Inspection on 20/05/08 for Hillcroft Nursing Home

This inspection was carried out on 20th May 2008.

CSCI found this care home to be providing an Poor service.

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

Hillcroft Nursing Home 04/12/08

Hillcroft Nursing Home 18/02/08

Hillcroft Nursing Home 04/09/07

Hillcroft Nursing Home 21/08/06

Hillcroft Nursing Home 12/12/05

Hillcroft Nursing Home 06/06/05

Hillcroft Nursing Home 18/01/05

Hillcroft Nursing Home 20/07/04

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Heathlands

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Inspirations

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Hillcroft Nursing Home 135 High Street Wordsley Stourbridge West Midlands DY8 5QS Lead Inspector Jean Edwards Unannounced Inspection 07:55 20 & 21st May 2008 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 Hillcroft Nursing Home DS0000004878.V364759.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. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillcroft Nursing Home Address 135 High Street Wordsley Stourbridge West Midlands DY8 5QS 01384 271317 01384 271112 christinedalwood@hotmail.com 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) Mr. Jayantilal James Bhikhabhai Patel Mrs. Kailash Jayantilal Patel Mrs Christine Dalwood Care Home 28 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (28) of places Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to include up to 28 OP and up to 10 DE(E) Service Users to include up to 28 OP and up to 10 DE(E) Date of last inspection 18th February 2008 Brief Description of the Service: Hillcroft Nursing Home is situated in a residential area of Wordsley close to a main bus route, shops and other local facilities. The home has been converted from a traditional domestic dwelling and extended for its present purpose a care home providing nursing care to a maximum of 28 residents in the category of old age, many of whom have complex needs and require a high level of care. Ten of these 28 places can be allocated at any one time to older people who have a diagnosis of dementia. Hillcroft, as stated, is registered to provide nursing care and therefore has a registered nurse on duty at all times. The home is on two floors. The ground floor housing the lounge, dining area, conservatory, kitchen, laundry rooms, office, a number of bedrooms, toilets and an assisted bathroom. The home has an attractive garden to the rear and car parking space to the side. The home offers ramped access, has a passenger lift, hoisting equipment and other aids and adaptations to enhance, safety, accessibility and independence. For information about fees that the home charges you are advised to contact the Home Manager. This home may charge a third party top up fee. Other additional costs include hairdressing and private chiropody, which can be provided within the home on request. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We, the Commission for Social Care Inspection (CSCI), undertook an unannounced key inspection visit. This means the home has not been given prior notice of the inspection visit. Two CSCI inspectors spent two weekdays at the home from 07:55 to 20:40 hours, accompanied for part of the inspection by the CSCI pharmacy inspector. We have monitored the compliance with Statutory Regulation Notices and all Key National Minimum Standards have been assessed at this visit. The range of inspection methods to obtain evidence and make judgements includes: discussions with the registered proprietor, registered manager and staff on duty during the visit, discussions with residents, observations of residents without verbal communications and examination of a number of records. We also spoke to relatives visiting the home. Other information has been gathered before this inspection visit including notification of incidents, accidents and events submitted to the CSCI. The registered persons did not submit the home’s Annual Quality Assurance Assessment (AQAA) until after the given timescale and after the inspection visit. Information relating to the exact number of residents being cared for at the home was not produced during the inspection visit. We sent resident surveys, relatives surveys, health care professional and staff surveys to the home to be distributed and requested they be returned to the CSCI office in Birmingham to be collated and included as part of this report. We took a tour around the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents’ bedrooms, with their permission, where possible. The quality rating for this service is Zero stars. This means the people who use this service experience poor quality outcomes. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There were some small improvements to the way the home plans each persons care. Some improvements had been made to the environment; a large visual office space / nurses station had been created in the lounge, so that residents could see staff, whilst they could complete records in privacy. We were told that additional nursing profiling beds with integral bedrails had been provided aid residents comfort and protect them from the risks of accidents. The lounge had also been redecorated, providing a lighter more airy feel for residents. The home had strived to increase activities on offer for residents, mainly provided in the home. We observed the movement to music session on the second morning of this inspection visit, which the majority of residents enjoyed participating or watching. There was also a church service in the afternoon, with communion for those who wished it. The church members brought their musical instruments, providing a pleasant background to the hymns. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 7 What they could do better: The registered persons had been issued with Statuary Requirement Notices following the last inspections in January and February 2008. These Notices were to make sure essential improvements were made to the way care was provided and risks were managed. They also included actions the registered persons must take to make sure areas such as medication, and staff recruitment promoted residents’ health, safety and well being. When we inspected these actions we found that the registered persons had not made the required improvements and in some areas such as the medication system there had been a serious deterioration. As identified at previous inspections and in the Notices resident’s care records must be more detailed and reflect all residents individual needs, choices and capabilities and provide staff with comprehensive instructions how their needs should be met. The poor quality of records of food, drinks and care of people in bed must be improved to offer confidence that the care needed is actually provided. Advice and support must be sought from the community dietician for all residents were assessed as being at risk of poor nutrition or loosing weight. There was a recommendation to look at stimulation for those residents who spend all or the majority of time in their bedrooms to give them an increased quality of life, which has not been actioned. The systems for resident’s prescribed medication must be reviewed and improved urgently and an immediate requirement notice was left at the home. This was to make sure all residents receive the medication prescribed by their GP for their health and well being. We found that there were incidents, complaints and allegations, which the registered manager had not referred or actioned to the Local Authority, as required. At the previous inspection it was highlighted as requirement to undertake actions including referral to safeguard residents for any unexplained injury. At this visit we found a number of unexplained accidents and records of bruises, which were not reported to other agencies, including the CSCI. This meant that because required actions were not undertaken at of any sign of potential abuse there were no assurances that residents would be protected from harm. The registered persons must continue with the refurbishment and decoration of the home and with the replacement of furniture and facilities, especially bathing facilities to make the home a safer and more comfortable home for residents. The need to provide appropriate storage for wheelchairs to improve access around the home had not been actioned. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 8 There was a requirement issued at the previous inspection to review the numbers of staff on duty. This was because the number of people at the home with dementia and constantly wander particularly at night had increased. We could find no evidence that action had been taken and the review of staffing levels must be undertaken as a priority. The recruitment of staff at the home has not been undertaken either safely or appropriately to meet the regulations for some time and this remains the situation. The appropriate and safe recruitment of staff will mean that the risk of people who are unsuitable to work with vulnerable people will be reduced. It is acknowledged that some required changes have been undertaken but other requirements remain unmet and this continues to put residents at risk. The failure to undertake required actions has lead to the need for Statutory Requirement Notices, which could have been avoided if required actions had been taken. The management team need to ensure that they solicit advice and take the advice that is given and act upon it to enable care and practice at the home to be developed and improved and give confidence that high quality care is consistently provided. There has been further deterioration in the management of the home, which has the potential to place residents at risk. As already highlighted Statutory Requirement Notices were issued at the previous inspection but none have been complied with. Care planning, risk management, health monitoring and recruitment practices must improve in order to meet residents’ needs and reduce the risk of harm. Staff should be provided with specific training to meet the needs of residents. This should include dementia, diabetes, challenging behaviour, person centred approaches to care and skin care. Staff should be supported by being given regular formal supervision. This would ensure they understand their roles and responsibilities. Improvements to some health and safety monitoring should occur in order to promote the safety and well being of residents. These should include completing risk assessments for cleaning products, staff in relationships who work on the same shift together and for moving and handling of a named resident. Action should also be undertaken to ensure wheelchairs are regularly serviced. 