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Inspection on 14/09/06 for Havencroft Nursing Home

Also see our care home review for Havencroft Nursing Home for more information

This inspection was carried out on 14th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a comfortable homely environment. Many of the bedrooms have been personalised by the resident, and this helps to give a more homely appearance.

What has improved since the last inspection?

Some improvement to the environment has been made since the last inspection a few bedrooms have been redecorated. The home is undertaking appropriate fire alarm and emergency lighting tests.

What the care home could do better:

The home`s failure to progress in meeting the requirements from the last inspection and additional visits has resulted in an immediate requirement notice and an urgent action notice being issued for the home to address. The main areas of concern: 1. 2. 3. 4. 5. Care documentation, Management of medication, Staff training, The management of diabetics, and Staffing levels.See the main inspection report for further information. A response to the immediate requirement notice has been received by the CSCI detailing how the home has addressed the serious concern.

CARE HOMES FOR OLDER PEOPLE Havencroft Nursing Home Lea End Lane Hopwood Birmingham West Midlands B48 7AS Lead Inspector Chris Potter Unannounced Inspection 10:00 14 September 2006 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 Havencroft Nursing Home DS0000004115.V305567.R03.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. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Havencroft Nursing Home Address Lea End Lane Hopwood Birmingham West Midlands B48 7AS 0121 445 2154 0121 445 2159 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) Regal Care Limited Lesley Ann Owen Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32), Physical disability (4), Physical disability of places over 65 years of age (32) Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2005 Brief Description of the Service: Havencroft is a large, Victorian, 3 storey residence which is located in the village of Hopwood, close to the boundary of the City of Birmingham. The home is registered to provide nursing care for up to 32 frail elderly people, who may have a physical disability, and for up to 4 service users, between the ages of 55 and 64 years, who have a physical disability. The maximum number of people who can be accommodated is 32. The registered providers are Regal Care Limited, and the Registered Manager for the home is Lesley Owen, who is a first level registered nurse with many years experience working in both the National Health Service and the private sector. Havencroft’s fees range from between £440.00 for a shared room and £460.00 for a single room. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s key unannounced inspection, which took place on the 14th of September 2006 by two inspectors from the CSCI. The inspection totalled 12 hours of inspection time. The last full inspection was in December 2005 and the home has, in addition, had two further additional visits in February and May 2006 to monitor their progress with requirements from the December inspection. At the time of the inspection the home was caring for 26 residents. The inspection focused on the environment, the residents care delivery through case tracking their care documentation, staffing levels, training and recruitment, medication, and maintenance records. The views of the residents, relatives and staff were sought at the time of the inspection and prior from the comment cards. Comments were received from one service user, four relatives and two general practitioners. Comments included:” My ***** has recently moved into the home. I am very happy with the care. The staff are extremely friendly and welcome us at any time.” “We are pleased with the standards of care… Staff seem caring and approachable as is the manager.” “I am not 100 satisfied with the care, but standards have improved lately. I blame this on the fast turnover of staff. The bulk of the staff are casual staff who do not know the resident and have little compassion.” No issues were identified by the general practitioners. The inspectors raised serious concerns at the inspection, and an immediate requirement notice was issued for the home to address within 48 hours. A further notice was issued for the home to address within 28 days (see the relevant sections in this report). What the service does well: The home provides a comfortable homely environment. Many of the bedrooms have been personalised by the resident, and this helps to give a more homely appearance. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home’s failure to progress in meeting the requirements from the last inspection and additional visits has resulted in an immediate requirement notice and an urgent action notice being issued for the home to address. The main areas of concern: 1. 2. 3. 4. 5. Care documentation, Management of medication, Staff training, The management of diabetics, and Staffing levels. See the main inspection report for further information. A response to the immediate requirement notice has been received by the CSCI detailing how the home has addressed the serious concern. 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. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 7 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 Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 The outcome for this area is poor. This judgement has been made using available evidence including visits to this service. By failing to assess residents appropriately prior to admission, the home potentially places residents at risk - as the home may not have the ability to meet prospective residents’ needs. EVIDENCE: A copy of the Statement of Purpose and Service User’s Guide were available in the home. The documents need to be upgraded to include recent changes to the home’s registration. Neither had not been reviewed since 2004. The care records had a copy of the contract included in them which contains the terms and conditions of the home. Seven recently admitted residents’ care files were reviewed during the inspection. These were concerning given the home is no longer registered to accept residents with dementia type illnesses. This issue was raised at the Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 9 previous inspection in December 2005, and the CSCI had received reassurances that residents were being appropriately assessed prior to being accepted. The home advised CSCI that dementia training sessions had been booked one was provided on the 1st of June and the second booked for the 1st of November 2006. An urgent notice has been issued by the CSCI for the home to comply with their category of registration and provide training for staff. Pre-admission assessments had not been completed appropriately. The nurses had also failed to generate a care plan to reflect the residents’ care needs with appropriate risk assessments undertaken. In relation to staff competencies, the nurses must receive training to ensure that their clinical practice is up-to-date and reflects current good practice. Relatives spoken to at the time of the inspection confirmed that they had been provided with the appropriate information to assist them in making their choice. The small percentage of residents able to comment about their rooms said that they were pleased with them. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The standard of care records within the home is poor. Records are not sufficiently detailed to ensure that individual residents’ needs are met in a safe and consistent manner, neither are they effectively reviewed to ascertain the effectiveness of the prescribed care. Medication management places residents at significant risk of harm, and the clinical knowledge base of registered nurses working within the home is inappropriate in relation to people with diabetes who are insulin-dependent, and individuals who possess dementia. EVIDENCE: Eleven residents’ care files were examined during the inspection. Each resident had a care plan in place, which had been completed by a registered nurse, but the quality and content of care plans was poor. Care plans failed to effectively specify how care is to be delivered. This was of particular concern for individuals who are diabetic. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 11 The following deficits were noted about care documentation; 1. Care plans had not been formally agreed with and counter-signed by the resident and/or their next-of-kin. This is necessary to ensure that the home (a) works in participation with the individual (rather than working to preclude the individual from the care process), (b) engages the individual within the care process, and (c) ensures that the individual understands and consents to the care provided. 2. Some care plans need to be more specific and directive. For example, one care plan relating to the management of diabetes failed to clearly specify the signs and symptoms of hypoglycaemia and hyperglycaemia. This is important if care staff are to understand the symptoms they are supposed to be monitoring. 3. Care plans were not being reviewed in accordance with the frequency specified by the National Minimum Standards i.e. at least once a month. This is important to ensure that (a) any changes to a person’s condition are noted, and (b) the plan of care is amended in response to any change/s noted. 4. Although each file contained a range of risk assessments and health care assessments, some required further development as; (a) one file failed to contain any weight record, (b) one file contained a “Waterlow” pressure ulcer risk assessment which cited the individual as being at “high risk” of pressure ulcer development. However, the risk assessment had not been regularly reviewed. 5. Care plans for pressure ulcers did not effectively demonstrate the nursing care and nursing interventions necessary to address the problem/s identified. A range of health care risk assessments had been undertaken (such as fall risk assessments and pressure ulcer development risk assessments). When risks had been identified through assessment, plans of care necessary to reduce or eliminate the identified risk had not been completed. During the inspection, opportunity was taken to examine all residents’ MAR (Medication Administration Record) charts. Each resident has a MAR chart, onto which all prescribed medication is listed. It is the responsibility of all registered nurses to ensure that medication is administered as prescribed by signing the MAR chart once medication is administered (or enter an identified code when medication is not administered detailing the reason for nonadministration of prescribed medication. All medication and MAR charts are provided by a local pharmacy. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 12 The medication system within the home details a list of all staff with their corresponding signatures to identify each individual. All medication prescribed is printed onto MAR charts. On the rare occasion when the chart is not printed (for example, when an individual has been newly admitted into the home), two registered nurses enter the details onto the MAR chart(s) manually and then countersign the MAR chart(s) to confirm the accuracy of the information recorded. During the examination of MAR charts, it was noted that one person who had been prescribed fast-acting insulin (so-called because it lowers blood glucose levels for between one and four hours’ duration) and long-acting insulin (socalled because it lowers blood glucose levels for up-to 16 hours’ duration) had not received their long-acting insulin for the previous seven-day period. The insulin (“Insulatard”) had been prescribed by a medical officer to be administered at 10pm each night. The