Inspection on 17/05/07 for Greenhill

This inspection was carried out on 17th May 2007.

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

Greenhill 05/06/08

Greenhill 16/05/06

Greenhill 13/12/05

Greenhill 05/07/05

Greenhill 28/02/05

Greenhill 28/07/04

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

CARE HOMES FOR OLDER PEOPLE Greenhill 5 Oaklands Road Bromley Kent BR1 3SJ Lead Inspector Miss Rosemary Blenkinsopp Key Inspection 10:30 17 and 25 May 2007 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 Greenhill DS0000042521.V336207.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. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenhill Address 5 Oaklands Road Bromley Kent BR1 3SJ 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 8289 7925 020 8290 9131 sheilamears@missioncare.org.uk Mission Care Vacant Care Home 60 Category(ies) of Dementia (21), Old age, not falling within any registration, with number other category (39), Physical disability (9) of places Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. After initial registration all new admissions must be in the category of old age, not falling within any other category There are no changes made to the current staffing compliment, with the exception that the top floor designated as providing dementia care has a RMN as a team leader and that the use of RGN’s on this floor is done so on the basis that they have substantial experience or relevant training specific to dementia; and that a RGN working on this floor will always hand over to a RMN. Mission Care must conduct a review of staffing levels at the end of the first 6 months of this variation being agreed. That review must take account of incidents/accidents within the home, complaints received, the activity of service users at night and the ability of the staffing compliment to respond to such activity. A report of this review must be submitted to the Commission. 30th October 2006 3. Date of last inspection Brief Description of the Service: The home is a registered nursing home providing care for up to 60 residents. The ground floor is physical disability residents and the first floor is for frail elderly. The Dementia Unit occupies a floor with its own staff team. The home is a modern, purpose-built facility having opened in 2003, located close to Bromley town centre with its wide selection of amenities. The categories of registration include Dementia, Old Age and Physical Disability. The home comprises four floors, with services such as kitchen and laundry located in the basement. Bedrooms are well appointed with ensuite facilities; disabled toilets, baths and showers are located throughout the home. In the reception area there are two lifts, which access all floors. The reception area is large and spacious; residents enjoy sitting in this area. There is a garden area to the rear of the building and parking is provided. Fees range between £511 - £790 weekly. Additional cost are charged for chiropody £22, Hairdressing £8 - £26, newspapers and holidays variable. The report is made available in the hallway of the home and on request. Where needed, residents would be assisted with the reading and understanding of the latest inspection reports . Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 5 Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over a one and half day period by two inspectors. The first site visit was unannounced and the second by arrangement. Terry O’ Conner the Manager of Greenhill facilitated the two inspection days. During the course of the first site visit the two inspectors spent time on separate floors, one on the Dementia Unit and the second inspector on the Frail Elderly Unit. A tour of the premises was undertaken, a selection of residents files case tracked and the care practice observed during the visits. Staff personnel files health and safety certificates and quality assurance audits were also inspected. The inspectors met with staff on duty, residents in the home and any relatives who were visiting the home. The pre inspection questionnaire was not completed or returned for the first visit therefore the inspectors gave out comment cards during this visit. At the time of writing the report thirteen comment cards had been completed and returned to the CSCI, including one health professional and one relative .The information contained within the pre-inspection was not included in this report as it was not received at the time of writing .Comments received on the days of the site visits and from the comment cards have been incorporated into this report. What the service does well: The home provides a good standard of accommodation both in terms of communal areas and individual bedrooms. Two lifts provide easy access to all floors. The large reception entrance hall is an alternative area used by residents. Staff were said to be friendly and helpful from comments received, and this was evidenced during the two site visits. Overall a good standard of care was said to be provided. A Christian ethos prevails throughout the home. Activities had improved. People are able to choose where they would like to spend their day either communal areas or in their bedrooms although please refer to comments made regarding the Dementia Unit. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Fuller assessment and care planning documentation and training in core and specific areas would enable staff to have the information, knowledge and understanding to meet individual needs. Medication practices must be improved to ensure safety of residents. The recruitment of staff needs to be improved upon to evidence that safe recruitment practices are in operation. The Manager must be satisfied that staff working in the home are safe and suitable to do so. Complaints received by the home or those requiring investigation should be responded to in a timely manner to reduce any possible distress that delays may cause. Whilst the Manager has implemented internal audit systems the Provider must ensure they conduct monthly unannounced visits and report on the findings produced. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 8 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. Greenhill DS0000042521.V336207.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 Greenhill DS0000042521.V336207.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessment procedures are in place, which includes information obtained through other multidisciplinary team members. More documentation is required to confirm trial visits and pre admission information provided to ensure that residents and their families are fully equipped with all information before a decision is made. EVIDENCE: The inspectors selected care plans and assessment information from the units, which they inspected; these were part of their case tracking. The findings are related below. Dementia Unit. Contained within one file was the assessment information of one resident. The initial Mission Care documentation was completed. This assessment had been conducted December 06 and the resident had been admitted 6 days later. There was assessment information from the Local Authority including a care Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 11 plan, multi disciplinary information and panel papers in respect of the type of care required. Additional information was provided by the GP and from Oxleas Trust by way of a Dementia assessment. In the next care plan there was the referral assessment form, Mission Care’s own documentation was completed, an application form, and a FACE assessment, which provided good information in respect of the residents needs. The inspector was unable to locate the Terms and Conditions of residency. The inspector met with the wife of this resident who confirmed assessments had been conducted prior to his admission. In other care plans which were inspected assessment information, multidisciplinary reports and Local Authority Community Care assessments and panel papers were available, although varied in content and supplied staff within some cases limited information. The inspector was unable to evidence any trial visits or visits by next of kin involved. It was difficult to establish what information had been provided prior to admission to any of these parties. First floor. One resident who had recently arrived in the home told the inspector that their son had found the home on their behalf and had been provided with a brochure. Viewing of the individuals’ records showed that the home had obtained the Care Manager’s assessment and completed the Mission Care assessment forms. On the second day the inspector viewed the pre-admission information relating to an individual who presents with some aggressive behaviour. The home had obtained the Care Manager’s assessment and had completed their own assessment forms. The Care Manager’s assessment alluded to this behaviour with the report stating the reader to view the attached reports from psychiatry, occupation therapy etc. These reports had not been included. These documents could possibly have provided the person carrying out the assessment with more information on the way the individual behaved and the assistance required by staff to support the individual. Within the comment cards received two of the seven relatives said that they or family members, had not chosen the accommodation. Three relatives stated that they received information at the time of admission, and that they were very happy with how Mission Care came across and understood enough that their relative’s needs would be cared for at Greenhill. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 12 The inspectors were unable to evidence, written confirmation of the homes ability to meet needs following their assessment. Please see requirement 1. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plan documentation and supporting records give an outline of care required although not fully comprehensive in content hence specific care needs cannot be addressed. Staff are not fully conversant with the conditions, which they deal with, hence this would negatively impact on the individuals care. Medication administration procedures introduce a margin for error. Comprehensive medication policies must be in place to cover all aspects of medication administration and afford protection to staff. EVIDENCE: Of those residents in the home, the inspectors were informed that thirteen residents had pressure sores at grade one or two. There were no residents with MRSA. or clostridium dificile. Dementia Unit. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 14 Several care plans were randomly selected for viewing. The first care plan was that of a resident who had been in the home about six months. The assessment information was well-completed and provided good information to staff to develop a care plan. Supporting weight charts were in place, as well as manual handling and monthly waterlow assessments. This resident had a very high waterlow score which is indicative of skin integrity issues. This resident did have two areas where sores had occurred. These wounds had care plans in place and wound sheets. There was a second treatment chart in place also for the wound care this was confusing and seemed to duplicate the paperwork .The sheet headed wound assessed by” was without a staff signature. The resident’s care plan reflected physical health needs as well as mental health and communication problems. The interventions section was reasonably well completed and would have provided staff with enough information to address the care for that problem. There was a care plan in relation to possible malnutrition; this could have been more specific on actions to take. There had been referral to the dietician and an individual guidance sheet was in the file to assist with her nutrition problems. There were entries on the multi disciplinary sheet from a number of involved professionals including the optician, GP and the liaison nurse. The daily events documented related outbursts of aggression and issues around her agitation, which was outlined in the care plan. Staff need to be able to deal with this is a consistent and professional manner, all staff should be made aware of the care plan content