Inspection on 23/08/07 for Hays House

This inspection was carried out on 23rd August 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

Hays House 13/06/08

Hays House 22/01/08

Hays House 03/10/06

Hays House 10/11/05

Hays House 10/06/05

Hays House 24/01/05

Hays House 10/06/04

Similar services:

Hunters Care Centre

Manor Lodge

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hays House Sedgehill Shaftesbury Dorset SP7 9JR Lead Inspector Susie Stratton Unannounced Inspection 10:20 23 & 30 August & 7 September 2007 rd 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 DS0000015916.V342299.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. DS0000015916.V342299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hays House Address Sedgehill Shaftesbury Dorset SP7 9JR 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) 01747 830282 01747 830005 hayshouse@btconnect.com Park Healthcare Limited Vacant Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43), Terminally ill (1) of places DS0000015916.V342299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No more than 1 person in receipt of terminal care at any one time No more than 43 service users with Old Age at any one time. There are staffing conditions as agreed following the serving of the notice of proposal of 01 October 2002. 27th April 2007 Date of last inspection Brief Description of the Service: Hays House is an old country house, parts of which date back to the early Victorian era. The home is situated in eight acres of grounds and accommodation is provided over four floors. A new purpose-built wing was completed in the summer of 2002 and provides ground floor accommodation to the rear of the building. The home is owned by Park Healthcare Limited and the responsible individual is Mr R Clarkson, who visits the home on a regular basis. The registered manager’s post is currently vacant and an acting arrangement is in place. The acting manager is an experienced manager, who is also a registered nurse. She is supported by a team of registered nurses, care assistants, administrative and ancillary staff. The home is situated off the A350, between the villages of Sedgehill, East Knoyle and Semley. It is 3 miles north of Shaftesbury and 8 miles south of Warminster. The nearest railway station is in Gillingham, Dorset. Fees charged by the home are £500 to £720. Additional charges are made for hairdressing, newspapers and sundries such as toiletries. Two copies of the service users guide are available in the front entrance hall and a copy is given to all new residents or their supporters. DS0000015916.V342299.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included visits to the service and takes into account the views and experiences of people using the service. As part of the inspection, 40 questionnaires were sent out to residents and their relatives and 21 were returned. Questionnaires were also sent out to social workers and GPs and four were returned. Comments made by residents, their relatives, social workers and GPs in questionnaires and during the inspection process have been included when drawing up the report. The home provided an improvement plan following the last inspection and an annual quality assurance assessment was also submitted prior to this inspection. Both documents provided information to inform the inspection. A random inspection took place on 27th April 2007, following a complaint raised by a professional. At that inspection, no requirements or recommendations were identified. As Hays House is a larger registration, the site visits took place over three days, on Thursday 23rd August 2007 between 10:20am and 5:10pm, Thursday 30th August between 4:40pm and 5:40pm and Friday 7th September 2007 between 9:40am and 1:15pm. The prospective manager was on duty for the second two site visits. During the site visits, the inspector met with five residents and observed care for nine further residents for whom communication was difficult. The Inspector reviewed care provision and documentation in detail for six residents and considered specific documentation relating to a further six residents. As well as meeting with residents, the inspector met with three registered nurses, seven carers, the deputy manager, the activities coordinator, the catering manager, the maintenance man, three domestics, a laundress and the administrator. The inspector toured all the building and observed the lunch-time meal and several activities sessions. A medicines round was observed and systems for administration of medicines and the clinical rooms were inspected. A range of records were reviewed, including staff training records, staff employment records, maintenance records and financial records. What the service does well: Hays House is a large country house, where accommodation is provided over a range of floors. This means that all rooms are different from each other and many have extensive views over the surrounding countryside. The home benefits from well-kept gardens and many of the ground floor rooms have access via French windows. One person reported “Outside the gardens are DS0000015916.V342299.R01.S.doc Version 5.2 Page 6 beautiful”. The home employs two activities coordinators, who work flexibly, they are motivated and keen to develop their service. The owner of the home is closely involved in running the home and visits it at least twice a week. People made a range of comments about the home, one person reported “This is a first class nursing home and is run efficiently” another “My previous place was a terrible place, not like here” and another “Lovely home”. People also commented on the staff, one reported “They’re very good to me here”, another “I love the girls” and another “They do the best they can.” What has improved since the last inspection? At the last inspection, eleven requirements and twelve recommendations were made. Of these, three requirements have been met in full, three had been met in part and two showed progress. Of the twelve recommendations, eleven had been addressed in full. Residents are now not admitted until the home has confirmed that they can meet their needs in writing. Where a resident has a risk identified, a care plan is now put in place to direct staff on how the risk is to be reduced. All residents now have full risk assessments drawn up relating to their care needs. All residents have care plans in place, which relate to their care needs, including include skin care, diabetic care or instructions about treatments from professionals such as the physiotherapist. The wording of care plans is much more precise and measurable. Where a resident’s fluid intake is being recorded, the amount of fluids taken in every 24 hours is totalled. Where a resident has a diabetic condition, their care plan states in a measurable form what blood sugar levels are needed and actions to be taken if the blood sugar levels fall outside these levels. Where a resident is prescribed medication which can affect their daily living, such as aperients or pain killers, a care plan is in place so that staff can monitor the effectiveness of the treatment regimes. All staff now have access to information on residents’ past lives and preferences for activities. All frail persons who are not able to move their position or give themselves fluids have written monitoring systems. Where a person needs their position changing to prevent tissue damage, their care plan states how often their position needs to be changed and imprecise words such as regularly are avoided. Where a resident is having their dietary intake measured, documentation states what they have eaten. Where a resident has a wound, there are systems in place to ensure that the wound is regularly measured, so that the effectiveness of the treatments used can be assessed. Where residents have equipment in use such as safety rails, which are considered to be a restraint, an assessment of the need for this equipment is usually made. An interim system has been put in place to enable staff to communicate with each other across the home and to answer the telephone and front door DS0000015916.V342299.R01.S.doc Version 5.2 Page 7 A new manager was appointed to the home a few weeks before the inspection. A permanent maintenance man has also been employed. An interview assessment tool is now used for all prospective staff. What they could do better: At this inspection, 34 requirements were identified, six of which had been identified at the previous inspection and one of which had been identified at a previous inspection, and had now lapsed. Thirteen good practice recommendations were made, one of which was identified at the previous inspection. Many of the areas for improvement relate to the provision of care. All care plans need to be consistently completed to the same standard and accurately include all matters relating to the nursing and care of the resident. Care plans must be evaluated and revised when a person’s nursing or care needs change. Care plan evaluations must always include all matters which have been directed by external healthcare professionals, issues which are documented elsewhere in records, or are known about by staff. Where dates are set for the next evaluation of a nursing or care need, there must be evidence than an evaluation has taken place on or by that date. Care must always be provided in accordance with care plans, or where this is not possible, an accurate record of why this did not happen must be made. Improvements are needed in provision of care to very frail people and those who are unable to self-advocate. Records must be in place to show that residents who need frequent care are receiving this care. This is unmet from previous inspections. Such records must be accurately completed and at the time that care was provided. Nursing and care must always be provided in such a way that a resident’s privacy, dignity and comfort is maintained. Communal use of clothing must be ceased. Where residents like particular drinks and particularly where residents need to be encouraged to drink, the home must always ensure that the resident is offered such drinks and given