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 Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 9 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 10 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 Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is poor. The home has comprehensive assessment tools. The written information is not always fully completed or regularly reviewed, as needs change, which means that residents’ needs may not be fully assessed to ensure that all their care needs will be met. Standard 6 is not applicable This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were copies of the home’s statement of purpose and service user guide available in reception and we noted that there were welcome packs, containing information, hung the back of the doors in some bedrooms. At the key inspection on 18 February 2008 we noted that information about the home had been updated and included photographs of residents involved in activities. We noted that there was no further development to produce documents in any alternative large print, easy read or pictorial formats, which would improve access for residents and others with sensory or other disabilities. Information Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 12 about the range of fees that are payable was still not included in the service user guide or a sample contract / terms & conditions. The information that the home is required to make available remains incomplete and potential residents and representatives were not enabled to make an informed judgement about the home. It was strongly recommended at previous inspections that all information required by the Care Homes Regulations 2001 be provided and this should be easy to read and understand for people needing to use the service. This action remains unmet. We looked at 6 residents case files and requested that the registered manager provide us with all documents relating to each person. As noted at the inspection on 18 February 2008, there were no copies of resident’s contracts seen in any of the files examined. This has also been the situation at previous inspections. A copy of the reviewed contracts had been forwarded to the Commission for Social Care Inspection. However there remains an outstanding action for the registered persons to ensure that there is a copy of the residents contract, signed and dated by the resident or their representative and a representative of the home to be retained on individual case files in compliance with the Care Homes Regulations 2001. As noted at the previous inspection the resident’s needs have been assessed prior to them coming to live at the home. The majority of pre admission assessments show improvement and contained comprehensive information, though there was no documentary evidence of the active involvement of residents or their representatives, such as signatures, which would demonstrate good practice. At the inspection on 18 February the registered manager told us that she did speak to relatives and included these comments in the care assessment. At that time we recommended that family members, whenever possible, being invited to be present when assessing potential residents, the Manager confirmed that she would look at ways that she could do this more effectively. However there was no evidence at this inspection that this had taken place. From the care file examined we noted that 3 residents had deteriorated and though the registered manager had completed a comprehensive dependency assessment and score on admission this had not subsequently been reviewed. When we discussed these documents with her she acknowledged that they had not been reviewed and updated to show the current and accurate dependency levels. She could not show us any evidence as to how she monitored or revised staffing levels. This meant that staffing levels may not be adjusted to meet residents changing and in some instances increasing needs and dependency levels. We asked the registered manager how many residents were at the home on the first day of this inspection visit. She was not able to give us accurate information, stating there were 24 or 25. We questioned this number because Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 13 at the previous inspection 18 February 2008 it was recorded that there were 23 residents. Since that inspection visit the Local Authority had temporarily suspended funding for new placements at this home. Furthermore, when we requested residents’ case files, she informed us two residents were deceased. The registered manager told us that one person had died in hospital, the other at the home in April 2008. There was no recorded evidence to show that Regulation 37 notifications had been sent to the CSCI office in Birmingham. On one case file there was a front sheet, indicating a Reg 37, which was incomplete and the address was for the CSCI Halesowen office, closed in November 2007. The registered manager was unable to offer an explanation except to say that maybe the night nurse had posted the information. The lack of notifications in compliance with Regulation 37 was highlighted as a serious concern at the previous inspection and a requirement was issued, together with a serious concern letter to the registered persons. There was no evidence that the registered manager had put systems, procedures or protocols in place to ensure all nursing staff responsible for the running of the home were fully aware of compliance with Regulation 37. We looked at the case file for a temporary resident who had stayed at the home for a short respite stay from 10 – 14 May 2008 and noted that this persons assessment, care planning and risk assessment was less comprehensive and did not take account of all needs. There were significant omissions in healthcare assessments, risk assessment and care plans. Examples were there was no record of weight on admission, no nutritional assessment, no risk assessment for wandering or fainting episodes, no record of preferred rising, retiring, personal care routines or gender of staff to provide assistance. There were no care plans to give staff guidance relating to personal care, sleeping, wandering or for PRN pain relief. There were no records of formal reviews taking place, initiated by the home and involving the resident, their representative, and outside agencies or advocates. The home stated that it does not provide a service for people requiring intermediate care. Hillcroft Nursing Home DS0000004878.V364759.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. Care planning is not adequate to identify all peoples needs and fails to provide staff with sufficient instructions to meet residents needs and therefore does not provide assurance that people’s needs will be met. The arrangements for administration of medication do ensure residents receive their prescribed medicines and pose risks to their health and well being. Residents are treated respectfully. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This home had been served with a Statutory Enforcement Notice to improve care planning and care records to ensure all residents’ health and well being. Prior to this Key Inspection we had received assurance from the Registered Proprietor that all aspects of the notices had been actioned and care planning and care records were improved. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 15 However from the samples of care records examined we noted, although there were some further small improvements, similarly to the previous Key Inspection on 18 February 2008 there were significant omissions in each person’s plan for care and a lack of evidence of provision for their care. Although there was generally a comprehensive initial assessment of people’s needs a reassessment of changing needs was not documented as reassessments or monthly care planning evaluations. We looked at the care of a sample of six residents with complex needs. Examination of records, observations we made throughout the inspection and discussions with staff confirmed that the needs of some of these residents had changed significantly. We noted that although the care planning and assessment documentation indicated space for signatures of the resident / relatives or representatives, the sample of records examined only contained the signature of the registered manager or trained nurses on monthly evaluations and reviews. We did not seen any documentary evidence of regular formal reviews involving residents, families or outside agencies and the registered manager and a trained nurse confirmed there had been no action taken in involve any advocacy for residents lacking capacity, in relation to The Mental Capacity Act 2005. One person was no longer able to use the communal areas of the home and was being nursed in bed. This person had very quickly developed a pressure ulcer and although we were assured it was improving, there was no record that a Regulation 37 notification had been made to the CSCI when it was grade 34; and the nursing care plans and evaluations were not adequate to demonstrate a clear audit for the care provided. There were two residents being nursed in bed, neither person had a nursing care plan for oral care. One person had been nursed in bed for more than two years and was noted as having her own teeth on the initial assessment, “unable to attend to oral hygiene / mouth clean” but there was no nursing care plan to guide staff with this care or record that any checks had been sourced or provided from dental services. There was no mention of dental visits on any of the professional visit records on the six care files sampled. At the previous Inspection we