and have updates on the subject. The supporting fluid charts for this resident were inspected and again these were incomplete without full names recorded, totals incomplete and generally reflected insufficient fluid intake. There were few entries in the overnight period. There was a visual aid to fluid intake on display in the kitchen, this advised staff of what amount a vessel held as they vary considerably. This was a good prompt for staff to use. An observation chart was in place for one resident who was seen to be very restless on this unit. Handover sheets were competed and some had good information contained within them. This residents care plan was not selected for viewing. A second care plan was inspected. This resident had been admitted six days earlier. The assessment information included Mission Care’s own assessment; there was good information in some areas. Mission Care’s own application form had also been completed. The nursing assessment related relevant and comprehensive information on which staff could base a care plan. Further supporting information was provided from the hospital where the patient had Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 15 been prior to admission. At the point of the site visit the home had not received the Community Care assessment for this resident. The resident had not been issued with a Contract, or Terms and Conditions. A manual handling assessment and that for the use of bedrails were in place. The care plan was reflective of physical needs although limited in mental health issues. It was without a date or signature and the content needs to be expanded upon to provide comprehensive information for staff to address care consistently. Residents in the Dementia Unit would be unable to tell staff of how they wanted their care to be provided hence detailed information is essential. The daily events were also limited and again without full staff signatures, staff signing with first names only. A third care plan contained good assessment information obtained through Mission Care’s own procedures. Nutrition screening, manual handling assessments and waterlow had all been completed. The care plan was relevant to needs identified in the assessment and the content under the intervention section was detailed to provide staff with information on the care that this resident required. This resident also had nutrition problems and there was evidence of referral to the Dietician and guidance in place for this issue. There was a list of food preferences. There was information in respect of other multi disciplinary involvement in this residents care. On all care plans seen it could not be established if the next of kin or resident had been involved with their drawing up. On the second site visit the inspector viewed a care plan of a residents about whom concerns regarding her care had been raised with the Manager. This care plan was reflective of needs and contained additional information regarding her past life. Assessment information including that of her nursing needs, manual handling and nutrition were completed and reviewed. Evidence of referral and involvement by the multi disciplinary team was on file. The residents herself was seen in the lounge .She was bright responsive and demonstrated good signs of well being. She was drinking independently and was provided with supplement drinks. In general care plans and supporting documentation had improved although more attention to detail is required. There was more documentation in respect of the input from the multi disciplinary team. Staff need to ensure that they Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 16 are not duplicating records, as this is confusing. The example of one care plan, which had three separate wound care records, all with different information on. This could have been amalgamated in to one and would have provided a comprehensive information record. The daily events and care plans must be fully reflective of identified and presenting needs. First floor. The inspector was able to discuss the care provided with one resident. The experiences of this individual were mixed with positive feedback regarding the care provided during the morning and lunchtime although this was not continued through the remainder of the day. The individual said that afternoon/night staff were not fully aware of the individuals needs and often did not listen. It appeared from the resident’s information, that physical disabilities were focussed upon, staff lack the understanding that the resident has the mental capacity to make their own choices and decisions. The resident spoke positively of the day staff that supported him to make daily contact with his wife. They were disappointed that the physiotherapy and occupational health support promised, whilst in hospital, had not yet materialised. This resident had the support of the hospice team and therefore access to specialist healthcare should be made easier without referral through the drawn out GP referral process. The individual felt that staff were not aware of their specific illness or its presentation. The Motor Neurone Disease Society had provided the home with an information pack, however, the staff did not have the time to read and digest the information. It is preferable that due to the deteriorating nature of the illness that the home accesses direct training through the specialist rather than cascading information, as this may be timeconsuming and to the detriment of the residents care. The inspector noted that the resident was seated in a wheelchair where they spent most of their day and transferred onto the bed with the use of a hoist. The resident was seated in the wheelchair with the hoist sling still placed under him. It looked uncomfortable and according to the resident it was so. It was understood that an adaptation to the chair is required or a new chair provided. This needs to be actioned; the home should access the relevant agencies without delay. The care plan and supporting documentation was viewed in relation to this individual. The information recorded provided general information on how staff