relevant supports to drink them. All residents should have full records of their likes and dislikes for meals included in their records. Matters relating to medical care were identified. Where a resident has medical needs, there must be evidence that consultation has taken place with the relevant healthcare professionals, to ensure that these needs are met. All registered nurses must always administer medicines to residents and maintain medication records in accordance with the home’s policies and procedures and current guidelines, to ensure safe practice and that resident’s needs are met. The home’s medicines policy and procedure needs to be revised to reflect all areas relating to administration of medicines. The home’s homely medicines policy should also be reviewed so that any items which need to be taken regularly to be effective, are not included. Provision of correct equipment to meet frail residents’ needs continues to be an issue. Where equipment is in use which is not in accordance with the resident’s DS0000015916.V342299.R01.S.doc Version 5.2 Page 8 assessed degree of risk, the clinical indicator(s) for this different equipment must always be documented. This requirement is unmet from previous inspections. Where residents have equipment in use such as safety rails, which are considered to be a restraint, an assessment of the need for this equipment must always be made. Assessments must be regularly reviewed. This requirement had been identified at previous inspections. All residents who have manual handling needs need to be cared for in an adjustable height bed. This has been identified at previous inspections. Where a resident is assessed as needing equipment to prevent risk, this must always be provided. Equipment must be fit for purpose and correctly used in accordance with manufacturers’ instructions. Suitable stocks must be maintained. This has been identified at previous inspections. Residents must always be left with access to their call bell so that they can summon staff. Improvements are needed in the management of complaints and systems for safeguarding vulnerable people. All matters of concern raised with the home must be documented by the person being informed of the issue. Such documentation must be regularly reviewed, to ensure that concerns have been addressed. The home’s policy and procedure on safeguarding adults must be fully revised, to reflect current guidelines, to fully protect vulnerable persons. All staff must be made aware of their personal responsibilities under the procedure. Any issue relating to safeguarding adults must always be promptly referred, in accordance with local safeguarding adults procedures. The home needs to review its systems for security of the building and provide a written action plan to the CSCI as to how residents are to be safeguarded. The home needs to improve its systems for preventions of spread of infection, and all equipment needed to prevent spread of infection must be provided. This equipment must be properly used, be able to be kept in a clean state and not used communally. All staff must ensure that they follow infection control guidelines when handling used linen, sort linen appropriately and reduce handling of linen to a minimum. All areas in the home which present a high risk of cross infection, such as the laundry or sluice rooms must have walls which can be wiped down easily and all dust and debris must be promptly removed. Where a resident is having a dressing performed using sterile dressings, this must always be performed using sterile gloves, to ensure full aseptic procedure. This matter has been identified at a previous inspection, it was addressed at the time, but has now lapsed. All commode chairs and urinals should be labelled with the resident’s name and used only for that person. Damaged areas under soap dispensers in residents’ rooms should be repaired and protection provided to walls underneath. Effective systems for recruitment of staff need to be developed. All staff files must include two references, references must be directly sourced and obtained from the persons’ previous employer. Registered nurses must have a recent reference on their clinical skills. All staff files must include evidence of proof of identity, including a clear recent photograph. All gaps or discrepancies in employment history must always be fully investigated and records of relevant information maintained. Where staff are recruited by an agency, the agency’s DS0000015916.V342299.R01.S.doc Version 5.2 Page 9 interview assessment tool should be obtained, to ensure that a full assessment of the individual’s English language skills has taken place. Systems for straining and staff support also need to be improved. The home must support staff in training in NVQs and areas relating to resident nursing and care. The manger must ensure that all staff are supervised in their roles. A system for documentation of appraisals and supervisions must be put in place. This matter has been identified at the previous inspection. The activities coordinators should be supported in attending courses relating to their specialist field so that they can meet residents’ diverse needs. All staff should be trained in prevention of pressure damage. This was recommended at the previous inspection, it has not been addressed. All staff should be provided with badges which state their name and designation. The home should ensure that relevant matters about individual residents is communicated to support staff such as the activities coordinators and laundresses, so that these staff members can meet individual residents’ needs. Improvements are needed in all matters relating to documenting and reporting of residents’ health and well-being. Any person who observes matters relating to health and welfare must complete the records contemporaneously. All accidents to residents must be fully documented in the home’s accident book. There must be a full written audit trail of all valuables handed in for safekeeping. Improvements are also needed in ensuring the health and safety of people. The home must put in systems to ensure that all staff comply at all times with the principals of health and safety, including manual handling, infection control and fire safety and that they understand their individual responsibilities under Health and Safety legislation for reporting all matters of concern to relevant persons. There must be records to show that all fire safety tests have been carried out in accordance with directives from the Fire Brigade. Systems must be put in place to ensure that all electrical items brought into the home have been electrically tested. The home’s statement of purpose should be revised to reflect the full range of services offered by the home, such as types of nursing and care offered and minimum staffing levels. Systems to enable staff to communicate with each other across the home and answer front door should continue to be further considered. The number of requirements and the fact that several of them remain unmet from previous inspections, was discussed with the new manager and proprietor at the end of the inspection. It is appreciated that the new manager had only come in post shortly before the inspection and had not yet had opportunity to complete a review of service provision. The proprietor was therefore advised that on this occasion only, the CSCI would not be taking enforcement action to improve standards of nursing and care to residents. He and his new manager were advised that a random inspection would take place prior to the next DS0000015916.V342299.R01.S.doc Version 5.2 Page 10 inspection and that if any requirements continued to remain unmet, that enforcement action was very likely. 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. DS0000015916.V342299.R01.S.doc Version 5.2 Page 11 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 DS0000015916.V342299.R01.S.doc Version 5.2 Page 12 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. The home does not admit service for intermediate, so 6 is N/A Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. People who are admitted to the home are provided with information about the services provided and have a full assessment of their nursing and care needs, so that the home can ensure that their individual needs can be met. EVIDENCE: Hays House has a statement of purpose, which describes the services offered to residents. The information is largely comprehensive, but needs to be revised to include details of all the types of care offered, such as terminal care, and details of the minimum staffing levels, to properly inform people. Of the eleven people spoken to or who responded to questionnaires, ten felt that they were given enough information about the home to enable them to make a decision about being admitted and the one person who did not, reported that at the time of their admission, the brochure was being re-designed. One person reported that the information was “Very good” another reported “My DS0000015916.V342299.R01.S.doc Version 5.2 Page 13 relative had spent two weeks respite here previously and we had been satisfied with it then.” However one person did report that they “would like more information.” All of the residents met with who had recently been admitted were too frail to recall much about their admission to the home. Reviews of these people’s records showed that pre-admission information had been fully revised since the previous inspection, to provide a much more comprehensive admission assessment. Records had been completed in detail and provided a clear assessment of the person’s needs prior to and at admission. These reflected what was observed and what staff reported. The manager also now confirms in writing to all residents and their supporters that the home can meet their needs. DS0000015916.V342299.