Inspection on 13/08/07 for Keswick

This inspection was carried out on 13th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Keswick 25/04/06

Keswick 25/07/05

Keswick 13/06/05

Keswick 27/01/05

Keswick 30/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Keswick Keswick Eastwick Park Road Great Bookham Surrey KT23 3ND Lead Inspector Pat Collins Unannounced Inspection 13 August 2007 08:10 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 Keswick DS0000013691.V342321.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. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Keswick Address Keswick Eastwick Park Road Great Bookham Surrey KT23 3ND 01372 456134 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) keri.sherwood@anchor.org.uk Anchor Trust Ms Shona Bradbury Care Home 51 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (51), of places Physical disability over 65 years of age (10) Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 51 Residents accommodated, up to 15 may fall within the category DE (E). Of the 51 service users accommodated, up to 10 may fall within the category PD (E). 25th April 2006 Date of last inspection Brief Description of the Service: Keswick is a care home providing personal care for older people. Anchor Trust, a non-profit making national care provider, operates the home, which is situated in a quiet residential area in the village of Great Bookham. The high street is nearby where there is a small range of shops and other amenities. The home is adjacent to a health centre and junior school. Accommodation at the home is arranged in seven residential living units. Each has six to eight single occupancy bedrooms, a communal lounge/dining room with open plan kitchenette, bathroom and toilet facilities. The two-storey building is wheelchair accessible throughout with passenger and wheelchair platform lift provision. A large lounge/dining room on the ground floor is used for activities and social functions organised by the home. Anchor Trust operates a day centre service for older people living in the community in this lounge during the week. People living in the home have an ‘open invitation’ to join in the day centre activities at any time. A spacious conservatory overlooks the home’s attractive garden. There is a furnished patio, lawns, mature trees, shrubs and flowers. Access to an enclosed garden is through the lounge of one of the residential units. The main entrance lobby is light and airy with a reception desk and a seating area. Car parking spaces are provided to the front and side of the property. Fees charges are £630 per week Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit forms part of the key inspection process. Judgements about the home’s management and standards of care are based on the cumulative assessment, knowledge and experience of service provision, since the last key inspection in April 2006. Information supplied to the Commission for Social Care Inspection (CSCI) by the home manager has been taken into account. Also the findings of an unannounced random inspection carried out in August 2006 by the CSCI. The report of that inspection is available to the public on request to the CSCI. Ms Pat Collins, Regulation Inspector, undertook the latest inspection visit. This commenced at 08:10 hrs and concluded the same day at 18:20 hrs. In the manager’s absence the deputy manager facilitated the inspection process. An assistant area manager attended the feedback session at the end of the visit. The inspection process does not include assessment of day care services which are unregulated. The inspector has looked at how well the home is meeting the national minumum standards set by the Government. Judgements about standard of service provision are detailed in this report. A partial tour of the premises took place and records were sampled. The views of people living in the home were sought through consultation at the time of the visit and through a questionnaire survey prior to the visit. Thirteen questionnaires were returned to the CSCI from people using the home’s services, also one from a relative and three from professionals with regular contact with the home. Communication with some people using services was limited due to difficulties with communication. Observations of their body language and appearance, also information from staff and in records, mostly indicated a sense of their well-being. The term ‘residents’ is used hereafter in this report when referring to people using the home’s services. This is in accordance with the expressed preference of individual residents consulted in this matter during the visit. The inspector would like to thank all who contributed to the inspection process; also the residents at Keswick and staff for their time, hospitality and assistance throughout the inspection visit. What the service does well: Residents’ health and personal care needs are overall well met and each has an individualised plan of care. The values and principles of privacy and dignity are put into practice in the delivery of care and the home’s operation. There is management commitment to staff training and development, ensuring staff have the necessary skills and competencies to meet residents’ needs. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 6 Admissions to the home are on the basis of comprehensive needs assessments to ensure needs can be met. The assessment process continues for a specified period of time after admission. The home is well maintained, clean and hygienic and odour is well controlled. The layout of the accommodation in individual living units provides a positive care environment for residents. The units are domestic in style and character, which increases individual feelings of comfort and security and promotes independence in familiar surroundings. The design and furnishing of units is aimed to reduce confusion and aid orientation, enabling residents to recognise their bedrooms and locate toilets and communal areas. Seating in the combined lounge/dining rooms is arranged in a way that encourages interaction between residents. Residents have access to their bedrooms at all times and their rights and choices are respected if they prefer not to socialise with others. The environment and deployment of staff creates conditions that support good observation of residents whilst moving freely around the home. The environment and staffing arrangements supports continuity of care and promotes professional, friendly relationships between staff and residents. A number of staff have been employed at the home for many years and demonstrated awareness of the needs and preferences of residents in their care. The meal served on the day of the inspection visit looked appetising and