should address care to the resident. However, the information could be more specific in light of the individuals physically debilitating disease. The care plans should also detail the action being taken by the various agencies involved in the individuals care e.g.: St Christopher’s Hospice and Speech and Language Team. The inspector noted that the individual had a bed, which had bedrails attached and a lap belt attached to the wheelchair that was in use. The records Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 17 identified the use of bedrails but did not clearly identify the reasoning for this including the advantages and disadvantages of their use. There was no risk assessment in respect of the lap belt, which can be considered a form of restraint as well as providing safety. The resident was not aware of why it was being used. The resident said that they were not prone to falling or sliding out of the chair. The reason for their use must be clearly recorded and where possible discussed with the resident and next of kin, to ensure this is in the person’s best interest. A second care plan, of a resident with pressure sores, was also viewed. The care plan had been developed with supporting risk assessments. The staff had recorded the monitoring of the sores and completed a review form. Feedback from the PCT identified that the home was often referring residents to the tissue viability nurse a little too late Staff must be more proactive in approaching the team at an earlier stage when the team can be of more assistance. As in the previous resident’s records the home had not completed a risk assessment in respect of the restraint used. Medications –Dementia Unit. The clinical room was inspected. This area was tidy with no overstocking evident. The temperature records for the clinical fridge were in place and within acceptable limits. Eye drops in use were dated on opening. The unit had one resident on Phenobarbitone, which in itself is not a controlled drug, although they were storing and recording it as such. The records were accurate as was the stock balance. The covert administration policy is in draft form, although not yet a working document this needs to be finalised. Staff had attended a pharmacy meeting in February as the service provision to the home had undergone a change in supplier. The Manger conducts frequent medication audits alternating between record keeping and the safe storage aspects of medications. Medication charts were completed with photographs and allergies recorded with two signatures for hand transcriptions. Medications for disposal were recorded and dispensed into an appropriate container. A list of staff signatures was available. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 18 First floor. Medication practices on this unit were audited with the inspector observing lunchtime medication administration and viewing of some records. The administration was undertaken by the RGN on duty. The file contained a list of staff authorised to administer medication together with their initials. The homely remedies policy was dated 27/7/05 and therefore needs to be updated to reflect current residents. There was evidence of a medication audit during May 2007 that detailed shortfalls in the procedures and practices. All medication is recorded on pre-printed medication administration records (MAR) with some, but not all, detailing whether the resident had allergies. All those viewed showed a photograph of the resident. Where there are a number of MAR sheets, these should be numbered accordingly e.g. 1 of 2 etc, to reduce the margin for error. The records were generally satisfactory, although the actual blister packs were in some disorder and not reflecting the MAR. For example, different weeks medications were missing with possibly the administrator taking medication from the wrong week. The inspector also noted during the observation that medication was signed as being administered before the residents was given the medication. This practice needs to cease. Please see requirements 2 and 3. Please see recommendation 1. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities are provided usually by way of group sessions. One to one activities and interactions could benefit residents who are not able to engage in group activities. The serving of lunch and the ambience created around meal times could be improved upon to make this a pleasant relaxed an enjoyable experience for residents. EVIDENCE: Dementia Unit. The inspector spent time in the communal lounge area of this unit. In the lounge there were 12 residents. The atmosphere was relaxed olde tyme music was playing and drinks were provided during the course of the morning. Two residents were nursed in recliner type chairs staff stated this was because of the following: one resident was prone to falling, and the second had very stiff limbs. The inspector requested that staff seek the advice of the physiotherapist Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 20 or occupational therapist to offer advice on suitable seating. One resident was in a wheelchair in the lounge. Staff were giving out drinks and there was evidence of the high calorie thickener and supplements in use. At 10 50 coffee, tea and biscuits was served by the domestic on duty. At 11.15am some residents still needed assistance with drinking and a little while later staff did attend to this. Staff shortages and lack of availability particularly at busy times, was cited in the comment cards received. This was evident in the site visit. The residents in the lounge looked nicely presented. One relative commented on the dress of her husband, which she felt, was good. Prior to lunch the dining tables were well presented and the correct menu on display although salt and pepper were absent. Lunch was served it had two choices offered, the inspector noted that many of the residents required a level of assistance and supervision. Four staff were helping with the lunch and the kitchen assistant was serving it. Some residents would have benefited from adapted cutlery, plate guards and non-slip mats to assist them to eat