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to this service. People have care plans in place, however as not all care plans are evaluated and some staff are not following care plans, there is potential for residents, particularly frail and vulnerable residents, to be put at risk. There are inadequate systems to ensure that residents are treated with respect at all times. EVIDENCE: The home have fully revised all its assessment and care planning systems since the previous inspection. The new records are easy to use and have been individually completed. All residents now have full assessments, including pressure damage, manual handling needs and nutritional risk assessments. One person reported “Hays House has been implemental in improving my mother’s condition”. Where a resident is assessed as having a risk, a care plan is drawn up to direct staff on how risk is to be reduced. For example, one resident’s assessment showed that they were at risk of falls and had a clear care plan in place to direct staff on how risk was to be reduced, another resident had needs relating to an ostomy and had a care plan in place to direct DS0000015916.V342299.R01.S.doc Version 5.2 Page 15 staff on how to meet their needs in relation to this ostomy. Some care plans could be improved by including more detail, one resident had a care plan relating to the use of thickening agent in their drinks but the plan did not state the consistency to which the drink was to be thickened, another resident’s pressure relieving care plan stated that a particular type of equipment was to be used, when a different type was in place in their room. One resident did have a care plan relating to the continence aids they needed but another resident had an unspecific care plan about use of continence aids and two different types of aids were noted in their room, with no directives on which was the most appropriate for them in their care plan. Following the introduction of the new care plans, work still needs to be done on the effective evaluation of care plans. Two of the people considered in detail had specific dates documented for when their care plan evaluation was to take place, but their records showed that an evaluation had not taken place on the dates specified. One person had a specific amount of fluids which needed to be taken in to reduce risk of dehydration documented on their care plan and when they did not take in this amount, this was considered in their evaluation and the care plan revised, however this was not the case for another person with similar needs who had not taken in the specified amount of fluids for several months, and this had not been considered in their care plan review. One person’s records showed that they could experience behavioural care needs, however records included in their daily records about use of mood-altering drugs had not been included in their care plan, so the effectiveness of these drugs was not considered when the care plan was revised. One person’s records showed that the pressure relieving equipment on their bed had been changed to lower specification equipment, although their risk continued to be assessed as high. The reasons for this was not documented in their care plan evaluation. Similar issues were identified at the previous key inspection. The home responded with an improvement plan, stating actions being taken and that it would be implemented by 14/1/07. Hays house cares for some very frail people, who need to have their conditions regularly monitored. Such people have care plans in place, directing staff on how often their position needs to be changed and how they need to be supported in taking in an adequate diet and fluids. To ensure that care is given to such people, at the frequency that they need, monitoring charts in are placed their rooms. The standards of completion of monitoring charts needs to be improved. All of the frail people considered in detail had records stating that their position needed to be changed every three to four hours, to prevent risk of pressure damage. However when their monitoring records were considered, only one person’s records showed that their position had been changed at that frequency. For example, one person’s records showed that their position had not been changed between 8:00am and 3:00pm and another person between 9:00pm and 5:00pm. This matter had been identified at two previous inspections. After the previous inspection, the home responded with an DS0000015916.V342299.R01.S.doc Version 5.2 Page 16 improvement plan, stating actions to be taken and that it would be the subject of ongoing implementation. The observations made on the first site visit may relate to some records not being completed contemporaneously. For example, one person was visited at 11:30am and their chart showed that they had last had their position changed at 8:00am, however when they were visited later in the afternoon, two records relating to changes of position had been included between 8:00am and 11:30am to show that their position had been changed. As well as some records not being completed contemporaneously, others were not accurate, for example one person’s record stated that the had been placed in bed in a sitting position, but were observed to be on their left side, another person’s records stated that they were lying on their left side, when they were on their back and another person’s record stated “sat out for tea”, when they were lying in their bed. The records that were completed also did not always provide evidence of changes of position, with wording such as “repositioned” or “commode”. Records should state what position the person had been left in after care has been given. Some records and observations provided evidence that care was being given in accordance with care plans. All persons considered in detail who needed their food intake monitoring by use of a food chart had clear records of what food they had eaten, this conformed to what was observed. However other records and observations did not provide evidence of an effective care planning system. One resident clearly had issues relating to an itchy skin. This was confirmed by a carer. Their care plan did not reflect all of the topical applications noted in their en-suite. A review of their daily records showed that itchy skin had been observed previously and referred to their GP, who had commenced new treatments. These treatments had not been included in their care plan and response to these applications had not been documented in their daily records, although it was known about by staff. One person whose care records stated they needed the use of thickening agent in their drinks, to enable them to swallow safely had one drink in their room to which thickening agent had been added, but the other drink had not been thickened. Three carers who were spoken with about use of thickening agent in a different resident’s drinks, because the person’s care plan about use of such agents was not clear, gave different responses about the use of such agents. One resident with a diabetic condition had a very clear care plan about management of their condition, however their records did not provide evidence that actions had been taken in accordance with their care plan when their blood levels were outside the specified parameters. The failure to act in accordance with directives in care plans could put the residents at risk, as actions should have been taken to ensure the persons’ medical stability. Staff spoken with reported close working links with local healthcare professionals. Residents’ records showed that they were referred for further advice when indicated. One person’s records showed evidence of prompt DS0000015916.V342299.R01.S.doc Version 5.2 Page 17 referral to their GP when they were unwell. One resident had a very clear and detailed plan from their physiotherapist. One person who had a wound reported “The staff look after my legs, they are much better than they were before.” Only one resident had a wound at the time of the first site visit. This person had clear records and monitoring systems in place, so that a full assessment of the wound to treatment could be assessed. One registered nurse reported that the home no longer had any people with pressure ulcers, the most recent person that they were aware of, had been admitted with the ulcer and it had now healed. She also reported that none of the residents had urinary catheters and that the home tended to remove such catheters, once a person had settled into the home. This is regarded as good practice. One person had a diabetic condition. Their records stated that they must be referred to their GP if their blood sugar levels were above a certain level, their records did not show that this had taken place. Their records did show that they had been referred to a diabetic nurse, who had ordered certain blood tests, these had been taken, but the results had not been followed up after initial enquiries and none of the staff spoken with knew of the current situation, although the bloods had been taken some period ago. Some members of staff work hard to ensure residents’ privacy and dignity. One person reported “They’re very good to me here”. The laundress was observed to routinely knock on all residents’ doors prior to admission and await a reply before entering. One domestic was very aware of a resident’s needs for privacy relating to dressings to a wound and was able to describe in detail the steps she took to ensure that the resident did not feel concerned by issues relating to management of the wound. The Inspector heard two carers carefully explaining to a resident how they were going to assist them to move using a hoist, thanking them for helping in the process at various stages. However this was not the case on all occasions. One person reported “The care is not always up to standard” and another “The urine bottle is sometimes not emptied – so embarrassing”. One resident was observed to have an unclean mouth from breakfast or their tablets after 10:30am. Another resident was observed to be sitting on a commode, with the door to their room left open by the carers and the person could have been observed by anyone passing their room. One resident who was unable to move themselves had been left with one of their knees pressing on their safety rail and although the rail was covered by protectors, as such bed rails are hard, it must have been an