mentor sign, once they have been fully inducted into the area. One staff member described their induction as “very full and detailed”. All newly employed staff are allocated to a “buddy” on commencement of their role. Staff spoken with reported that they found this system supportive, as there was always someone they could go to if they felt they needed more information or support. One person reported that they had felt “very, very supported” when they started working in the home. The Glenside Group supports NVQ training and approximately 80 of care staff are trained to NVQ 2 or above. Additional training to meet service user needs is provided in a range of areas, for example prevention of pressure damage and diabetic care. One carer reported “we get lots and lots of training here”. All staff undergo regular mandatory training in areas such as manual handling, first aid and fire safety. Home managers are responsible for ensuring that their staff receive mandatory training. Information is freely available in each registration to show which members of staff need to attend which training. Three relatives felt that the staff “always” had the right skills and experience to look after their relative properly. The Glenside Group has a central human resources (personnel) department, which handles all applications for employment. Much improvement has been made since the previous inspection in a range of areas relating to employment of staff. All staff have a criminal records check and are checked against the vulnerable adults list. If positive results are identified, their suitability for their role is assessed and a risk assessment performed. All prospective staff complete an application form and health status questionnaire. At least two suitable references are now always obtained prior to employment. All staff are interviewed, using an interview assessment tool. These are fully completed on a individual basis. The prospective manager reported that she had been involved in interviewing prospective members of staff. Staff files showed that there were systems for management of performance, including absences. Where issues were identified, these were followed up with the individual staff member. DS0000048135.V329306.R01.S.doc Version 5.2 Page 27 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There is an internal arrangement for management of the home while a prospective registered manager’s application is progressed. The Glenside Group regularly reviews quality of service. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Systems are in place to ensure the health and safety of service users, however service users could be put at risk, as certain areas have not been considered when assessing risk. EVIDENCE: The home does not currently have a registered manager in post and there is an acting up arrangement, while an application is made to the CSCI. The person acting into the registered manager’s role is an experienced registered DS0000048135.V329306.R01.S.doc Version 5.2 Page 28 nurse and was previously the deputy manager. This person has made a good start in her role and should develop, as she gains more experience, so that there will be fewer requirements identified at the next inspection. A deputy is to be appointed to support her in her role. The Glenside Group has a team of senior managers who work an on-call rota to support all the registrations on site. When the manager or her deputy are not on duty, there is always a registered nurse to take charge of the home. In discussion with the training manger, it appears that persons who may be in charge of the home are not regularly trained in this role or their responsibilities. This is indicated, so that such persons can properly support the manager and do not need to call for assistance from the senior management team, unless indicated. The owners of the home have a system for reviewing quality of care on a regular basis. The documents reviewed considered a range of indicators in a detailed manner. The documents do not seek to “sell” the service, but detail good points and the areas which need to be addressed, including action plans and timescales. One outcome from quality audits for example, was that the menus have been reviewed and new menus put in place, to suit the range of services provided on site. As identified in Standard 26 above and Standard 38 below, audits need to take more account of health and safety issues. The Glenside Group has a clear system for regular staff supervision. All staff spoken with confirmed that they had received supervision at least every six weeks and an annual appraisal. Records relating to supervision and appraisal were seen on staff files. Supervisions and appraisals were individual in tone and issues relating to training and development were consistently included. Records showed that supervisions were also performed when it was considered that a member of staff needed additional support in a particular area. Supervision and appraisal records cross-referenced to training records, so that it was clear that where a member of staff has requested, or was assessed as needing, training in a particular area, arrangements had been made for the person to attend training, in a timely manner. None of the service users were able to look after their own moneys. All service users had an identified person who managed moneys on their behalf. These persons were invoiced for sundries, such as hairdressing and chiropody, on a quarterly basis. Full records of charges and payments were maintained. Where a service user did not have a relative who could purchase clothing for them, arrangements were made by the home, and their named person invoiced accordingly. As noted in Standard 29 above, the home has systems to ensure that staff are trained as required in a range of matters relating to health and safety. A recent fire safety audit had taken place across services on site. At present night staff are trained in fire safety twice a year. The home are advised that, as fire officers consider the risk to service users at night, when there are fewer staff to be higher, that all staff who work nights need to be trained in fire DS0000048135.V329306.R01.S.doc Version 5.2 Page 29 safety four times a year. It was noted during the inspection that two doors, one to a frail service user’s room and one to a sitting room, had been held open by a device which had not been approved by fire services. If service users wish or are assessed as needing their door to be held open, a device which has been approved by the fire officer must always be used. Many of the service users had safety rails on their beds. These were noted in their records, however a full assessment of the needs for use of this equipment, the equipments suitability and compatibility with other equipment had not taken place, as set out by the Health and Safety Executive. Any assessment relating to safety rails must be reviewed regularly, as service users’ conditions may change. As noted in Standard 19 above, some of the deteriorated flooring in ensuites was lifting and this could present a risk of tripping injury to service users. Additionally issues were noted in Standard 26 above relating to prevention of spread of infection. Such risks had not been taken into account in risk assessments or in quality audits. A review of maintenance records and discussions with the maintenance manager showed that other areas relating to health and safety, such as lift, hoist and boiler servicing, fire safety checks and water temperature testing takes place at the regularity advised. DS0000048135.V329306.