medication had not been given since 07 September 2006. Registered nurses had failed to administer the insulin as “BM machine faulty” had been recorded onto the MAR chart. An examination of the home’s daily entries for the individual concerned revealed a further explanation for the insulin being withheld. The reason given was that the individual’s blood glucose level was cited as “low” i.e. at, or about (but not below) 4mmol/ltr. The recognised normal blood glucose level parameter is 4-7mmol/ltr. Nursing staff had not taken the necessary action to safeguard the individual or promote their wellbeing. The course of action deemed clinically acceptable (safe) in this scenario is to: (a) (b) (c) Administer the prescribed insulin while administering carbohydrates (to elevate blood glucose levels while ensuring better blood glucose control over a longer (16 hour) period), Monitor blood glucose levels more frequently to prevent hypoglycaemia (whilst responding effectively if blood glucose levels fall) and Acquire a functional blood glucose meter to monitor and ensure blood glucose levels are stable (i.e. preventing hypo and hyperglycaemia). It was interesting to note that blood glucose levels were not being recorded during the daytime period (as “faulty machine” had been recorded) but fastacting insulin had been administered as prescribed. Failure to follow prescribed medical instructions in this instance placed the individual at risk (of hypoglycaemia and /or hyperglycaemia). Undiagnosed hypoglycaemia can, if untreated, result in death. There was no evidence to prove that registered nurses had undertaken appropriate safeguards to Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 13 promote the health, safety and wellbeing of the resident concerned and, as a consequence, the Commission issued an immediate requirement to specifying; (a) (b) “Only registered nurses who are competent to manage people with diabetes must manage any resident who is insulin-dependent and living within the home” and “Safe protocols for diabetic management must be adopted and implemented”. The timescale imposed was “with immediate effect”, as Regulations 12(1)(a), 12(1)(b), 13(2) and 18(1)(a) of The Care Homes Regulations 2001 had been contravened – placing residents at risk. The resident’s care plan was examined and failed to demonstrate detailed action to effectively meet the individual’s clinical care needs – in contravention of Regulation 15(1). Several other residents’ MAR charts demonstrated gaps that failed to prove that either; (i) (ii) Prescribed medication had been administered in accordance with the prescriber’s instructions, or Prescribed medication had not been administered for specific reasons i.e. the resident had refused the medication. One resident had been prescribed a painkiller, but the medication had not been given to the individual for a period of 25 days as it was recorded as “not required” on the MAR chart. There was no evidence of medical review. Some medication had been prescribed on a variable dose basis, but nursing staff had not recorded the actual dose administered. This is important to ensure that people are not given too much medication (i.e. through accidental overdose). The amount of medication being received into the home was not always being recorded. It is essential to record quantities received for stock control and audit reconciliation purposes. Many residents within the home possessed a short-term memory problem as a result of a dementia-type illness. It was clear from the (lack of) activities being undertaken and the interventions from staff that the home was not equipped to meet the needs of people with a short-term memory problem. On one occasion, a member of staff was taking an afternoon break. The staff member was seated in the dining area with her back to the residents. One male resident was stood behind her and occupying himself with a tablecloth and a vase of flowers. There was no attempt to engage the resident. There were no other staff available to either supervise the residents in the lounge/dining room Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 14 or engage the residents in meaningful conversation and activities. The only staff interaction viewed was in relation to the provision of direct care. Visitors were seen interacting with residents during the course of the inspection. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The outcome for these standards is adequate. This judgement has been made using available evidence including visits to this service. The opportunities for residents to partake in activities are limited by the availability of staff and therefore in need of improvement. EVIDENCE: The activities for residents are limited and not suited for all residents. On the day of the inspection residents were either in their bedrooms, or in the lounges. A movement to music session was held in the one lounge. Few residents were participating. Some residents are taken out to the shops and for pub lunches. The home should review the activities to ensure that they are suited for the residents. More development should be included in the care records to evidence what activities the resident has participated in. Relatives spoken to at the time of the inspection confirmed that they are able to visit at any reasonable time. Comments received from relatives prior to the inspection advised that staff were welcoming when they visited. Menus were inspected and found to be balanced and interesting and mealtime arrangements are also flexible enough to accommodate individual preferences. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 16 Menus were based on a four-week rotational basis, and residents could have up to three cooked meals a day if they so desired. The central kitchen area looked worn, but the cook stated that there were plans to develop the kitchen (although specific dates had not been provided). Catering staff are provided throughout the seven-day period, and the cook is on duty 40 hours each week. When interviewed, the cook could convey a detailed knowledge of the residents and their food preferences. However, staff were not keeping a detailed record of each resident’s daily dietary intake .The cook has worked in the kitchen for a period of three years, and was formerly a carer at the home. She had not undertaken any catering courses, neither had she gained any catering qualifications such as a City and Guilds certificate. She possessed a basic food hygiene certificate and NVQ Level 2 in Care. Opportunity must be taken to ensure that catering staff possess qualifications relevant to the duties they are undertaking. Comments received about the food stated that the quality of the food was good. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 17 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The outcome for this area is poor. This judgement has been made using available evidence including visits to this service. There is a complaints procedure in place to fully safeguard the residents. However, the complaints procedure must be adhered to. EVIDENCE: Since the last inspection the home has reported having received only one complaint and this was partially upheld. CSCI received a complaint and an additional visit to the home was completed to investigate the issues raised by the complainant. The majority of issues were upheld, and a referral to the adult protection co-ordinator for Worcestershire was made. From discussion with relatives and residents during the inspection it was apparent that not all the complaints had been recorded or the homes complaint policy adhered to. The home had a resident who was on the vulnerable adults list. The resident was challenging to both staff and residents, and this created many problems for the home. The home failed to report some significant events to CSCI and social services. Following an anonymous complaint to CSCI, the resident was transferred to a more suitable placement, as the home was failing to address the care needs. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 18 The home must ensure that residents are only admitted within the homes category of registration and the staff are competent to maintain the care needs fully. Some staff have attended protection of vulnerable adults training. Staff who were spoken with during the inspection confirmed that they had received information and would report any concerns that they had. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A rolling programme of investment within the home continues to ensure that a decent environmental standard is maintained. There are areas within the home that have been identified by the organisation as areas that require investment, and an informal improvement plan is currently being implemented based on the redecoration and upgrading of rooms when they become vacant EVIDENCE: The home has capacity to accommodate 32 residents in seven double and 18 single bedrooms. The home’s physical environment was examined during the course of the inspection. Opportunity was taken to examine all bedrooms – many of which had been tastefully redecorated to a positive standard. There was clear evidence of some residents being able to personalise their bedrooms with their own furnishings and belongings. However, some bedrooms have yet Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 20 to be decoratively upgraded, and the home has no formal improvement/ development plan (despite plans to extend the home). This was raised in the previous inspection report, but has not been addressed. At present, rooms are decoratively upgraded as they become vacant. Opportunity needs to be taken to formally commit to environmental upgrades - through the development and implementation of a redecoration programme - to ensure that residents know that the home they live in is (or will be) a decoratively pleasant and comfortable home. Many bedroom windows on the first floor of the home possessed low-level glazing (i.e. the windows were below one metre from floor level), which presents as a potential injury risk to residents should they fall against the glass. The windows did not possess either a “British Safety” kite mark; neither did they have any protective glazing film in case the windows shattered. It was noted that there are communal toilet and bathing facilities throughout the home. The home’s maintenance man has upgraded several shower rooms to a positive standard, while it is planned that a ground-floor toilet/shower facility will be upgraded by external contractors due to the need to complete the work within a very short period of time as a result of the high usage from residents. Several toilets were small, and two were reportedly not used due to their limited size. Opportunity must be taken to assess the suitability of communal toilets to ensure that they are all suited to the needs and capabilities of residents. Some toilets were too small to allow access by wheelchair-users with carer support. Whilst examining the home’s physical environment, carers were seen assisting a wheelchair user to the toilet. The resident’s privacy and dignity was compromised as the carers failed to close the toilet door. Communal space also includes two lounges (including one lounge/diner). The communal lounges provide good levels of floor space for residents, but the carpets and wall coverings were beginning to look worn. The manager stated that the carpets were over six years old. There was a glazed patio door leading from the dining area into the garden. The patio door needed motifs applied to the glazing to ensure that residents who possess failing eyesight and/or shortterm memory problems can see that the doors are there, thereby preventing any potential accidental injuries. Although sluicing facilities are provided on all three floors of the home, the ground floor only possessed a manual sluice. This increases the potential for infection, and a mechanical sluicing disinfector is required to promote infection control standards. Domestic cover is provided for between 50 and 60 hours each week within the home. However, on arrival at the home, there was a noticeable malodour permeating through the communal areas. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to this service. Staffing levels and competencies are not sufficient to safely and effectively meet the needs of residents using the service. EVIDENCE: During the afternoon period the home was staffed by just four carers. There were insufficient staff on duty for the number of residents, the dependencies of residents and the design and layout of the home. The home must clearly show the registered nurse on the duty rota. Some of the off duty provided to CSCI failed to clearly identify who the registered nurse was. Examples of this include W/C 24/07/06, 17/07/06, 10/07/06, 03/07/06. The home should also review the number of hours the registered nurses are working as it was evident that one nurse is rostered for both day and night duties albeit with a break. An urgent notice was issued following the inspection to increase the staffing levels. Relatives had commented about the high turnover of staff and felt this resulted in poor communication and staff not being aware of the residents’ needs. Of the staff on duty, one carer was assisting a resident and another carer was seated in the dining area taking an afternoon break. This left just two carers with 26 residents who were located on three floors of the home. Residents Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 22 were, therefore, unsupervised in the lounges and in their rooms. On another occasion, one member of staff was assisting a resident to the toilet while two staff were assisting a resident in their bedroom. This left just one member of staff to “supervise” and engage with the residents on three floors. The home is working towards 50 of staff with NVQ Level 2 award; presently they have only 7 care staff with the qualification and 1 member of staff with the NVQ Level 3 award. The staff training records were examined, and these evidenced that not all staff were up to date with their mandatory training. 21 staff had completed infection control training, however the date was not recorded when the training was completed. All staff were up to date with moving and handling training and food hygiene. Gaps were evident for health and safety and first aid training. No staff had completed the 4-day first aid at work course, which is necessary to ensure that the home has one fully qualified first aider on duty for the entire 24 - hour period. Only 11 staff had completed a dementia course. This was disappointing as this was recommended in the December 2005 inspection report. 17 staff had completed a prevention of abuse-training course. Other than medication training no specialist training had been provided for either the registered nurses or care staff since the last inspection. Three new staff files were reviewed at the time of the inspection, and these evidenced that the home was not adhering to their recruitment procedure. Staff had commenced employment without having a clear CRB result or POVA first clearance. One staff member commenced 15/05/06 and the CRB was not received until the 21/07/06. Another applicant had commenced eight days before the CRB result had been provided. The one application form did not include reasons for leaving employment. Only one reference had been received. Another applicant had not provided a reference from their most recent employer and no explanation had been provided for this. The home was issued with an urgent notice to adhere to their recruitment procedure to further protect the residents. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to this service. Quality assurance and quality monitoring systems, based on seeking the views of residents were not in place. The home was unable to measure its success in meeting the aims, objectives and statement of purpose of the home. EVIDENCE: Although the home had been subject to Birmingham City Council’s Social Services Department’s “Quality Premium” in November 2005 (when the home had scored 723 out of a possible 765 points), and had a “Business Management System” tool, there was little evidence of any self-audit based on seeking the views of residents. The outcomes from the “Quality Premium” failed to accurately reflect the true state of the home. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 24 There was some evidence that feedback had been sought from relative’s nextof-kin, but there was no evidence regarding the response rate, when feedback had been received and what action had been taken in response to criticism raised by respondents. The results of resident surveys had not been published, neither had they been made available to current and prospective residents, their representatives and other interested parties. There was no annual development plan for the home, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for residents. The home does not actively get involved with residents’ own financial affairs. The manager said that residents’ finances are managed by the resident concerned, their family, their representative or their solicitor. The manager is a first level nurse and has completed the NVQ Level 4 Registered Manager’s Award. As recommended on the previous inspection report, given the areas of concern it indicates that additional support and more registered nurse’s input is required. Staff confirmed that the manager was approachable and would listen to any issues raised. Comments from some relatives and residents indicated that issues were not addressed. It had been alleged that money was missing from a resident’s room however, no investigation had been commenced and CSCI had not been notified. Some staff supervision is being undertaken. This needs to be undertaken for all staff employed at the home. The home must ensure all records and registers are up to date, including residents’ care records, the complaint register, staff supervision records, and accident records. Maintenance records were available and up to date and insurance certificates were displayed. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 1 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 3 2 2 3 3 3 2 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 3 3 2 2 2 Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 26 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 OP1 Regulation 4 (1) Requirement The Statement of Purpose must be updated to reflect the changes to the home’s registration. The Service User’s Guide must be updated to reflect the recent changes to the home’s registration. The home must ensure that residents are admitted within the homes category of registration, to ensure that their care needs can be fully met. The home must be able to demonstrate that it can meet the assessed needs of the residents fully. The registered nurses must generate a care plan for the residents to fully reflect their care needs and how care staff are to deliver that care. The home must ensure that all appropriate risk assessments are DS0000004115.V305567.R03.S.doc Timescale for action 31/12/06 2. OP1 5 (1) 31/12/06 3. OP3 14 (1) 30/09/06 4. OP4 12 (1) 30/09/06 5. OP7 15 (1) 17/11/06 6. OP7 13 (4) 17/11/06 Havencroft Nursing Home Version 5.2 Page 27 completed, and show evidence of monthly review or more frequent review if residents’ conditions change. 7. OP7 15 (1) The care plan must evidence that 17/11/06 the resident or their representative has input into the care plan. The home must ensure that accident / incident records are completed and appropriate authorities advised where necessary. The home must be able to audit all medication in the home. The registered nurse must ensure all medication administered is signed for. When medication is not given, an appropriate code must be entered onto the MAR chart. All registered nurses administering insulin must be competent and clinically updated in the management of diabetes. The registered nurses must ensure that a medical review is arranged when medication is no longer required or requires altering. The home must review the activities provided. More suitable activities must be available for the more highly dependent residents. The home must ensure that their complaints policy is followed. All complaints must be acted upon, and a record contained within the complaints register detailing DS0000004115.V305567.R03.S.doc 8. OP8 12 (1) 30/09/06 9. 10. OP9 OP9 13 13 30/09/06 30/09/06 11. OP9 13 30/09/06 12. OP9 12 (1) 30/09/06 13. OP12 15 (1) 17/11/06 14. OP16 22 30/09/06 Havencroft Nursing Home Version 5.2 Page 28 the investigation and the outcome of the complaint. 15. OP18 12,13 Procedures for responding to 17/11/06 suspicion or evidence of abuse or neglect must be drawn up within the framework of the Public Disclosure Act 1998 and the Department of Health guidance “No Secrets”. The home must provide suitable locks to enable residents to lock their doors if they wish to do so. 31/12/06 16. OP24 16 17. OP19 13 An environmental risk 17/11/06 assessment must be undertaken. Not reviewed at this visit The home must ensure that all staff have the appropriate skills through training to meet the care needs of the residents. All staff must be appropriately supervised and a record of this maintained on their personnel records. The home must ensure that staffing levels and competencies are adequate to meet the needs of the residents. The registered person must supply the CSCI with a refurbishment programme, which includes carpeting and décor. The home must be effectively managed to promote and safeguard the interests of the residents. The home must notify the CSCI DS0000004115.V305567.R03.S.doc 18. OP30 18 17/11/06 19. OP36 18 17/11/06 20. OP27 18 (1) a 30/09/06 21. OP19 23 30/10/06 22. OP22 10 30/09/06 23. OP37 37 30/09/06 Page 29 Havencroft Nursing Home Version 5.2 of significant events / incidents that occur in the home. 24. OP29 18 1 a The home must ensure that the appropriate checks are completed for all new staff prior to them commencing work. Protective glazing film must be applied to all areas of low-level glazing. Visual motifs must be applied to the patio doors. Communal toilets must be reviewed to ensure that they are suitable for the needs and capabilities of residents. Appropriate action must be taken in response to the review. A mechanical sluicing disinfector must be provided on the ground floor. Keep the care home free from offensive odours. Care staff must receive training in the promotion of privacy and dignity, and receive appropriate supervision to ensure that training received is transferred into care practice. A daily record of food eaten by residents must be maintained in sufficient detail to enable the home to demonstrate that residents have received a wholesome, nutritionally balanced diet. Catering staff must receive recognised and accredited training in relation to diet and nutrition. An annual development plan for the home, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for residents must be developed and implemented. A quality assurance system DS0000004115.V305567.R03.S.doc 30/09/06 25. 26. 27. OP24 OP25 OP21 13(4) 13(4) 16 31/10/06 31/10/06 31/10/06 28. 29 30. OP26 OP26 OP30 13(3) 16(2)(k) 18(1)(a) 30/11/06 30/09/06 30/11/06 31. OP15 16(2)(i) 30/09/06 32. OP27 18(1)(a) 30/11/06 33. OP33 24 30/11/06 33. OP33 12 30/11/06 Page 30 Havencroft Nursing Home Version 5.2 based on seeking the views of residents must be developed and implemented. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP27 Good Practice Recommendations The off duty should clearly evident the registered nurse responsible for that shift. Havencroft Nursing Home DS0000004115.V305567.R03.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 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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