uncomfortable position to be left in. One person who was able to use a call bell but was not able to move, had been left without a bell to hand and so was not able to summon assistance if they needed it. This was also commented on by people, one person reported “there are still frequent times when my relative does not have her bell within reach” and another “I’m sometimes not left with the bell”. One visitor commented that their relative’s wheelchair was labelled with their name but it was often used for other residents and that they found this “Very frustrating”. DS0000015916.V342299.R01.S.doc Version 5.2 Page 18 The laundress appreciated the importance of ensuring that residents’ own clothing was returned to them, however this was difficult for her to achieve as there did not appear to be a clear understanding of who had responsibilities for marking of residents’ clothes. The laundress was able to show the Inspector a range of items which were not marked, had been poorly marked or where the marking had faded. Without clear responsibilities for ensuring that residents’ clothing is properly marked, it is likely that clothing will not be returned to them and may be given to different residents. Additionally the system for marking of net underwear has lapsed since the last inspection, so such items are being used communally. This is not acceptable. There are safe systems for the storage of medicines, with a very tidy and well organised clinical room and medicines trolleys. This ensures that correct medicines will be used and no out of date stock items are held in the home. Residents who wish to self-medicate can do so, with full risk assessments completed. These are regularly reviewed. Where residents are prescribed Warfarin, it was noted as good practice that all blood test results were obtained in writing. No residents were prescribed Controlled Drugs. On the lunchtime on the first day of the site visit, the registered nurse performing the medicines round was observed to carefully fully follow standard procedures, checking that the resident had taken their prescribed medication and not signing records until this had taken place, prior to taking medicines on to the next resident. However, not all registered nurses are performing medicines rounds to the same standards. None of the medicines records on one floor of the home had been signed for on the morning of the first day of the site visit, although they had been reported to have been given. This is contrary to both standard practice and the home’s own policies. Additionally several residents were prescribed variable doses of that drug and although the home had directed that the registered nurse must state how much of the drug had been given on each occasion, the records showed that this usually did not take place. Non completed records were observed on at least six occasions. Registered nurses must document if a resident has taken a prescribed drug and if they have not, why not. The home has a policy and procedure to direct staff on administration of medicines. This policy is largely satisfactory but needs revision in certain areas, for example it does not document that where a resident is prescribed a drug on an “as required” basis, a care plan needs to be put in place to direct staff on when the medication to be used. There are no directives that where a person is prescribed a medicine by injection, that the injection site need to be rotated and the records the home expects relating to this. There were also no details on the administration of drugs via a PEG feed. The policy on medication errors does not direct that the CSCI needs to be informed in accordance with Regulation 37. The home does have a clear policy on homely medicines, which has recently been signed by GPs, however it includes one medicine which is only effective if given regularly and therefore needs revision so that this medicine is not included. DS0000015916.V342299.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 at least once during a 12 month period. 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 visits to this service. People in the home are supported in some respects to live the life that they prefer, however while enthusiastic staff support their recreational and dietary needs, there were inadequate systems to ensure that residents could always exercise choice, that all dietary needs were met in practice and frail people properly supported at mealtimes. EVIDENCE: Hays House has developed detailed care plans relating to social care, choice and dietary needs since the previous inspection. One relative described the “good food, occasional trips”. At the random inspection of 27th April 2007, it was noted that two residents had references in their care plans relating to the importance of relationships to them and that three members of staff spoken to separately were aware of such factors and how the home responded. The home employs two activities coordinators, they work some weekends and evenings, as well as during the day. These two members of staff were very DS0000015916.V342299.R01.S.doc Version 5.2 Page 20 much in evidence during the morning of the first site visit, leading groups, supporting residents at coffee time and ensuring that people who were confused were included and reminded of what was taking place. As the home has several different sitting rooms, the activities co-ordinators could run different groups to suit different resident’s needs. Of the eleven people who responded to the questionnaire, four reported that there were always, six sometimes and one never activities arranged by the home which they could take part in. One relative commented that the one of the “good aspects of Hays House is the good level of activities”. One resident commented “I love the quizzes”. On the afternoon of the first site visit, four residents were taken out of the home to a local beauty spot, followed by afternoon tea. The activities coordinator is enthusiastic in her role and keen to develop services. She and her colleague have not received specific training in their speciality and this would be of benefit to support them. One relative commented that residents could be more supported if the home could recruit volunteers to run small groups for the more mentally able, as most activities were as was most needed, run for the benefit of residents who needed more mental support. Another relative commented that some residents could be helped by developing links with organisations who provided support for the visually impaired. Residents reported that their visitors could come into the home whenever they wished. More than one resident commented on how they appreciated having a phone to keep in contact with their relatives. Of the eight people who responded to this part of the questionnaire, five people reported that the home always and three usually helped their relative to keep in touch with them. However one relative commented “I would like more information as they don’t always inform me about illness”. This is a local home in a rural area and some visitors know several residents in the home, helping to give a family atmosphere. The home is visited by local clergy once a fortnight. One person reported that they could eat in their room or the dining room, it was up to them. It was noted that the bath rosters allowed flexibility, so that residents could choose not to have a bath on their “designated” days and have one later in the week if they wished to do so. Some people reported that their lives had been restricted recently by the lift which did not always function properly and some people felt that lack of availability of staff affected their ability to choose how they spent their lives (see Standards 19 and 27 below). The home have appointed a new chef since the previous inspection and have also fully revised their menu. The new chef is experienced in a wide range of areas and is knowledgeable about a wide range of matters relating to management of catering services. When she has completed her induction period, she is keen to further develop her service. Of the eleven people who responded to this section of the questionnaire, one reported that they always, eight usually and one sometimes, liked the meals in the home. Comments ranged from “I don’t think the food is very good”, through “The food’s not bad, not good” to “Very nice” or “The food is good” One person commented on how DS0000015916.V342299.R01.S.doc Version 5.2 Page 21 much they liked the stews, another commented on the helpfulness of the chef, reporting “Chef will go out of her way to be helpful. Comes to see me and asks if I have any problems” and another commented on the recent changes in the menu, reporting “The menu has improved and there is choice and a good balance”. All residents who have dietary needs have care plans relating to their needs and preferences. Generally most of them are clear but not all were completed to the same standards. One of the people considered in detail had no information relating to such needs, although their records indicated that they were visited by relatives, who would have been able to inform staff, even if the resident could not do so themselves. The chef was aware of residents who needed specific diets and who had allergic conditions. Several members of staff reported that a certain resident was not keen to drink, but loved tea and would drink that. However on the day of the first site visit, their records indicated that they had not been given any tea during the afternoon, although the person was in their room the whole time. One relative reported “Cups of tea are often missed”. Another resident who needed to be encouraged to take fluids had a full cold beaker of tea on their table at 4:30pm. Tea had been given out from 3:00pm. A lunchtime meal was observed on the first site visit. Residents sat at tables in the dining room or meals were taken to them on trays in their rooms. Staff take trays out to residents first and support residents who need assistance to eat but remain in their rooms, before giving our meals in the dining room. The chef has an organised system for ensuring that residents are given the meals that they have asked for, although one person reported “Occasionally you get someone else’s food – not often”. This may relate to agency staff or staff supervision, rather than the home’s organisational systems (see standard 27 below). Staff are available in the dining room and one of the carers’ leads, to ensure that all residents are supported. One member of staff was observed to remind residents not to touch their plates as they were hot and check that the resident had understood and not hurt themselves. Another carer was observed to remind a resident about their meal when their attention had wandered. Generally carers sat down with resident to assist them in taking in their meals and to try to make it a social occasion, however this was not the case for all staff. One member of staff was observed to be standing to assist a resident to eat, not to be talking to the resident while they were doing this and to need to be reminded of how to support the resident by another carer. During the lunch-time period, one registered nurse was fully engaged in performing the medicines round, however the other registered nurse was not in evidence, spending their time in the office, not supervising the carers. In many homes, as nutritional intake is regarded as a key factor in care and registered nurses are available throughout the meal time, supervising what is taking place and supporting staff, particularly where residents have a swallowing difficulty. DS0000015916.V342299.