discussed with the registered manager the issues of social isolation for people nursed entirely in bed in their rooms. At this inspection visit there were no records of a socialisation care plan or recorded interaction between the resident, who had been cared for in bed for two years, and staff or clear records of visitors. This was also the case for the other resident nursed entirely in bed since January 2008. There were some references in daily progress reports of visits from this person’s daughter. We were told by the nurse in charge that staff frequently ‘pop in’ but she acknowledged there were no records to show this happened. We also noted that the 24-hour fluid balance charts and special care charts were not properly completed. One example was that only trained staff were to feed a particular resident and instructions on each chart stated “ encourage Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 16 slips, allowed time for delay when swallowing, expressive dysphasia will prevent tongue movements for several seconds. Ensure X is fully alerted before feeding. Give supplements of Forticreme and enriched pureed diet.” However the daily fluid intake varied considerably from 1100 mls – 550mls, there was no specific detail about food at each mealtime, the food supplements were not consistently recorded, neither was urinary output. Some days no food intake had been recorded after 13:00 hours. These records were not signed to indicate which members of staff had fed this resident, therefore it was not possible to determine whether they were trained staff or not. We examined the care progress charts for four residents with complex needs and noted that some records cover as many as 3 days and are difficult to read. A resident’s records for 8/9/10 May 08 are incomplete, and 12-14 May 08 the times of meals and food / drinks do not appear to correspond with the 24-hour fluid balance chart. There is no indication as to the changed position, with the term, “ repositioned” frequently used. This person’s nursing care plan identifies “daily bed bath” there was only one entry from March – May on 16/5/08, which indicated “04:40 bed bath”. There were other examples of inadequate daily records for residents with complex needs and identified in nursing care plans as at risk of dehydration and malnutrition. The quality of these records remains poor and they did not provide assurance that residents’ health and welfare needs would be met. At the previous key inspection it was noted that there was no plan for pain relief for a resident with arthritis, osteoporosis and dementia. We could not find a written care plan on this person’s file and when we asked the registered manager and nurse in charge neither were aware of whether it was in place. Later on the first day of the inspection visit the registered manager stated that another nurse had written the care plan but no-one knew where it was, possibly somewhere in the building. The registered manager then wrote a care plan for this person, dated 20/5/08 and gave us a copy at approximately 5.00 pm. We noted on the March 2008 Accident Audit, which the registered manager told she undertaken “X is gathering strength following her fracture and is becoming more adventurous. To maintain her safety, I have instructed the care staff to encourage regular walks along the corridor of the ground floor to enable this lady to use up some energy, perhaps helping her to sleep better at night, which is another area of high risk” there is no record of this instruction in X’s care plan for mobility or risk assessment, or daily notes. Additionally there are further accident records when this person has attempted to walk unaided. Therefore, the value of these accident audits must be questionable. The home had also been issued with Statutory Requirement Notices relating to risk assessments and the use of bedrails. We were told that 4 residents were had nursing profile beds fitted with integral bedrails. We viewed each person’s Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 17 bedroom and examined their records. There were risk assessments in place, however the written risk assessments did not specify compatibility with the individual pressure relieving mattresses and the monthly evaluations / reviews had not taken account of the number recorded accidents or incidents. For example there were daily progress records for a resident, of times she had removed the wedges and had been recorded as having her legs through the bedrails and one of the accident record dated 31/3/08, when her leg was entrapped in the bedrail. We also noted that on another person’s bed, the bed bumpers, which had been provided, were not the full length of the bedrail and this had not been noted as a potential risk. There was no evidence of consideration of any other measures to minimise risks or advice sought from other professional sources. A resident’s nursing care plan for being prone to chest infections identified, “at high risk of developing a chest infection” and there was a detailed plan for prevention, however on 4/3/08 - care plan evaluation “prescribed antibiotics for chest infection” and 4/3/08 (health care professional visits)” prescribed amoxicillin syrup”. There was no evidence of a short-term care plan for this chest infection, no details of the dosage of medication, any additional care, any additional fluids, or monitoring. Similarly there was no short-term care plan for a resident with a urinary tract infection. The monthly evaluations of nursing care plans, healthcare screening and risk assessments had not been expanded to give more information, as required at the previous Key Inspection, to give assurance that any changes in care needs would be clearly identified and fully met by all staff. No changes had been made to care plans since the last inspection, 18 February 2008, to reflect choices such as each person’s preferred time to go to bed, to get up in the morning, bathing or showering or gender of staff to give assistance with personal care. Also at the previous inspection we noted that care plans did not contain any detail to tell staff what preferred toiletries were. When we discussed toiletries found in the home’s bathroom, which potentially could be used communally, the registered manager told us that the home purchases toiletries in bulk and residents could choose from four fragrances. We explained to her this practice demonstrated an institutional approach to care, rather than a person centred approach. There were daily progress records and professional visit records to show that residents have generally have appropriate access to other health professionals such as GP’s, Chiropodists, Opticians, though not as already noted dentists. We used the expertise of the Pharmacist Inspector, undertook inspection of the control and management of medication within the service on 20th May 2008. Systems were not in place to ensure that prescribed medication was available to treat diagnosed medical conditions. A written statement in the medicine policy states, ‘ It is the responsibility of the Nurse in Charge of the home to Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 18 ensure that sufficient supplies of regularly prescribed medicines are available for each of the service users for the forthcoming seven days’. We saw the current medicine records and identified that ten people had not been given their prescribed medication because it was not available in the home. For example, one person’s medicine records show that a medication for the treatment of high blood pressure was not available to administer from the 8th to the 14th May 2008. Another record seen showed that medication to treat diabetes had not been available in the home between the 12th and 13th May 2008. One person had not had a sleeping tablet administered from 7th May to the 20th May because it was not available, however a delivery from the pharmacy arrived and the medication was shown to us during the inspection. This was discussed with the registered manager, who said that she had ‘been trying to liaise with the pharmacist regarding the medication supplies. Over the last few months it has become increasingly obvious that the system is not robust. At the end of the month we find we are short of supplies.’ The registered manager also commented that ‘staff had not informed her that medication was running out’. There was no evidence that a GP had been informed of the situation or if the resident’s healthcare needs were being monitored. This means that people who use the service are at high risk of harm and are not safeguarded. Some medication could not be checked to ensure it had been administered correctly because monthly balances of medicines were not available. For example, we looked at one person’s medication records and checked the medication supplies available. The checks identified that out of eight prescribed medicines available only one of the medicines counted and checked was correct. This means that accurate checks on medication could not be made to ensure that medication had been administered to the people living within the service. As identified at the previous inspection residents’ last wishes had started to be recorded usually by talking to their family about their wishes. A questionnaire had been completed on each file looked at, which included information about wishes for resuscitation, and surgery for a PEG for feeding. No further action had been undertaken to show that an assessment of the residents mental capacity had been undertaken and these decisions could and should be made by a third party as required by the Mental Capacity Act 2005, where family members had made decisions. The registered manager told us she had been concentrating on improving other areas, such as care plans. Staff were observed treating residents with respect. Residents were seen to be dressed appropriately for the weather and efforts had been made by staff to ensure clothing co-ordinated, promoting residents dignity. We discovered a written complaint on a personnel file relating to the behaviour and practice of two members of night staff. One of the allegations was that a resident’s rights to privacy and dignity were compromised. Other written responses to a quality questionnaire from staff raised concerns about the Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 19 frequency of someone’s personal care needs being met by other staff. There was no evidence that the registered manager had investigated or responded to the allegations. When we questioned her about her actions or lack of action she told us that they were untrue. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 20 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. There are a variety of activities for some people to take part in. Food is tasty and homemade and is enjoyed by the homes residents. Residents are able to maintain contact with their friends and families. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As mentioned in the Health and Personal Care section of this report rising, retiring, bathing or showering preferences were not recorded in care plans and activities preferences were not recorded in any meaningful or person centred way. The routines of the home were not generally geared around each persons needs and preferences. From observations and discussions the routines were centred around staffing and how best they feel they can attend to each person’s essential needs in the time available. As at previous inspections we noted that some people were seen to get up and have their breakfast an hour before lunch, although we were unable to ascertain if this was their choice. The home had some activity records but they were listed as follows: 20/4/08 – bingo with names of three residents; 21/4/08- (name of entertainer - 1400 hrs Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 21 sang until 15:30 enjoyed by everyone; 22/4/08-nails cleaned and filed x 4 residents; 23/4/08 -bingo-three residents; 25/4/08 sing-a-long – (name of singer) with guitar (everyone); 26/4/08 Dominos - two residents; 28/4/08 music to movement – (name of entertainer) - All; 29/4/08 nail care - five residents; 30/4/08 Church –singing; 01/5/08 bingo - four residents; 02/5/08 cards-two residents; 3/5/08 planted tomatoes; 4/5/08 all went to sleep or had visitors today; 5/5/08 beanbag - four residents; 7/5/08 music & exercise – All. We noted a written message from the registered manager to staff stating that they must provided an activity every day at 2pm. This again did not demonstrate a person centred approach to offering fulfilling and satisfying stimulation for people living at the home, especially for people with dementia, sensory and other disabilities. We also noted an extract from document on staff meeting file completed by the registered manager “we are cooking with the residents on Wednesdays at 11am so the camera has been busy (although I was praising their efforts two hours later – they looked blankly at me having forgotten all about it). One does ones best!” Although this may have been an attempt at humour there was a real concern that manager was giving wrong impression to staff. At the previous inspection we discussed the care of people who are nursed in bed with the registered manager and at that time she told us that they have very poor or virtually no eyesight or hearing so TV and Radio would be of no benefit to them. We asked whether it was possible to bring them downstairs for some company and the manager said she would look into this further. One person is no longer at the home, and the manager obtained a letter from the GP about the other person, in which he gives his opinion that this person should be nursed entirely in bed. We noted that one other resident had deteriorated since the last inspection and was nursed entirely in bed. The nursing care plans for ‘socialisation’ for the two residents were in place for being nursed in bed but were not specific regarding actions and there are no records of staff interactions or stimulation in daily progress records or monthly evaluations. This was also confirmed with the nurse charge on the first day of the inspection visit. She admitted that they could start to improve these records. On the second day of the inspection visit an entertainer came to the home with her guitar and spent two hours with the residents in the lounge singing a selection of their favourite tunes. The majority of the residents appeared to enjoy this music session. During the afternoon the local church group visited and gave a communion service, followed by hymn singing in the communal lounge. We noted that assessment information on file for each person included their religion, which was positive. One person’s was recorded as ‘Quaker’ and an entry on the record stated ‘inform Meeting House Stourbridge’ but there was no record to show whether this had been actioned, or whether the person still wanted to participate. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 22 The home has a visiting policy and there was a notice on the front door to request that people do not visit at mealtimes as this it can disrupt residents. There were a number of visitors to the home during the two day inspection and those we spoke to told us that they were made to feel welcome. We indirectly observed a number of meal times, spoke to staff and examined records and found that residents receive a wholesome, appealing, balanced diet in pleasing surroundings, at times convenient to them. Dinning tables are arranged in small group settings in the main area of the lounge. Tables looked attractive with all required cutlery and condiments. Residents were seen being assisted by staff when required and the atmosphere was relaxed and informal. A member of staff is employed to assist residents at breakfast and lunchtime five days a week. The cook confirmed that he provides a number of special diets and that he makes his own soups, cakes and pies. We noted that most residents seated in the communal lounge chose either cereal, porridge and toast for breakfast although the menu did state there was cooked option. There were two cooked options for lunch each day and during discussions with the cook, we were told that the residents who needed puréed meals were given the same options in individualised portions, which makes the food more attractive in appearance. Unfortunately the food intake records did not record the food preferences at any mealtime apart from breakfast. On the second day the lunchtime options were boiled bacon, cabbage, creamed potatoes, and mashed Swede or alternatively steak and mushroom pie. The evening meal was served at approximately 17:30, jacket potatoes with alternative fillings or sandwiches, which looked appetising and the residents told us they were enjoying them. One resident told us that, “the food is delicious” and another relative told us that his brother loves the food and will often be at the table 20 minutes before the meal is due to be served. At tea times we noted that there were three care assistants feeding or assisting residents with their meal and whilst staff were seated at the tables and did their best to provide sensitive support, this was not easy to manage. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 23 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. People cannot have confidence their concerns or complaints will be listened to or investigated and the management practices do not protect residents from harm or abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed on the main notice board in the hall of the home and also included within the Welcome Pack and within the service user guide. It was pleasing to see a copy of the homes complaints procedure also on display in all bedrooms that we viewed. This helps people to understand who to approach if they are unhappy or wish to express concerns. We noted that the home had 2 complaints books; the registered manager told us that one book was kept in her office and was confidential and the other was used for staff to record complaints if she was not on duty. The book commenced 1998 contained three complaints; the other book commenced 1/4/02 - contained one complaint in 2006 and one complaint in 2007. There were no recorded complaints in the complaints books since the last inspection 18 February 2008. However we did find written complaints in the homes quality assurance file and on a staff personnel file. There was no evidence that the registered manager had investigated any of these complaints. When we spoke to her about them she told us that they were malicious and not true. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 24 On a positive note they were 18 cards of thanks and compliments from relatives, displayed on the notice board in the reception area, complimenting the staff and care at the home. Management practices have the potential to place residents at risk of harm or abuse. We found that staff have been given information about safeguarding procedures but that these are for a different local authority than where the home is placed. At the last inspection the registered manager informed us that all staff would undertake training in the Protection of the Vulnerable, which will include the management of challenging behaviour. At this inspection we found arrangements have been made for some staff to undertake Protection of Vulnerable adults training but that this does not include the management of challenging behaviour. It was also noted that neither of these training needs are included on the homes training and development plan. We were concerned with the contents of a notice to staff completed by the registered manager. This states ‘We all need now to be trained in abuse and pova (the book says) for those homes particularly who have dementia residents. Guess what - I have the DVD’s and the test questions for our files ready, so please let me know when you want to watch either or both. I’ve timed them when I watched them – instead of my usual Corrie. They’re a bit depressing but not too long to suffer. I managed to see Emmerdale anyway!’ The language used by the registered manager is of concern as it could give the impression to staff that safeguarding is not viewed as a priority. We noted there were accident records, body maps and daily progress reports indicating bruise to a number of residents at various times. There was no consistency in how these were monitored, investigated or referred either as regulation 37 notifications records indicating “POVA” or “APA”. Examples were notably accident records for X - 16/3/08 02:00 “ bruise noticed on right wrist ?cause, bruise black in colour POVA form completed “ needs to be monitored” but no record of any action taken; and record for X 4/5/08 20:30 reported by care assistant, that X has a bruise on right forearm 9cm x 4cm ?haematoma, ?cause. There was no action taken to investigate cause. Whilst sampling staff recruitment records we found evidence that the registered manager has been made aware of a safeguarding incident but did not refer the issue to the local authority. We discussed our concerns with the registered manager to clarify what actions she had taken to safeguard residents. At first the registered manager stated that she had carried out an investigation but “totally forgot to record”. We then asked the registered manager if she was aware of the local authority safeguarding procedures and what these instruct. She stated, “contact XX, she carry’s out investigation, I just forgot, I put in file but forgot, if wanted to conceal I would have destroyed”. We explained to the registered manager that we could find no evidence of any actions being taken by her to follow the local authority procedures including making the appropriate referral. The registered manager stated, ““what happened was, I called staff in and told about statement, they Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 25 said they didn’t do it, if I had left out I would have been breaking confidentiality, I forgot all about it”. We explained that due to our concerns we would be making a safeguarding referral. A Statutory Enforcement Notice was issued at the last inspection instructing the home to improve its recruitment practices. At this inspection we found this not to be met, with practices still placing residents at risk of harm. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 26 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24, 26 Quality in this outcome area is adequate. Residents live in a comfortable environment. Infection control practices in the main promote the wellbeing of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We undertook a tour of the premises, including sampling some bedrooms and found that generally the physical environment meets the needs of residents. The home has a large lounge that is divided into two areas, with one also used as a dining area. It was pleasing to see that people’s chairs were arranged in small groups and not “all the chairs round the four walls” format. The lounge areas are clean and comfortably furnished with a variety of styles of chairs. Several of the residents have little side tables with personal photos and trinkets on them, which was lovely to see. The home has small garden and a balcony area off the lounge. Current outside facilities provide limited Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 27 opportunity for residents and particularly those with dementia to wander out into the garden. The home employs a full time maintenance person who was seen carrying out works during both days of the visit. This ensures the physical environment is maintained to an acceptable standard. There is a mixture of single and double glazed windows throughout the building with appropriate window restrictors in place. Since the last inspection a room has been built in the lounge area that once fully completed will be used as an office where staff can complete records whilst still being able to view residents in the lounge. All bedrooms were found to be pleasant, clean and in most cases personalised with peoples treasured possessions such as photographs, pictures and ornaments. It was pleasing to find efforts have been made to co-ordinate decoration of rooms with soft furnishings and carpet. None of the bedroom doors that we viewed had locks that enable residents to restrict access as per their individual wishes. The registered manager informed us that these would be fitted if any resident requested. As we explained to the registered manager the home should initiate obtaining the views of residents with regards to locks on doors, as people may not be aware of their rights in this area. We also explained that additional consideration should be taken with regard to people with dementia to ensure their views are sought (involving advocates if necessary). Toilets are situated throughout the home and again are accessible and have grab rails. There is an assisted shower room and bathroom with a bath on the ground floor and a bathroom on the first floor. All of these facilities are very sparse, with only the basic fitments. Improvements to the decoration of these rooms should be considered to promote a homely ‘feel’ as is felt in residents bedrooms and the lounge areas of the home. We were informed that all but 2 residents prefer using the ground floor shower room. We found this facility to be very small, with insufficient space for 2 staff to assist residents if required or for a hoist to be used. Staff explained that residents are changed out of day wear in their bedrooms and then brought to the shower room, then taken back to their rooms when showering has finished to complete any assistance with personal care. We informed the registered manager that an assessment of this facility should take place by a suitably qualified person such as an Occupational Therapist to ensure it is safe and meets the needs of residents. We also raised concerns with the impact on residents privacy and dignity when using this facility, having to be escorted around the building in night wear and being hoisted outside of the shower room due to lack of space. A number of what appeared to be communal toiletries were seen in the shower room. This practice should cease, not only for good infection control practice but again to promote individuals’ dignity and choice. The home has a variety of aids and adaptations throughout which are suitable for dependent people such as a passenger lift and an emergency call system. There has been a considerable investment in the provision of new equipment Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 28 including electric “profiling” beds which residents can adjust the height, back and footrests to assist their comfort. At the last inspection we advised that alternative storage should be found for wheelchairs as these were seen to be placed outside residents bedrooms restricting access. This was still the same at this inspection, however we were informed this is being investigated with alternative storage being arranged. We found the standard of hygiene and equipment available for use in the kitchen to be of a good level. Both cooks hold up to date food hygiene certificates and the member of staff on duty that we spoke to demonstrated a good understanding of his role explaining specific dietary requirements of named residents. As he explained, “have one or two who have to watch weight loss, so give custards made with full cream, food with lots of protein, we make all our own soups, cakes and pies, we do not purchase any ready made items”. Cleaning schedules and records evidence regular maintenance, foods were properly labelled and a good supply of food was seen to be in place. This included fresh products, cereals, full fat and semi skimmed milks, a range of meats and a good supply of dried goods. The Environmental Health Department visited the home August 2007 making minor recommendations. All appeared to have been met at this inspection. The home has a laundry and separate ironing room. This allows soiled laundry to be kept separate from clean, promoting good infection control. The laundry room is fitted with commercial washing and drying machines, with walls and flooring fully washable. We noted that there is no separate hand-washing sink for staff. This should be put into place to prevent the spread of infection. A colour coded mop and bucket system was seen to be in place with appropriate storage facilities but mop heads were seen to be badly soiled and no one was able to explain what if any system is in place for the sanitising of mop heads. The home has a separate sluice room with 2 electric machines. It also has a hand washing sink, disposable gloves, paper towels, liquid soap and good hand washing signage in place. We saw that a cupboard is used to store products regulated by the Control of Substances Hazardous to Health regulations. We advised the registered manager that advise should be sought for storing products in the sluice room from the Health Protection Agency to ensure good infection control practices are maintained. Hillcroft Nursing Home DS0000004878.V364759.