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 2 x x x 2 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 3 x 2 DS0000048135.V329306.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Where a service user has an assessed need or treatment (for example is a diet or tablet controlled diabetic or is prescribed or is assessed as needing a topical application), a care plan must always been put in place to direct staff on how this need is to be addressed. Where service users are assessed as needing to be offered regular fluids or have their positions changed regularly, there must be evidence that this is taking place in accordance with care plans. This was identified at the inspection of 4/10/05 The two medication errors must be reported to the CSCI, in accordance with Regulation and systems must be put in place to ensure that where a service user is prescribed medication on an intermittent basis, that medicines are given to the service user as prescribed. Prescribed items must only be used for the service user for DS0000048135.V329306.R01.S.doc Timescale for action 30/06/07 2. OP8 12(1)(a) 30/04/07 3. OP9 13(2) 37(e) 30/04/07 4. OP9 13(2) 30/04/07 Version 5.2 Page 32 5. OP9 13(2) 15(1) 6. OP9 13(2) 7. OP22 23(2)(n) 8. OP22 23(2)(c) 9. OP24 16(2)(c) 10. OP26 13(3) 11. 12. OP26 OP26 13(3) 13(3) whom they are prescribed. Where the service user is no longer in the home, all prescribed items must be disposed of. Where service users are prescribed a medication on an “as required” (prn) basis, a care plan must always be drawn up to direct staff on the indicators for the use of such medication Where a service user goes out of the home for a period of time and their supporter needs to be given medication for them to take, there must be clear guidelines and protocols drawn up relating to this, which fully supports all persons involved. A policy and procedure on equipment shared across the site must be put in place to ensure that adequate equipment is provided. This must conform to health and safety and infection control guidelines. An audit of all items used in service user care, such as bed screens and safety rail protectors, must take place and any deteriorated items disposed of. The deteriorating flooring in ensuite bathrooms must be replaced. Requirement outstanding from inspection held 4/10/04. Last compliance date was 1/12/05 Systems must be put in place to ensure that where service users share a room, that wash bowls are not used communally. All items used in service user care must be in a clean state and free of debris. All topical applications must be labelled with the service user’s DS0000048135.V329306.R01.S.doc 31/05/07 30/04/07 30/06/07 31/05/07 31/12/07 30/04/07 30/04/07 30/04/07 Page 33 Version 5.2 13. OP26 13(3) 14. OP38 14(a)(c) 15. OP38 23(4)(c) (iv) 16. OP38 14(a)(c) name and used only for that service user. Suitable cleaning implements must be provided to ensure that the areas between the washing machines can be cleaned and be free of dust and debris. All parts of the home must be reviewed for risk of tripping injury and action taken to reduce risk. If a service user needs to have their door held open for any reason, a device which has been approved by the fire office must be used. Where safety rails are in use, a full written assessment of their need and suitability must be undertaken. Such assessments must be reviewed on a regular basis. 31/05/07 30/06/07 31/05/07 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP7 OP7 OP7 OP8 OP8 OP8 Good Practice Recommendations Where care plans are up-dated following evaluation, all additions should be dated. Liquid paper should not be used when correcting errors in documentation. When performing evaluations of care, there should be evidence to show that cross-referencing has taken place to all relevant information relating to the service user. Where service users need to be offered fluids to prevent risk of dehydration, the amount of fluids aimed for in 24 hours should be stated on their care plan. Where service users are having their fluid intake measured, this should be totalled every 24 hours. Where a service user is assessed as being at risk of DS0000048135.V329306.R01.S.doc Version 5.2 Page 34 7. 8. OP8 OP9 9. OP12 10. 11. 12. 13. 14. 15. 16. OP15 OP16 OP21 OP22 OP27 OP31 OP38 pressure damage, care plans should state how often that individual needs to have their position changed. Where service users are assessed as needing thickening agents to assist them in swallowing, their care plan should state how much thickening agent they need. Contact should be made with the clinical waste company who removes medicines, to ensure that all dropped/found/spat out/refused tablets are also taken for disposal. Following comments relating to the provision of activities, the provision of such services should be reviewed. Consideration should be given to systems for documentation of individual activities undertaken by home staff. A larger supply of crockery and cutlery should be provided. Where a complaint/concern has been dealt with locally, this should be supported by documentation, detailing when this took place and the matters dealt with. A disabled showering facility should be provided on the ground floor. There should be a review of the call bell system, to identify if the number of repeater buttons can be increased and the tone of the door bell altered. There should be a review of whether increased supervision of domestic roles is indicated or if there are enough domestic hours for the work to be performed. Management training should be provided to all persons who are in charge of a shift of duty. Staff who work on night duty should be provided with fire safety training four times a year. DS0000048135.V329306.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 DS0000048135.V329306.R01.S.doc Version 5.2 Page 36 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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