in a more dignified manner. One lady did not eat her lunch nor was she assisted and the lunch was removed at 14.00 hours. Comments received in respect of food varied enormously. A comment received from a relative requested that the soft diet was exactly that and not completely pureed. Relatives met with both the inspectors during the two site visits .In addition comment cards were received into the CSCI office and provided further information. Staff were said to be kind and helpful and specific staff were identified as particularly kind and caring .On occasions the workload was said to be heavy and delays occurred in certain areas, assistance with drinking and responses to call bell were cited. Another relative visiting the top floor stated,” This is the best place that I have seen“. He also said he was happy with the care provided to his wife who was restless the majority of time. Two other relatives of a longer term resident indicated their satisfaction and felt staff and the receptionist were friendly. One comment card stated, “The lady guitarist that sings and entertains is excellent.” First floor. The activity room is located on the first floor with activities going on that day included crafts and cinema afternoon. One resident spoken to said that they sometimes joined in activities but may at times only be able to observe due to the physical restriction, and commented, “Staff are too busy to chat”. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 21 There are comments within other sections of this report, which refer to routines, decisions and choices. Routines often prevail and lack the flexibility to maximise choice and independence. This was evident from the mealtime routines. The lunchtime meal was observed and the inspector found that there was not enough staff to assist residents who required assistance. Meals had been left in the corridors for some residents, whilst staff supported others. The staff had also served the desserts, which included custard, and these were left to go cold. This meant the meals were getting much cooler. The inspector also noted that some of the plates came back with much of the food left uneaten. The staffing and routines at these times must be reviewed to ensure hot meals are provided, with residents supported in a relaxed and sensitive manner. The inspector noted that the temperatures were only recorded when placed into the trolley yet the meals were cooling, as they are being served and left on plates. A review of the practices for recording of food temperatures needs to be undertaken. One resident spoken to said it is like any “hospital food”. The inspector noted that there was a choice of hot meals although the cheese and onion pasty did not look appetising. The catering staff also provided pureed meals for those who required soft or pureed diets. However, there was no choice of these diets with the meal for the pureed diets being that of chicken. Please see requirement 4. Please see recommendation 2 Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information is available through which complaints can be raised. Supporting documentation was lacking in the information required to confirm that these were fully representative of those received, or that investigations had been undertaken satisfactorily. Staff had a working knowledge of adult protection procedures and the reporting of such. EVIDENCE: The complaints procedure was in place and a record of complaints logged. This was in the form of handwritten records. The register of complaints did not log all complaints that the Commission are aware of and neither does the register allow for details of how the complaint is investigated, the action taken, outcome and whether the complaint had been resolved. The Commission is also aware that there has been delays in investigating complaints that goes well beyond the timescales detailed in the procedures. In such cases there was no evidence of any contact with the complainant about this or an explanation regarding the delay. This approach may possibly, increase dissatisfaction and lead to disgruntlement. The way in which complaints are recorded and investigated must be improved upon to ensure openness and transparency of the organisation, including the Manager and Provider. The organisation has adult protection and whistle-blowing procedures. There has in the past year been incidents requiring investigation under these Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 23 procedures. These incidents have mainly come about from information provided by people external to the home and not from within. Again this had often been a long drawn out process with lengthy investigations. The records for these require further improvement both in terms of content and audit trails. Investigation reports are provided after some time but it is difficult to determine, at times, what action is being taken. One member of staff spoken to was very clear about their role in reporting any incidents that may constitute abuse and was able to demonstrate their knowledge and understanding. There was evidence of some staff attending adult protection training. Previous comments have highlighted the need for the Manager and Provider to ensure there are adequate procedures, training and guidance in place in respect of violence by residents, physical intervention and restraint. Information from seven comment cards indicated that two relatives concerns had been actioned satisfactorily whilst five stated that concerns had usually been actioned. Comments in six questionnaires indicated they knew how to complain, although one did not know the procedures. Staff spoken to, were asked about adult protection measures, they demonstrated a reasonable knowledge although external avenues for reporting such were usually not relayed or limited. In respect of dealing with complaints, staff stated they would refer these through the homes own management. Please see requirement 5. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is purpose built with equipment aids and accommodation specifically designed to meet resident’s needs. Ensuite facilities afford residents with privacy. Communal areas provide opportunities to socialise and entertain family members. EVIDENCE: The inspectors undertook a brief tour of only a few areas in the home. Dementia Unit. The lounge area was clean and tidy. Bedrooms were locked when not in use to dissuade wandering residents accessing them. The reason for locking bedrooms should be made clear to all visitors and relatives, as a few relatives were unclear about this. Alternative avenues to manage this problem must be sought to ensure that residents are not restricted or have limitations placed upon their freedom. This practice must not be used as a substitute for staff Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 25 shortages or to ensure that all residents are located in one area where there is ease of observation. All other areas were clean and tidy. Those bedrooms inspected, were in the main personalised with TV’s and radios evident. In some of the bedrooms, the call bell and the fluids were both out of reach. The lack of clocks and calendars was evident. These would provide an aid to orientation, which with this type of resident is essential. There was a reality orientation board in the corridor, this was correct. More pictures had been applied to the dining room and this gave a more domestic feel. Some areas of paintwork in the dining room needed attention this was true of the corridors and skirting boards in many communal areas. Some deep cleaning would also need to take place particularly in these areas. Wear and tear was evident in places. Areas of hazard i.e. domestic cupboards were locked, as was the sluice. First Floor. The environment was clean and fresh with no odour, although there was a strong odour in the reception area during the morning. The orientation board had been changed to ensure residents were aware of the day, weather and staff on duty. The activity room is located on this floor and, was during the morning and afternoon occupied by the activity co-ordinator and residents. Call bells were located in all rooms in the home. The inspector noted that, in the case of one resident, the call bell was not in reach. They were not able to reach the bell themselves and relied on the placement of the bell where they could actually use it. The inspector noted that there were a number of hoists in use all of which have been regularly serviced. The inspector also noted that previously the home had been required to ensure the pressure relieving equipment is used correctly and the mute button on the alarms not used. On this occasion the inspector observed in one room the mute button had once again been activated. Staff have received further training in this area, however extra vigilance is needed. On the second site visit there was an odour present on the ground floor entrance hall and corridor and second floor lounge, which had not been present at the first site visit. Again this was a morning period, hence cleaning would have been underway to address this. Please see requirement 6. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 26 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to meet the needs of residents, although at peak times the numbers are insufficient to meet all needs. Recruitment procedures in operation, and documentation retained in the home do not wholly confirm robust recruitment checks and therefore protection to residents. Induction and training needs to be provided in a more timely manner specifically the mandatory topics and those relating to patient care to ensure staff are safe to work in the home. EVIDENCE: Dementia Unit. At the time of the first visit there were 21 residents on site. There was one qualified nurse on duty with four care staff. The Unit Manager was on a supernumerary office day; she was also in the unit, although not in a hands on capacity. Ancillary staff were provided throughout the building. The off duty rota for this floor was inspected, it indicated that staffing levels were met with the occasional use of bank or agency staff. Approximately 2–3 shifts per week were covered by temporary staff, this had significantly Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 27 reduced. The Manager advised the inspectors that there are usually five care staff on duty although Head Office had stated that unless the unit had four or less care staff; they were not to employ additional staff. This must be kept under review and sufficient staff employed to meet the resident’s needs. Peak periods of work should have additional staff allocated to ensure residents’ needs are met. There had been some revision to the night duty staffing levels in so much as four nights of the week had two qualified only to cover the three floors, although additional care staff were employed. This was said by the Manager to be working well and positive feedback received from the night staff themselves. This must also be kept under review. The inspectors were advised that the period between 31/3/06 and 31/3/07 a total of 22 staff had left, including thirteen care staff and one qualified nurse. Recruitment had taken place and currently the home has 0.4 whole time equivalent vacancies. Currently agency staff covers 1- 2 shifts each week. Staff interviews. Dementia Unit. The Team Leader was interviewed. She felt that things in the home had improved and felt this had been particularly noticeable since the new Manager had arrived. Specific improvement, which she identified, related to monthly staff and relative meetings, improved activities for residents and regular supervision with the Manager. She related training, which was specific to the resident population, and updates in the mandatory topics. Manual handling was one topic where updates had not been recently received, this needs to be actioned. The domestic was interviewed; she had been in post for three weeks having transferred from Elmwood after a period of fifteen months in post. She stated that she had had a one day induction in Elmwood and one day in Greenhill. Her induction period at Elmwood had covered fire procedures although not formally conducted in Greenhill she was aware of the fire