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. The numbers and skill mix of staff do not always meet the needs of residents. The homes recruitment procedures continue to have the potential to place residents at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with management and staff and examination of records confirm that there is a trained nurse on duty on every shift. There are also 4 care staff on the morning shift, 3 of an afternoon and 2 during the night. In addition to this a person is employed to assist with the feeding of residents at breakfast and lunchtime and the registered manager is employed 5 days per week, in a supernumerary capacity. It is recommended that the practice of staff undertaking double shifts be reviewed as some that we spoke to state this causes tiredness. For example one person said, “there are 5 trained nurses in total, we work long shifts, it’s a long day when we have to come back at 7.30 in the morning” We were informed that separate kitchen, domestic and laundry staff are employed but the names of these individuals are not included on the staff rotas. The registered manger informed us that a domestic is employed Monday to Friday 8am until 1.30pm and then another person 2.30pm until 4.30pm. She also said that kitchen staff are employed 7 days per week and laundry staff 5 days per week. We observed kitchen staff to be on duty both days of our visit and a laundry person on one of the days. When we asked to Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 30 speak to the laundry person and the domestic on the second day we were informed no one was present. Staff also confirmed laundry staff are not always on duty. As one explained, “2 days a week Friday and Saturday and when staff on holiday we have no laundry so one of the 3 care staff have to do these duties leaving only 2 to care for residents”. At the last inspection the home was instructed to ensure staffing levels are reviewed to ensure that residents’ needs are consistently being meet thorough out the day. We could find no evidence of action being taken to address this. We sampled staff files and viewed training documentation and found that staff receive in-house training in areas such as first aid, food hygiene and health and safety but that specialist training to meet the needs of people living at the home is almost non existent. The training plan for the home does not include areas such as dementia, diabetes, challenging behaviour, skin care or person centred approaches. It was unclear how many of the care staff hold a National Vocational Qualification as the training plan does not identify what role staff are employed in and no information for agency staff was in place. The plan states that 12 staff have achieved this qualification, however certificates maintained on staff files do not evidence this. No information was available to demonstrate remaining staff have been enrolled to undertake this qualification. As a result of the January 2008 inspection a Statutory Enforcement Notice was issued instructing that the home improvement its recruitment procedures to ensure residents are not placed at risk. At this inspection we sampled staff records and spoke to the registered manager and other staff and found that this Notice has not been met. The homes recruitment procedures have the potential to place residents at risk of harm. For example the staff rotas for March and April 2008 detail 18 shifts that have been covered by agency workers. We asked the registered manager what records are in place that validate agency workers have had the appropriate checks and are suitably qualified. She stated, “none, the agency visit about once a year with a list of workers, always provide same staff, ask us how getting on, they say staff provided have had required checks and hold appropriate qualifications”. She also stated, “we don’t use agency very often and we always use same workers if possible”. The records for March and April 2008 do not validate this comment as these state 10 different agency workers have worked at the home. As we explained to the registered manager it is her responsibility to ensure any staff, including agency workers have had to required checks. Of the 7 permanent staff files that we examined all contained evidence of an enhanced CRB disclosure being obtained (an improvement on the findings at the last inspection) references, application forms and job descriptions however inconsistencies with information contained within the various documents causes concern. For example one member of staffs references do not include their most recent employer and are not care related despite the person Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 31 working in different care environments. The same persons application form gives no employment history after 2006, contains a blank induction form and no training certificates apart from a moving and handling certificate (application form states holds GNVQ in Health and Social Care). Another member of staffs records include references dated after they commenced employment at the home, which also do not include a reference from their most recent employer. It was also noted that this person also works for another employer. We discussed this with the registered manager explaining that an assessment should be undertaken to ensure residents are not placed at risk due to the worker regularly undertaking excessive hours. It was pleasing to find a number of training certificates for this person covering a range of specialist subjects. However it was noted that another employer has provided all of these. Another member of staffs records include an application form that only asks for a 5-year employment history. We were informed that a young person is currently undertaking work experience at the home arranged by the school they attend. No evidence could be provided that the appropriate insurance or risk assessment being in place. Further concerns with regard to the recruitment practices undertaken by the registered manager were identified when examining another member of staff’s records. These evidence that the registered manager was aware of a police caution that the staff member received but did not disclose on their application form. In addition to this the person was suspended from the previous place of work but again did not disclose this information and under ‘reason for leaving’ the staff member had stated ‘new career opportunity’ when in a statement later they state they resigned due to being suspended. The work contract in place for this person states ‘in making the offer of employment to you the company has relied on the personal and career information that you have disclosed on your application forms and during your pre employment interviews. Should any of this information found to be inaccurate or misleading then your employment is liable to termination without notice’. The registered manager signed this. We discussed these discrepancies with the registered manager who confirmed she was aware of the caution and that she knows the member of staff personally. She stated, “I feel this person does not pose risk to residents”. She did not demonstrate any understanding of following recruitment procedures or ensuring practices comply with legislation. Further concern was raised as we felt evidence indicated she made decisions to recruit based on personal knowledge of the individual which could have the potential to discriminate against other applicants if they were not known personally the registered manager. The registered manager does not support or encourage the development of a competent staff team. We found evidence on the staff files sampled that new workers receive an induction so that they understand what is expected of them. However none of the files sampled contained evidence that inductions Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 32 have been completed in full. It appeared that staff were given copies of induction packs and then no monitoring had undertaken by the registered manager to ensure these were completed. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 33 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 Quality in this outcome area is poor. Management of the home has deteriorated to such an extent that it places residents at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has managed the home for several years, is a qualified nurse and has the required management qualification to manage a home. It was noted at the last inspection that the registered manager had failed to address longstanding requirements. Evidence contained throughout this report indicated there had been further deterioration in the management of the home, which had the potential to place residents at risk. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 34 Statutory Enforcement Notices were issued at the previous inspection but none have been complied with. Due to concerns regarding the registered manager the proprietor of the home was contacted and visited during the inspection where these were discussed. The proprietor was informed that evidence obtained from the inspection would result in CSCI holding an internal meeting to discuss enforcement options. We also informed the proprietor of concerns regarding the manor in which the registered manager has been conducting herself and relaying information to staff employed within the home. As we explained we had found 3 letters to staff that the registered manager wrote with regard to the CSCI and visits to the home. In one she states ‘We are trying to ensure that any promises made will be actually carried out, at the next ‘unplanned inspection’, rest assured they will come back – just to catch us out! Another ‘I am struggling through ‘what the inspector uses to mark us’ guide. It has several bits that we have already got in place, such as the ‘mandatory training’ – at present we are ALL perfect with that – until March 12th when we get our visit on quality! Groan…….. Soooooo I am trying to fend off a mad panic like last time and getting things sorted in advance – if I haven’t topped myself before then!!. As we explained to the proprietor there is an expectation that someone in a position of authority conducts themselves at a level of professionalism that is an example to staff they are responsible for. The contents of the letters bring the managers professionalism into question. We found some evidence of systems being in place for the monitoring of quality. However we question the effectiveness of some of these due to serious deficiencies we found during this inspection. For example the registered manager showed us copies of medication audits she has completed, none of which identify low stocks of medication resulting in residents not being administered medication. Prior to the inspection the proprietor had contacted us requesting that we visit, as he felt confident the Statutory Enforcement Notices had been complied with but evidence finds these to remain unmet. The registered manager did not demonstrate support or encouragement for the development of a competent staff team. There was inconsistent supervision of staff with infrequent individual sessions and no staff meetings for over twelve months. The most recent minutes available for a staff meeting were recorded for 2006. We asked the registered manager if staff are supervised on a one to one basis, receive appraisal and have the opportunity to attend staff meetings. She said “yes”. We questioned this reply as none of staff files or staff meeting folder evidence this taking place. She said, “Minutes are in note form for staff meeting, not yet typed up”. We asked if she could produce these so that they could be looked at. She then said it was not an official meeting and could not say for sure when last staff meeting took place. The home only holds small amounts of resident’s monies for temporary safekeeping. We were told that only the registered manager has access but if residents want money it can be taken from petty cash and later reconciled. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 35 We looked at a sample of residents monies held by the home and balances were accurate. However the receipts for each transaction were either held in receipt books or in bundles in date order and were mainly from the hairdresser and private chiropodist. From the sample of records we looked at there were a number of receipts, which did not correspond to the dates of the transactions. Examples of receipts from the hairdresser dated 15/04/08 some residents predated the individual records when each person had their hair done. The registered manager stated that this was because the hairdresser sometimes did the receipts in advance. This practice has the risk that the resident may not have their hair done and may still be charged for the service. Additionally the numbers of the receipts were in random order in the receipt book, which the registered manager told her she had purchased for the hairdressers use and she told us that the hairdresser does not necessarily use the receipts in order, which means numbers are not sequential. None of this demonstrates a robust system or good practice in terms certain safeguarding residents’ finances. The records of financial transactions were held in a bound book, one page for each resident’s transactions and although there were two signatures for each transaction, the registered manager told us that the hairdresser and private chiropodist countersign transactions made for their services. This system did not demonstrate compliance with The Data Protection Act and did not maintain the residents rights to privacy. We explained to the registered manager that neither the hairdresser nor the chiropodist had rights to know what transactions each resident had made or the balance of their funds. At the previous Key Inspection the registered persons were made aware that following breaches of Regulation 37 notification must be forwarded to the Commission of Social care and Inspection of any incident that has affected the health, safety or wellbeing of the service user at the care home. A warning letter of possible enforcement action was sent to the home in relation to the requirement following the Key Inspection 18/02/08. However there was evidence, as identified throughout this report, to demonstrate compliance. Some examples were: Resident with grade 3-4 pressure ulcer (February 2008) Deaths of 2 Residents (April 08), Incidents of unexplained bruising found in accident records, body maps, daily progress reports and allegations of abusive behaviour, which have not been reported. We sampled a number of safe working practice records and found some of these promote the safety of residents. For example records and checks undertaken by the maintenance person demonstrated visual checks of the environment and equipment including fire doors, hoist slings and fire exists were undertaken. We also found monthly in-house wheelchair checks were carried out. We found no evidence of wheelchairs being serviced. Records confirmed hoists were serviced 06/03/08, the fire alarm and emergency lighting serviced 27/03/08, a water bacterial test undertaken 14/12/06 and water temperatures checked on a monthly basis with all maintained within safe temperatures ranging from 41 – 43 degrees. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 36 Throughout the two days of the inspection staff were indirectly observed undertaking moving and handling of residents. In all but one case good practices were observed. For example staff were seen using hoisting equipment, positioning residents correctly and offering reassurances to residents throughout processes. The one procedure that caused concern was when we witnessed a member of staff bring a resident into the lounge in a wheelchair with a Zimmer frame perched on top of the resident. The member of staff was seen pushing the resident with one hand and holding the Zimmer frame in the other. We informed the registered manager of this when giving feedback about the inspection, instructing that this must not occur. She said, “this is X, she would go mad if staff took Zimmer frame off her, she wants to be pushed in wheelchair like this”. We asked if a risk assessment is in place for this and she was unable to say. We explained that the risk of injury to the resident must be assessed and other ways of managing situation explored to reduce the risk of injury to both resident and staff. When examining recruitment documentation for staff employed at the home we found that a couple who are in a relationship work together on the same shifts. Records indicate that there has been an incident when these staff were on duty together. We questioned the appropriateness of this with the registered manager who stated, “They only work together on occasional shifts, when cover needed, only then”. We produced staff rotas that show they are rotated to work together on all night shifts. We advised that this practice be reviewed to ensure the health and wellbeing of residents is promoted. Training and development plans viewed detail high numbers of staff having undertaken fire, food hygiene, infection control, first aid, manual handling and health and safety training. Further work should be undertaken to ensure documentation is in place to reduce the risk of injury to staff by products covered by the Control of Substances Hazardous to Health Regulations. No risk assessments or safety data sheets were available for any of the products stored in the ground floor sluice room. The registered manager stated “only toilet rolls stored there” but when we viewed this a number of products were seen to be in place. We attempted to examine records of accidents sustained by residents in relation to other care records. This was not easily done because although the registered manager had undertaken a monthly analysis, with impressive pie charts and written notes copies of accident records were not collated into any particular order, either in date order nor ordered by residents’ names. We also found additional accident records on individual residents files and references to bruises, some of which had no accompanying accident record or body maps, during examination of care files. We also found references to bruises and one ‘wound’, which was recorded as healing in residents’ daily progress reports. There were no corresponding accident reports or body maps. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 37 There were accident records relating to incidents and injuries relating to residents have their legs caught in bedrails and the evaluations of risk assessments and care plans had no reference to any review or consideration of additional professional advice to minimise further risks to residents’ safety. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 38 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X 2 2 X 3 X 2 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 1 1 2 Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 39 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 The registered provider must ensure that each residents care plan reflect ALL of each residents needs. And includes the following; wound dressing regimes, nutritional care to include special dietary regimes. Management of any risks. Previous timescales of 01/07/05, 05/01/06 and 15/09/06, 30/9/07 and 18/01/08 were not met. The home has received a statutory requirement notice in relation to this requirement. – This has not been met. Action must be taken to ensure that the all health care risk assessments and care plans reflect all changes to residents’ health and needs. This is to ensure care for residents’ health and well being is properly provided at all times. Systems must be introduced to DS0000004878.V364759.R01.S.doc Timescale for action 21/05/08 2. OP8 13(1) 01/07/08 3. OP9 13(2) 21/05/08 Page 40 Hillcroft Nursing Home Version 5.2 4. OP16 22 5. OP18 13(6) ensure that adequate supplies of prescribed medication are available within the service to administer to people who live within the service. This is to ensure that the health and welfare of people living in the service are safeguarded. The registered persons must 01/06/08 demonstrate that all complaints are fully investigated, with records of outcomes, actions and responses to complainants where they are known. This is to ensure that the health and welfare of people living in the service are safeguarded. There must be suitable and 01/07/08 appropriate arrangements in place that includes staff training to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Previous timescales of the 31/12/07 and 30/01/08 and 31/03/08 not met. The registered persons must ensure that ALL allegations or suspicions of abuse are referred to the designated person in accordance at the Lead Agency in accordance with the multiagency ‘Safeguard & Protect’ Procedure without delay. The registered persons must ensure that action is taken to minimise and review all aspects of risk for each resident, with documented, up to date risk assessments and risk management strategies in place. This is to ensure that the health and welfare of people living in the service are safeguarded. The registered persons must take action for an assessment of DS0000004878.V364759.R01.S.doc 6. OP18 13(6) 21/06/08 7. OP18 13(4) 01/07/08 7. OP21 13(4) 01/08/08 Page 41 Hillcroft Nursing Home Version 5.2 8. OP27 18(1)(a) the very small showering / bathing facility by a suitably qualified person such as an Occupational Therapist to ensure it is safe and meets the needs of residents, especially in relation to privacy and dignity. Staffing levels must be reviewed to ensure that residents’ needs are consistently being meet thorough out the day. Timescale of the 30/04/08 Not met. The registered provider and manager must obtain for each staff member all of the required documents detailed in Schedules 2 and 4 . A copy of each of these documents must be held on each staff members personal files. Previous timescales of 18.01.05, 01/07/05, 12/12/05, 21/09/07, 30/9/07 and 18/01/08 were not met. The home has received a statutory requirement notice in relation to this requirement. – This has not been met. Notification must be forwarded to the Commission of Social care and Inspection of any incident that has affected the health, safety or wellbeing of the service user at the care home. Timescale of the 30/9/07 and 18/01/08 and 18/02/08 Not met All incidents affecting residents are not notified Examples: Resident with grade 3-4 pressure 01/06/08 9. OP29 19(1) 17(2) 21/06/08 10. OP37 37(1) 21/05/08 Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 42 ulcer (February 2008) Deaths of 2 Residents (April 08) Incidents of unexplained bruising Allegations of abusive behaviour A warning letter of possible enforcement action was sent to the home in relation to this requirement following the Key Inspection 18/02/08. 