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 inspected at least once during a 12 month period. 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 visits to this service. People are able to complain about the service provided, however the policies and procedures in the home and staff compliance with such procedures mean that at times some residents may not be fully safeguarded. EVIDENCE: Hays House has a complaints policy and procedure, which people are informed of in the service users’ guide, and information is available in the main entrance. Of the eighteen people who responded to this section of the questionnaire, fifteen reported that they knew how to make a complaint. One person reported “Nothing I can complain about here” and another “I’ve had the odd grouse and have had to go and say something”. One person reported “On one occasion we were not happy with the attitude of one or two people, I went to see the Matron and staff attitude has changed a bit since.” People reported that they would bring issues up with the Matron or the sisters if they had matters to raise. However not all people were so positive, one reported “If I’m troubled, I talk to myself. I’ve never seen the Matron” and another “I don’t know who I’d talk to.” Some people felt that the home responded well when issues were raised, one person reported “the care team have always responded appropriately by answering any questions”, however another person felt that their concern “Has been pushed aside.” DS0000015916.V342299.R01.S.doc Version 5.2 Page 23 Discussions with staff and a review of comments sent in by residents or their supporters indicated that a range of matters have been brought to staff about individual concerns and perceptions of deficits in service provision. Evidence from staff and a review of records indicated that many such issues are dealt with at the time. However as no records are made of such matters, management is not in a position to review the types of areas brought up and if staff are dealing with them in an effective or consistent manner. Since the previous inspection two matters have been raised with the CSCI. One matter relating to an individual was investigated during a random inspection and no requirements or recommendations were identified as a result of the random inspection. Another matter related to a specific matter to a member of staff, this has been investigated by the owner of the home. The home has a policy and procedure on safeguarding adults. The policy is very brief and needs expansion, to ensure that all staff are aware of all areas of safeguarding adults which may affect them and of their individual responsibilities for reporting issues relating to safeguarding adults. The acting manager reported that she was currently putting training in safeguarding adults in place. One carer spoken with was aware of the date and that she would be attending. This is needed because of some of the issues identified during the inspection relating to ensuring residents’ privacy and dignity and manual handling practice (see standard 10 above and 38 below). Two matters have been reported via local vulnerable adults’ procedures. One matter was identified via a person who whistle-blew to the CSCI. The matter was not referred by the home, although there was evidence that it was a matter known about in the home. The issue was referred by the CSCI via the local procedures and meetings held, with a decision that the home must fully investigate the matter and report back. At the time of this inspection, this investigation was not yet complete. A second matter was reported by the manager of the home and investigated according to local procedures. Issues appeared to relate to inappropriate manual handling procedures (see standard 37 below). Where residents need restraints such as safety rails to ensure their safety, the home has a standard documentary system for assessment and evaluation of their use. Generally there were full assessments undertaken, with regular reviews of these assessments, however in one case, a resident was observed to have safety rails in place but no assessment of need for such rails had taken place, although consent from their relatives had been sought. As use of bed rails can put residents at risk, the home’s procedures must always be followed. One resident who had frail skin and a risk of bruising, had protection provided on only one rail and another resident had protection but it was not correctly fitted to the rail and as the resident was observed to be restless in bed, they could have dislodged the protection and have put themselves at risk. DS0000015916.V342299.R01.S.doc Version 5.2 Page 24 Assessments for bed safety rails and use of protectors to the rails need to be part of training for staff in safeguarding adults, to ensure that all staff follow the home’s procedure and that residents are properly protected. The home has several side doors as well as the main door. During the inspection, it was observed that many of them remained open and unsecured. One person reported their concerns about this, stating “The front door is permanently unlocked apart from at night and there are umpteen side doors. There should be a way of knowing who is in the building. The visitors’ book is not obvious.” During the inspection it was noted (see Standard 27 below), that staff were not always obvious in the building, so they were not in a position to monitor who was coming into the building. This could present a risk to residents who are frail and unable to communicate as they would not be fully protected from persons who they do not know coming into the home or even their room. DS0000015916.V342299.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to this service. People can enjoy a well maintained home environment, where improvements have been made in the provision of equipment. Not all equipment was being correctly used and emphasis needs to be placed preventing risks of cross infection, to fully protect vulnerable residents. EVIDENCE: A full-time maintenance man has been employed since the previous inspection and the effect of this was visible during the inspection, with many areas generally improved. One carer reported on how one matter was identified and how promptly the maintenance man had responded. Another matter was noted during the inspection and quickly taken up by the maintenance man. The maintenance man has ensured that all wheelchairs and all hoists have been serviced since he came into post. One person commented “He’s got a nice room and it looks very pleasant”, another said that it was a “Lovely home, the property is nice”. Two people commented particularly on the French DS0000015916.V342299.R01.S.doc Version 5.2 Page 26 windows for rooms on the ground floor of the home, one saying “He likes the patio doors open and sitting in the sun.” One area which needs improvement is the areas under the soap dispensers in some rooms, as tarnishing from the soap was visible down some walls underneath the dispensers. The home has recently installed a new lift. This lift has not been functioning properly at all times, since its installation. This was reported by staff, residents and visitors. The owner is aware of this and was making continued efforts to rectify the situation as speedily as possible. Since the last inspection, improved communication systems have been put in for staff. The new manager is aware that these are interim measures and reports that she is continuing to review the effectiveness of different systems to assist staff in communicating with each other across what is a building with a complex layout. The home has a range of equipment to meet residents’ disability and nursing needs. Staff informed the inspector that they had enough hoists to meet residents’ needs, with at least one hoist per floor. One carer described to the Inspector how they used a hoist in one assisted bathroom. Use of pressure relieving equipment has improved with the pressure on all air mattresses correctly relating to the resident’s weight. Manufacturers instructions state that for air mattresses to be effective, that bed sheets must not be tucked in. This was largely complied with, however on two occasions, bed sheets were observed to be tucked in and on one occasion fitted sheets were used. On two occasions, residents had been supplied with mattresses which provide comfort, not pressure relief, although they were assessed as being at high risk of pressure damage, there were no records in their notes to indicate why this was. One resident was assessed as being at high risk of pressure damage and had a high specification mattress on their