exits. A tour of both premises was provided and work routines outlined. She was able to describe the principals of infection control and the precautions needed. She had a limited knowledge of adult protection and Dementia; further training would be needed to enhance her knowledge on these topics. A care staff was interviewed during the first site visit. She had been in post since 31 March 2007. She had worked in health care previously. She demonstrated a good knowledge of the topics she was questioned about except that of the specific condition Lewy Body’s Dementia. Within the unit there were several residents with such a diagnosis, and this has specific behaviours, which are associated with it. Staff should be familiar with Lewy Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 28 Body Dementia and all conditions, which are present on the unit. She did state that she had not had the company induction yet. She added that she does undertake two roles, that of carer and that of a domestic although she had only been issued with a contract as a domestic. These two issues need to be addressed. The inspector checked this personnel file and was able to locate only the terms and conditions and a contract for that of the role as domestic. Records relating to recruitment including identity checks, application form and CRB were on file for this employee, although no induction record. The inspector met briefly with the activities coordinator. She was outgoing pleasant and enthusiastic about her role. She confirmed that activities had improved, outings locally taking place weekly, and trips to the beach planned when the warmer weather arrived. On the second site visit the inspector met with a staff member on induction it was her second day. She confirmed that on her first day she had received fire training, instruction in use of hoists, and a tour. Prior to commencing employment she had been interviewed, CRB clearance obtained, references sought and identity confirmed. Staff personnel files The inspectors raised issues around how CRB confirmation is retained. On the personnel files there were parts of CRB checks. The inspectors were unable to identify how these had been confirmed as satisfactory, or indeed what checks and input the home Manager had to satisfy himself of the employee’s suitability to work in the home. The inspectors were advised that some information is retained in the Head Office, however recruitment procedures must evidence robust checks, which the inspectors and the Manager can confirm. Apart from this issue the personnel files contained identity checks, application forms, two references, interview schedules and occupational health screening. Some training certificates were retained on file although in two further personnel files the inspector was unable to identify if induction had taken place and what supervision had been conducted. The Manager did state that supervision was just starting to be introduced and many staff had not yet received it. In the personnel file of a qualified nurse the inspector was unable to establish what checks had been made in relation to her NMC PIN number. There was no confirmation regarding checks undertaken First floor. The Inspector had discussions with a fairly new member of staff. The member of staff demonstrated a caring, sensitive and knowledgeable approach to the Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 29 needs of the residents on the unit. The staff member had a good knowledge of what constitutes adult abuse and what they would do if they were confronted with such issues or concerns. She also had a good understanding of infection control and moving and handling procedures. She discussed the way she had been inducted into the home explaining about the induction booklet that she had to complete. This booklet was viewed and since the member of staff commenced in December 2006 it is expected that the induction booklet and therefore their certificate to leave, be almost complete. However, the main parts of the induction booklet had not been completed although the individual did demonstrate a sound knowledge of care principles, adult protection, accident reporting and manual handling. There are some gaps in the training required, with food hygiene and first aid not yet completed. It is recommended that all staff receive some form of training in relation to pressure care. The staff member felt that her line Managers were approachable and supportive and that they would deal with any issues or concerns raised. She confirmed that formal supervision had taken place. Discussions with staff on the second day, particularly around the support provided to one individual, showed that they had received little in the way of training and support to care for one person who presented with aggressive behaviour. Training and information on restraint and physical intervention had not been provided. Some staff were feeling very stressed by the level of, “abuse thrown at them” and felt that they were not supported by management in this. The training records viewed were mixed although the Manager had implemented a recording system, which should in the future enable easier monitoring of training provided. One member of staff spoken to had not received food hygiene or first aid training but had received instruction in moving and handling. The inspectors were concerned about the lack of core and specific training for some staff especially first aid, food hygiene, infection control and Dementia. The inspector has also commented on the need for training, which is reflective of individual residents needs and support. The two examples being that of Motor Neurone Disease and Lewy Body Dementia. Please see requirements 7 and 8. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 30 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager has brought strong leadership to the home to provide direction continuity and monitoring of all aspects of the day-to-day management. This provides residents with confidence that the home is well run. Quality assurance is being developed and is still in its infancy. The lack of provider’s visits is still evident, which means they are not fully conversant with the workings of the home, and this provides little opportunity for residents staff or relatives to make face to face contact. EVIDENCE: The home has been without a permanent Manger since September 2005 with temporary arrangements in place. The current Manager has been in post for Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 31 three months having transferred from another Mission Care facility. He has been in management for a number of years and is a trained nurse. The Manager is currently going through CSCI procedures to become the Registered Manager of this facility. Since taking over this position, changes and improvements have been addressed. Improvements implemented by the Manager were evident in many areas of the home. Systems for auditing and reviewing the care and services provided in the home were some of the areas actioned. Further work will need to be undertaken and the current work continued, to ensure that all aspects of the operation of the home are up to scratch. Health and Safety Ten staff are first aid trained including one night staff, out of a total of 86 employees, this does not provide sufficient cover for the 24-hour period although, the Manager had this in hand. One staff member on each of the three floors is a manual handling trainer. The Manager is the Health and Safety representative. A selection of health and safety certificates were inspected including those for gas, electrical, water, both legionella testing and temperature checks, these were satisfactory. The employers liability insurance was current. The two lifts were in working order and the lift inspection reports were dated 15/11/06. The fire risk assessment was dated July 2006. The fire records evidenced that weekly fire alarm checks and monthly emergency lighting tests were undertaken. The record of fire drills was available and two drills had been conducted May 07. Staff need to sign for all training instead of the list simply listing the attendees. All day staff should receive fire training twice a year whilst night staff should receive it four times a year. Previous reports have detailed the lack of monitoring of the quality of care by the Providers in the form of the visits required by Regulation 26. These are still spasmodic and in need of a more professional approach, conducted monthly unannounced and a report on the findings made avaialble. It is positive that the new Manager has set up a system for regular monitoring of various care practices and reports regarding these were available. Discussions with one member of staff showed that they felt well supported and could approach senior staff with any issues or concerns. The staff member also stated that they received formal supervision. It was evident from the four records viewed that regular, formal supervision is yet to be developed. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 32 Please see requirement 9. Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 33 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 3 Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 34 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 OP3 Regulation 14 Requirement The Manager must ensure all residents are fully assessed including information from the multi disciplinary team and Social Services, available on all prospective residents. Terms and conditions, contracts and confirmation of the homes ability to meet residents needs must all be in place and available. Previous timeframe for action 30/06/06. This is now outstanding. The Manager must ensure that care plans are in place which are fully reflective of needs, have supporting risk assessments, including those for bed rails, in place, and all other appropriate documentation, which is kept under review. Previous time frame for action 31/10/05. This is now outstanding. The Manager must ensure that guidelines policies and procedures are in place before covert administration of medications is applied. These DS0000042521.V336207.R01.S.doc Timescale for action 30/10/07 2 OP7 15 30/10/07 3 OP9 13 30/10/07 Greenhill Version 5.2 Page 35 must be developed. Previous time frame for action 30/06/06.This is now outstanding. 4 OP15 16 The Manager must ensure that all foodstuffs are served at the correct temperature, is appetizing to residents includes choice and served in a relaxed manner The Manager must ensure that all complaints are recorded and suitable records retained, fully investigated and responded to in a timely manner and where possible in the timeframes as set out in the regulations The Manger must ensure that all health and safety aspects in the home are addressed including availability of call bells The Registered Person must ensure that all recruitment items as stated in Schedule 2, are in place prior to employment. Previous timeframe for action 13/12/05. This is now outstanding. The Registered Person must ensure that all staff are trained including mandatory topics and those specific to residents’ needs. Induction must be provided in a timely manner The Registered Person must ensure that Regulation 26 visits are undertaken monthly unannounced and a report provided covering all aspects of the Regulation. Previous time fame for action 30/06/06. 30/07/07 5 OP16 22 30/07/07 6 OP24 7 OP29 23 30/07/07 19 30/10/07 8. OP30 18 30/10/07 9. OP33 26 30/07/07 Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 36 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 OP9 2. OP15 3 4. OP19 OP38 Refer to Standard Good Practice Recommendations The Manager should ensure all medication charts are maintained in an orderly fashion The Manager should ensure that feeding aids and staff assistance is maximised during all meal times. The serving of meals should be reviewed. The Manager should ensure orientation aids are maximised within the Dementia Unit. The Manager should ensure that accident reports are retained and stored appropriately once completed. Not checked at this inspection Greenhill DS0000042521.V336207.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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