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 statement of purpose and service user guide should detail the fees that the home charges This is a previous good practice recommendation and was not met. A signed copy of the terms and conditions of residency should be retained within the resident’s records. This is a previous good practice recommendation and was not met. The prospective resident or whenever possible their representative should be actively involved in the preadmission assessment of the persons needs and this should be recorded. This is a previous good practice recommendation and was not met. It is strongly recommended that regular (at least 6 monthly or as changes arise) formal reviews take place, initiated by the home and involving the resident, their representative, and outside agencies or advocates so that the assessment of each person’s needs is kept up to date. That all residents be offered access to dental services, with records of visits, advice, treatments or refusals to accept dental checks. That advice from community dieticians be sought for all DS0000004878.V364759.R01.S.doc Version 5.2 Page 43 2. OP2 3. OP3 4. OP4 5. 6. OP8 OP8 Hillcroft Nursing Home 7. OP11 residents assessed to be nutritionally at risk, with records of support and advice offered and that a record be maintained of staff training in relation to nutrition. Residents’ last wishes in respect of death and dying should be explored and be recorded within their personal file. This is a previous good practice recommendation and was not fully met. There should be a record of peoples preferred leisure activities and their choice of daily life and routines such as getting up and going to bed. This is a previous good practice recommendation and was not met. There is a review of those residents care who spend all their time in bed with only very minimal stimulation. This is a previous good practice recommendation and was not fully met. That a regular documented audit of residents preferred activities be undertaken from which a structured weekly programme be devised and displayed in appropriate formats to encourage participation and individual weekly activity planners be introduced for each person to record planned and spontaneous activities, refusals and evaluation of activities offered, ensuring records accurately reflect participation (or none). That action be taken to ensure each person’s individual spiritual needs are met, according to their wishes. For example the person who was recorded as ‘Quaker’ and an entry on the record stated ‘inform Meeting House Stourbridge’. That each residents property inventory be fully completed on admission with clothing, furniture, valuables, hearing aids etc. and thereafter kept up to date signed and dated by staff, resident and / or relative. It is recommended that the home obtain a copy of the Dept of Health guidance Mental Capacity Act 2005 core training set published July 2007 This is a previous good practice recommendation and was fully met. That action is taken to involve appropriate advocacy for decision making for residents lacking capacity, in relation to The Mental Capacity Act 2005. It is recommended that the home obtain a copy of the Dept of Health guidance Mental Capacity Act 2005 core training set published July 2007 DS0000004878.V364759.R01.S.doc Version 5.2 Page 44 8. OP12 9. OP12 10. OP12 11. OP12 12. OP14 13. OP14 14. 15. OP14 OP14 Hillcroft Nursing Home 16. OP15 17. OP18 18. OP18 This is a previous good practice recommendation and was fully met. There should be appropriate organisation of meal time sufficient numbers of staff available at all meal times to ensure minimal disruption when residents are being assisted with feeding to ensure an enjoyable experience and adequate food and fluid are taken. That behaviour care plans be expanded with fuller information to guide staff to understand behaviour triggers for individual residents and how to manage behaviour that challenges, such as agitation, wandering etc. Staff should be made aware of the homes abuse policies and Dudley Council’s Adult Protection procedures. It is advised that staff sign and date when they have read these documents. This is a previous good practice recommendation and was not met. Consideration should be given to improving the decoration of the WC’s shower and bathrooms to promote a more homely ‘feel’. That any toiletries, which could be used communally be removed from communal bathing / showering facilities to maintain effective infection control and residents rights to individual choice. There should be adequate and appropriate storage of wheelchairs. This is a previous good practice recommendation and was not fully met. That the registered manager the home should initiate obtaining the views of residents with regards to locks on their bedroom doors, as people may not be aware of their rights in this area. 1) That a separate hand-washing sink for staff be installed in the laundry to prevent the spread of infection 2) That systems be put in place for the sanitising of mop heads 3) That advise should be sought for storing products in the sluice room from the Health Protection Agency to ensure good infection control practices are maintained. It is strongly recommended that the practice of allowing ‘partners’ to work together on night duty, when there are reduced staffing levels be reviewed to ensure the health and wellbeing of residents is promoted. DS0000004878.V364759.R01.S.doc Version 5.2 Page 45 19. 20. OP21 OP21 21. OP22 22. OP24 23. OP26 24. OP27 Hillcroft Nursing Home 25. OP28 26. OP29 That copies of NVQ qualifications for 12 staff claimed to have achieved NVQ 2 award and information to demonstrate remaining staff have been enrolled to undertake this qualification be available on staff files, together with up to date training plans. 1) That monitoring arrangements be put in place to ensure induction packs given to staff are completed. 2) That documentary evidence be available that the appropriate insurance and Health & Safety (Young Persons) risk assessment is in place for any person working at the home (doing work experience). A thorough training needs assessment should be undertaken with a consequent training plan and an up to date training programme. This is a previous good practice recommendation and was not fully met. That all staff receive training relating to the Mental Capacity Act and have an awareness of its implications for all aspects of their work. There should be an effective assurance system in place that includes quality checking systems and meets all elements detailed in standard 33. This is a previous good practice recommendation and was not met. That the system for managing resident’s temporary safekeeping finances be reviewed and revised to ensure is it compliant with the Data Protection Act and maintains residents rights to privacy and security. That action be taken to the implement a structured staff supervision system, appropriate to their role, ensuring that each member of staff has a minimum 6 formal recorded supervision sessions in each 12 months. This is to ensure residents’ health and well being and safety is promoted by well trained and supported staff. That a documented annual schedule of supervision sessions and staff meetings be devised and displayed to encourage participation. That system be put in place to monitor and record personal care provided, such as a checklist matrix, together with a system to monitor records such as food and fluid balances, turns, night checks. That the registered persons review the documented accident analysis to more clearly identify continued risks, trends and record remedial / control measures, which should also be reflected in each person’s care planning and DS0000004878.V364759.R01.S.doc Version 5.2 Page 46 27. OP30 28. 29. OP30 OP33 30. OP35 31. OP36 32. 33. OP36 OP37 34. OP38 Hillcroft Nursing Home 35. OP38 risk management. 1) That advice be sought from the West Midland Fire Service and appropriate action taken relating to the practice of propping open resident’s bedroom doors 2) That risk assessments for the use of wheelchairs without footplates for individual residents be reviewed, account must be taken of The Mental Capacity Act for residents who lack capacity 3) That wheelchairs have a regular (at least annual) service. 4) That the risk of injury to the resident, transported holding onto a Zimmer frame must be assessed and other ways of managing situation explored to reduce the risk of injury to both resident and staff 5) Work should be undertaken to ensure documentation is in place to reduce the risk of injury to staff by products covered by the Control of Substances Hazardous to Health Regulations, with risk assessments and safety data sheets available for all of the products stored in the ground floor sluice room. Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 47 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Hillcroft Nursing Home DS0000004878.V364759.R01.S.doc Version 5.2 Page 48 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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