bed but did not have the same specification cushion on their chair, with no records as to why this was, although records did indicate that they got out of bed for periods every day. Issues relating to provision and correct use of pressure relieving equipment were identified at the previous inspection. The home responded with an improvement plan stating the actions taken and that it would be implemented by January 2007. Discussions with care staff indicated that they had not yet had training in prevention of pressure damage as recommended at the previous inspection. This is indicated to ensure that residents are not put at risk by incorrect use of equipment. Since the last inspection, the home have invested in further variable height beds, there are not yet sufficient to meet all residents’ needs, but the situation is much. All parts of the home inspected were clean. Domestic staff were observed performing their roles. They were careful, for example ensuring that undersides of items were cleaned as well as more visible areas. Of the twelve people who responded to this part of the questionnaire, eight reported that the home was always and four usually clean. One person reported “The cleaner is very thorough and extremely helpful” another reported “I’ve never seen such a place for being cleaned” and another “If anything happens, out comes the hoover again.” Cleaning staff reported that they had a good supply of gloves DS0000015916.V342299.R01.S.doc Version 5.2 Page 27 and cleaning chemicals. One reported that they had recently been provided with new vacuum cleaner. A variability was noted in practice, equipment and facilities to ensure good infection control practice were not all in place. Carers were observed to use gloves when performing personal care. Where two people shared a double room, there were clear systems to ensure that individual resident’s washing and personal items were labelled and separated. In several communal areas like bathrooms and sluices, nail brushes were provided, the purpose of such brushes was not clear and if such items are used communally, there is a major risk to cross infection. The soap dispensers in sluice rooms showed staining down the walls below, this included some damage, so that the walls could not be effectively wiped down. As sluice rooms are regarded as areas where there is the potential for major risk of cross infection all areas need to be fully wipable. Some sluice rooms had been provided with foot pedal operated waste bins, but not all. Bins for clinical waste must be foot-pedal operated to prevent risk of hand contamination when handling potentially infected waste. In communal bathrooms, some non-slip mats had been left to dry but others had not. The undersides of bath mats need to be dried after use, to prevent risk of cross infection when using bathrooms communally. The home appeared to have enough commode chairs for each resident to be allocated their own, however none were labelled with the resident’s name, even in shared rooms, so there is a risk that commode chairs could be used communally. None of the male urinals inspected had been labelled with the resident’s name and many of them showed signs of staining with lime scale. These should be replaced. In the laundry, it was observed that unused laundry was being sorted on the floor on one occasion, on all other occasions it was sorted in plastic receptacles. Used laundry should never be sorted on the floor as this presents a risk of micro-organisms being carried out on member of staffs’ footwear. During the first site visit, it was observed that staff did not at all times separate different forms of laundry. Subsequent discussions with a laundress indicated that she also found that not all staff follow the home’s policy and procedure on the management of used linen. This means that she has to sort items in the laundry. Current infection control guidelines are that the handling of used linen needs to be kept to a minimum. Dust and debris was visible behind the dryers. As micro organisms may live in dust, all dust needs to be regularly vacuumed away from dryers and debris removed. Some of the bins for sorting laundry had deteriorated and showed holes in their base, this means that they would not be able to be properly cleaned and could present a risk to cross infection. The laundress showed an awareness of some principals of prevention of spread of infection and showed a keenness to learn, however she had not been trained in the area and this is needed as laundries are regarded as areas for high risk of cross-infection. Discussions indicated that not all registered nurses use sterile gloves to perform dressings. One resident was having regular dressings performed DS0000015916.V342299.R01.S.doc Version 5.2 Page 28 using sterile dressings. The tissue viability nurse states that where a wound requires sterile dressings, that sterile gloves must always be used to ensure effective aseptic technique can be performed. This is a matter which was required at a previous inspection and had been rectified, so it is of concern that practice has lapsed. DS0000015916.V342299.R01.S.doc Version 5.2 Page 29 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): Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to this service. People are protected by adequate numbers of staff with an appropriate skill mix, however a higher than average turnover and use of agency staff may mean that residents needs cannot always be met. Residents are not fully protected by the current systems for recruitment of staff and more emphasis needs to be placed on improving training programmes, to support staff in meeting residents’ needs. EVIDENCE: Hays House has a team of registered nurses and carers who provide a 24 hour service to residents. Registered nurses and carers are supported by ancillary and administrative staff. The off duty roster indicates that there are sufficient staff on duty to meet residents’ needs, however a wide range of people felt that there were not enough staff to meet residents’ needs. This is likely to relate to supervision systems, not actual numbers (see standard 26 below). The number of agency staff used have reduced since the previous inspection, however they continue to be used, including one agency carer on the day of the inspection. Discussions with staff indicated that agency usage was higher at the weekends and on late shifts. Three different agencies are reported to be used by the home, it was reported that as much as possible the same carers are used but that this was not always achievable in practice. The annual quality assurance information provided by the home prior to the inspection DS0000015916.V342299.R01.S.doc Version 5.2 Page 30 indicated a higher than would be anticipated turnover in staff than would be expected in a home in this location and of its type. None of the staff met with wore any form of identification, so it was not possible for the Inspector to identify the roles of the people working in the home. None of the residents were observed to call staff by their own names, as tends to occur in homes where staff wear name badges. Discussions with staff such as the laundress and activities coordinator indicated that they were not routinely informed of such factors as changes in a resident’s condition or presence of infection. This is needed to ensure that such key staff can provide and effective and safe service to residents. The files of six members of staff were reviewed during the inspection. Most staff are interviewed by the home using an interview assessment questionnaire. A review of files indicated that a previous manager had commenced reviewing and improving the files, however some issues remain. All staff have had police checks, had completed a heath questionnaire and submitted an application form, including the names of two referees. Most staff had photographs on file but not all. Some staff had photocopies of their passport photograph, these were not clear and did not provide a clear image of what they looked like. One of the files reviewed only included one reference. One person had documented two referees but neither of them were from the person’s previous employer as was written on their application form. One of this person’s referees indicated that the employer documented on their application form may not have been their previous employer, but there was no evidence that this had been considered at their interview. This same person did not have a reference from a person who could comment on their current nursing skills. Their interview assessment record did not provide evidence if this had been explored during their interview. Two members of staff had been recruited by an agency on behalf of the home, they had references, which had been translated on file, but it was not clear if they had been directly sourced or were “to whom it may concern” references. Where staff had been employed by an agency, the agency’s interview assessment form was not included on their file, so it was not possible to assess if the person’s English language skills had been assessed prior to employment. One person’s interview assessment form stated that they had recent experience with elderly people, this was not expanded and was not supported by their CV. This person’s CV also stated one date for commencement with their previous employer while their application form documented a different date. There was no evidence that this had been probed at interview. Records on recently employed staff files indicated that they were provided with an induction on commencement of employment. During the first site visit, a senior domestic was observed to be supervising a newly employed domestic, to support them in awareness of a specific area in their role. All staff files have a brief induction on them relating to areas to be covered in the first 24 hours. The induction programme for carers complies with current guidelines and the DS0000015916.V342299.R01.S.doc Version 5.2 Page 31 records of one recently employed person had been fully completed on an individual basis. Staff spoken with reported that NVQ training was supported. One cleaner reported that the home had supported her in gaining an NVQ in cleaning. The annual quality assurance assessment provided by the home prior to the inspection indicated that the home did not yet have 50 of care staff trained to NVQ 2 or equivalent. Discussions with staff indicated that carers had not yet been provided with training in common areas relating to elderly people such as prevention of pressure damage, swallowing difficulties or diabetes. The new manager reported that she had identified a wide range of deficits in staff training and had already put in place a range of plans to address these deficits and improve staff understanding of nursing and care needs of residents. She planned to complete this by 30th April 2008. DS0000015916.V342299.R01.S.doc Version 5.2 Page 32 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): Quality in this outcome area is poor. This judgement has been made using available evidence, including visits to this service. Residents are not at all times supported by the management systems in the home to ensure proper supervision of staff, correct documentation and application of principals for health and safety. EVIDENCE: Hays House does not have a current registered manager. Since the last inspection, two different individuals have been appointed but both have not remained in their post. The owner of the home wrote to the CSCI shortly before this key inspection, to inform them that he had appointed a new manager. This person is an experienced manager and registered nurse, who has been manager of the proprietor’s sister home. This person has commenced the process so that she can be assessed by the CSCI’s registration DS0000015916.V342299.R01.S.doc Version 5.2 Page 33 team to become registered manager for the home. If is of concern that there are a wide range of requirements which have not been addressed for several inspections; however it is appreciated that the matters identified cannot be addressed immediately and will require training and support to staff. The proprietor was therefore advised that a random inspection would take place before the next inspection and that if matters remained outstanding, that enforcement action would be likely. There are safe standard systems for the management of residents’ moneys. No cash is handled and all payments are dealt with via invoices. All records are well maintained and easy to audit. The home does not have a receipt book to records items of value handed in for safekeeping, so there is no audit trail for such items. The home has a system for auditing the quality of nursing and care provided. It was noted that some of the issues raised that this inspection, such as matters relating to the laundry had already been identified. The new manager reported that residents and their supporters had in the past been sent questionnaires on which they could report on the quality of service provision but that this had not taken place during the last year. It was advised as part of the quality audit that not just the number of accidents but their type and times of day sustained should be audited. As noted in standard 16 above matters of concern raised by people are not documented, so the manger will not be aware of the range of factors affecting residents. As noted in standard 27 above, many people commented that they felt there were not enough staff on duty, comments included “Sometimes there is simply no one around to ask for help. I think maybe staffing levels could be the problem. When staff take a break they all seem to go off at the same time, leaving no one available to help. As some residents are unable to ring for help, there should be someone patrolling regularly round the rooms”, “They come eventually when you ring the bell” or “You don’t see many staff down here”. During the afternoon of the first site visit, the Inspector toured the home for an hour and did not see any staff. It is appreciated that some of the staff were in residents’ rooms, providing personal care. As the activities coordinators were taking some residents out on a trip, there were also no staff visible in the sitting rooms. One resident in a sitting room was asking for assistance. No staff could be found in the area and the Inspector had to go to the nurses’ station, where she found one registered nurse. At 3:00pm, two carers were observed assisting two catering assistants in buttering home-made scones. The manager confirmed that this was not part of their expected roles. Some matters relating to personal care were observed not to be being carried out in a manner which would ensure service user’s privacy and dignity (see standard 10 above). Issues relating to incorrect manual handling were identified during a safeguarding adults investigation (see standard 38 below). Some care was not being given in accordance with care plans and not all records were completed in a correct manner (see standards 7 & 8 above). DS0000015916.V342299.R01.S.doc Version 5.2 Page 34 None of the staff spoken with reported that they were regularly supervised in their roles. In a home where staff are properly supervised, correct care is performed, in accordance with care plans, all staff are aware of their responsibilities and any breaches in practice are noted and followed up. In such homes, senior staff monitor performance on a continual basis, to ensure that care needs are met and that staff are available to provide care when they are on duty. A requirement relating to staff supervision was identified at the previous inspection. The home responded with an action plan stating that the implementation date would be the end of April 2007. The home is required to maintain records in a correct manner. As noted in standards 7 & 8, some records were not completed accurately and in a correct manner. Additionally staff were aware of one person’s itchy skin but had not documented it. Two residents were noted in their daily records to have sustained accidents, one person had a skin tear and another had spilled hot tea on their arm. No records of these accidents had been made in the home’s accident book. Records of slips and falls were documented. Where such accidents were documented, there was evidence of review and follow-up by the manager. During the inspection period, a safeguarding adults investigation was taking place in relation to bruising, probably relating to incorrect manual handling. The acting manager and her deputy identified most of the persons who had sustained injury, but it was observed that although the bruising was visible and some of it was likely to have been there for several days, no records had been made by staff in either accident books or the residents’ daily records. Staff need to be aware that any accident, such as bruising, needs to be documented and reported as soon as it is observed. During another safeguarding adults investigation, it became clear that at least one resident and perhaps more had been distressed on one occasion when the lift failed to function but no records had been made about this in their records. Accurate records are needed to ensure that information is available to all staff over the 24 hour period, so that managers are aware of a situation and information is available to relevant other persons, such as GPs. There are systems in place to train staff in areas relating to health and safety, such as manual handling. During the course of a safeguarding adults investigation, it became clear that some staff, even if they have been trained, were not performing manual handling in a correct manner. This may relate to lack of appropriate training and or supervision. All training is performed by an external agency and the home does not have its own manual handling coordinator. It is understood that as a result of the safeguarding adults investigation that all staff are to be re-trained in manual handling and that an internal person will be appointed as a manual handling coordinator. As well as concerns about manual handling, a range of performance issues in relation to infection control were also noted (see standard 26 above). Another example was noted during the late afternoon of the first site visit where it was observed that a used pair of gloves had been left on the floor of the sluice DS0000015916.V342299.R01.S.doc Version 5.2 Page 35 room on the first floor and not disposed of correctly. Records of fire safety are maintained but not in accordance with directives from Wiltshire Fire Brigade on the frequency of checks and there were no records that routine checks on fire exits were performed, although the maintenance man reported that he routinely did this. This matter has been reported to the local fire brigade. The new maintenance man had not been trained in testing of electrical items, so he was not sure about how any new electrical items brought in by residents or their relatives were to be tested for safety. Increased awareness relating to fire safety is indicated. The door to the laundry room was observed on several occasions to be held open by a wedge but no staff were visible in the laundry. It is appreciated that the laundry room can become hot, but if the laundress leaves the room, she should always remove the wedge until her return. DS0000015916.V342299.R01.S.doc Version 5.2 Page 36 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 1 1 1 DS0000015916.V342299.R01.S.doc Version 5.2 Page 37 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Timescale for action 31/12/07 2. OP7 15(2)(b,c) 3. OP7 13(4)(c) All care plans must be consistently completed to the same standard and accurately include all matters relating to the nursing and care of the service user. Care plans must be properly 31/12/07 evaluated and revised when a service user’s nursing or care needs change. Care plan evaluations must always include all matters which have been directed by external healthcare professionals, issues which are documented elsewhere in records, or are known about by staff. Where dates are set for the next evaluation of a nursing or care need, there must be evidence than an evaluation has always taken place on or by that date. Where equipment is in use which 31/12/07 is not in accordance with the service users assessed degree of risk, the clinical indicator(s) for this different equipment must always be documented. UNMET REQUIREMENT: This requirement was identified DS0000015916.V342299.R01.S.doc Version 5.2 Page 38 4. OP7 12(1)(a) 5 OP8 17(1)S(3) (k) 6 OP8 17(1,a)S3 (3,k) 13(1)(b) 7. OP8 8. OP9 13(2) at the inspection of 10/11/05, when the timescale for action was 30/11/05. Progress was noted at the next inspection of 31/10/06 but it had not been addressed in full, a compliance date of 31/01/07 was set. As the new manager has been in post for a few weeks only, a new compliance date has been agreed. The manager of the home must ensure that care is always provided in accordance with care plans, or where this is not possible, than an accurate record of why this did not happen is made. Records must be in place to show that service users who need frequent care are receiving this care. UNMET REQUIREMENT This requirement was identified at the inspections of 10/11/05 and 21/01/06. As parts of the requirement had been addressed by the inspection of 31/10/06, more time was given to address the requirement in full, with a compliance date of 31/11/06. As the new manager has been in post for a few weeks only, a new compliance date has been agreed. Monitoring records relating to care of residents must be accurately completed and at the time that care was provided. Where a service user has medical needs, there must be evidence that consultation has taken place with the relevant healthcare professionals, to ensure that these needs are met. All registered nurses must always administer medicines and maintain medication records in DS0000015916.V342299.R01.S.doc 31/12/07 31/12/07 31/12/07 31/12/07 30/10/07 Version 5.2 Page 39 9. 10. OP10 OP10 13(4)(c) 13(4)(a) 11. OP15 16(2)(i) 12. OP16 22(2) 13. OP17 13(6) 14. OP18 37(1)(g) 15. OP18 13(7) accordance with the home’s policies and procedures and current guidelines. Service users must always be left with access to their call bell. Nursing and care must always be provided in such a way that a service user’s privacy, dignity and comfort is maintained. Communal use of clothing must be ceased. Where service users like particular drinks and particularly where residents need to be encouraged to drink, the home must always ensure that the service user is offered such drinks and given relevant supports to drink them. All matters of concern must be documented by the person being informed of the issue. Such documentation must be regularly reviewed to ensure that concerns have been addressed. The home’s policy and procedure on safeguarding adults must be fully revised, to reflect current guidelines. All staff must be made aware of their personal responsibilities under the procedure. Any issue relating to safeguarding adults must always be promptly referred, in accordance with local safeguarding adults procedures. Where residents have equipment in use such as safety rails, which are considered to be a restraint, an assessment of the need for this equipment must always be made. Assessments must be regularly reviewed. REQUIREMENT MET IN PART This requirement was identified at the previous inspection of 3/10/06, with a timescale of DS0000015916.V342299.R01.S.doc 30/09/07 30/09/07 30/09/07 31/10/07 31/12/07 30/09/07 31/12/07 Version 5.2 Page 40 16. OP18 13(4)(c) 17. OP22 13(4)(c) 18. OP22 13(4)(c) 19. OP26 13(3) 31/01/07. As the new manager has been in post for a few weeks only, a new compliance date has been agreed. The home must review its systems for security of the building and provide a written action plan to the CSCI. All service users who have manual handling needs or need to be fed in bed must be cared for on an adjustable height bed. REQUIREMENT IN PROGRESS: A similar requirement was identified at the inspection of 10/11/05, with a timescale of 28/02/05. Due to changes in management of the home, they were given more time to address the requirement, with a revised compliance date of 31/3/07. As the new manager has been in post for a few weeks only, a new compliance date has been agreed. Where a service user is assessed as needing equipment to prevent risk, this must always be provided. Equipment must be fit for purpose and correctly used in accordance with manufacturers’ instructions. Suitable stocks must be maintained, so that the service user is not put at risk. REQUIREMENT MET IN PART This requirement was identified at the previous inspection, with a timescale of 28/02/07. As the new manager has been in post for a few weeks only, a new compliance date has been agreed. All equipment needed to prevent spread of infection must be provided. This equipment must be properly used and be able to be kept in a clean state. Items such as nail brushes must not be DS0000015916.V342299.R01.S.doc 31/12/07 31/12/07 31/12/07 30/11/07 Version 5.2 Page 41 20. OP26 21. OP26 22. OP26 23. OP29 24. OP29 25. OP29 26. OP30 27. 28 OP35 OP36 used communally. All staff must ensure that they follow infection control guidelines when handling used linen, sort linen appropriately and reduce handling of linen to a minimum. 13(3) All areas in the home which present a high risk of cross infection, such as the laundry or sluice rooms must have walls which can be wiped down easily and all dust and debris must be promptly removed. 13(3) Where a service user is having a dressing performed using sterile dressings, this must always be performed using sterile gloves, to ensure full aseptic procedure. N.B. This matter has been identified at a previous inspection, it was addressed at the time, but has now lapsed. 19(4,i)S2 All staff files must include two (i) references, references must be directly sourced and obtained from the persons’ previous employer. Registered nurses must have a recent reference on their clinical skills. 19(4,i)S2 All staff files must include (6) evidence of proof of identity, including a clear recent photograph. 19(4,I)S2 All gaps or discrepancies in (6) employment history must always be fully investigated and records of relevant information maintained. 18(1)(c, i) The home must support staff in training in NVQs and areas relating to service user nursing and care. 17(2)S4 There must be a full written (9) audit trail of all valuables handed in for safekeeping. 18(2) The manger must ensure that all staff are supervised in their roles. A system for 13(3) DS0000015916.V342299.R01.S.doc 30/09/07 30/11/09 30/09/07 31/10/07 31/12/07 31/10/07 30/04/08 31/10/07 31/12/07 Version 5.2 Page 42 29. OP37 17(1,a)S3 (3) 30. 31. OP37 OP38 17(1a)S3 (3j) 13(4a -c) 33. OP38 23(4) 34. OP38 13(4)(b) documentation of appraisals and supervisions must be put in place. UNMET REQUIREMENT: This requirement was identified at the previous inspection, with a timescale of 31/03/07. As the new manager has been in post for a few weeks only, a new compliance date has been agreed. All matters relating to service users’ health and well-being, must be documented and reported to relevant persons. Records must be completed contemporaneously by the person who observed the occurrence. All accidents to service users must be fully documented in the home’s accident book. The home must put in systems to ensure that all staff comply at all times with the principals of health and safety, including manual handling, infection control and fire safety and that they understand their individual responsibilities under Health and Safety legislation for reporting all matters of concern to relevant persons. There must be records to show that all fire safety tests have been carried out in accordance with directives from the Fire Brigade. Systems must be put in place to ensure that all electrical items brought into the home have been electrically tested. 31/10/07 31/10/07 31/12/07 31/12/07 31/12/07 DS0000015916.V342299.R01.S.doc Version 5.2 Page 43 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 OP1 Good Practice Recommendations The home’s statement of purpose should be revised to reflect the full range of services offered by the home, such as types of nursing and care offered and minimum staffing levels. The home’s medicines policy and procedure should be revised to reflect all areas relating to administration of medicines. The home’s homely medicines policy should be reviewed so that any items which need to be taken regularly to be effective, are not included. The activities coordinators should be supported in attending courses relating to their specialist field so that they can meet residents’ diverse needs. All residents should have full records of their likes and dislikes for meals included in their records. Damaged areas under soap dispensers in residents’ rooms should be repaired and protection provided to walls underneath. Systems to enable staff to communicate with each other across the home and answer front door should continue to be further considered. All commode chairs and urinals should be labelled with the service user’s name and used only for that service user. All staff should be provided with badges which state their name and designation. The home should ensure that relevant matters about individual service users is communicated to support staff such as the activities coordinators and laundresses, so that these staff members can meet individual service users’ needs. Where staff are recruited by an agency, the agency’s interview assessment tool should be obtained to ensure that a full assessment of the individual’s English language skills has taken place. All staff should be trained in prevention of pressure damage. (This was recommended at the previous inspection, it has DS0000015916.V342299.R01.S.doc Version 5.2 Page 44 2. 3. 4. 5. 6. 7. 8 9 10 OP9 OP9 OP12 OP15 OP19 OP22 OP26 OP27 OP28 11 OP29 12. OP30 13. OP33 not been addressed). Review of accidents, including type, frequency and time of day should be included in the audit of quality of service provision. DS0000015916.V342299.R01.S.doc Version 5.2 Page 45 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000015916.V342299.R01.S.doc Version 5.2 Page 46 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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