well balanced and residents were offered a choice of food. There is opportunity for social interaction and stimulation and staff are caring and friendly in their approach towards residents. Feedback received from residents about staff was mostly positive. What has improved since the last inspection? A new assessment and care planning system has been implemented for all new residents. The care records sampled for new residents confirmed significant improvement in assessment and care planning procedures and practices. Existing residents are being gradually reassessed and new care plans generated, using the new, much improved assessment tools and ‘service user plans’ documentation The approach to assessment and care planning for these individuals is inclusive, involving residents within individual levels of capacity and relatives/representatives, as appropriate. The new care plans are clear and easy to navigate. A team leader has designated lead responsibility for co-ordinating the task of transferring information from the old style care records to the new format, ensuring staff are trained and supported in using the new system. The assessments and care plans using the new tools and documentation afforded a comprehensive, holistic view of residents’ needs and aspirations. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 7 It was good to note life history information is recorded for all prospective residents; also progress being made in obtaining the same for existing residents as part of their reassessment when transferring to the new care planning system. This information is an important aid to communication, giving staff good insight into what is important to each resident as an individual. It was positive to note improvement in staff induction practices and records. The team leader who has designated responsibility for co-ordinating the staff induction and training programme was enthusiatic and highly motivated to ensuring a skilled workforce. It was positive to note the ongoing programme of dementia training for staff and sensory impairement awareness training. Other areas of improvement include a new system alerting team leaders to concerns about the health or welfare of individual residents. This enables close monitoring of their care by senior staff and provides direction and leadership to staff to ensure needs are met. Staff who administer medication have had certificated medication training since the last inspection. Changes and improvements were noted in medication practices and medication monitoring record keeping. Also a record of staff supervision is now held. It was positive to see the substantial financial investment in the environment. Since the last inspection furniture has been replaced, a new emergency call system has been installed and new kitchenettes fitted in the living units and bathrooms are currently being upgraded. The hairdressing salon has been refurbished and a secure, enclosed garden has been developed. Work is currently in progress to increase car parking facilities. What they could do better: Care plans and other records for existing residents that have not yet transferred over to the new system were found to be of variable standard. Some were unsatisfactory and incomplete and not all up to date or evaluated monthly. A robust system must be in place for monitoring these care plans. There is a need also to ensure assessment tools identify residents who require a soft diet. This information must be communicated to catering staff and documented. It is important also for catering staff to be clear of the difference between soft and pureed diets. Records must ensure weights are recorded at least monthly and demonstrate action taken in response to significant weight variations. A review of practice is necessary to ensure prompt referral to district nurses in response to residents’ changing needs, specifically where pressure sore prevention risk assessments are needed and provision of pressure relieving equipment. Staff must not delay referrals until observing signs of tissue damage. There is a need to include pressure sore prevention strategies in the home’s care planning documentation. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 8 A review of CRB and POVA procedures is necessary, also arrangements for supervising contact between residents and student doctors. Improvement should be made also to storage of records to ensure confidentiality of information about residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 3, 5, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New service users are admitted only on the basis of a full assessment by people trained to do so, to which prospective residents, their relatives/representatives (if any) and relevant professionals have been party. Prospective residents can visit and assess the quality of facilities and suitability of the home. The home does not offer intermediate care. EVIDENCE: An equal opportunities policy underpins all decisions about who is admitted to the home. All new admissions are on the basis of comprehensive needs assessments carried out by people trained to do so, to be assured that the home can meet individual needs. The pre and post admission assessment documentation sampled demonstrated significant improvement in recording keeping, also in admission assessment procedures. T his observation is linked to use of a new ‘service users plan’ system and process for assessment and Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 11 care planning, which is corporately being implemented across all Anchor Trust care homes. The new system is enhanced by additional assessment tools, a more detailed care planning format and practice that ensures care plans are developed with, and owned by, residents and their representatives. The plan is person centred and focused on individual strengths and personal preferences. It draws on the life experiences of residents and sets out how needs and aspirations are to be met through positive individualised support. Implimentation of the new ‘service users plans’ and associated assessments was preceded by training for team leaders (former job title noted to be senior care officers). A team leader has delegated lead responsibility for cascading this training throughout the team; additionally for oversight of information transfer from the former care planning documents to the new format, for existing residents, over a defined time period. Information is gathered from a range of sources as part of the pre-admission assessment process. Summaries of care management (health and social services) assessments are routinely obtained for prospective residents whose placement is through care management arrangements. Assessment information is considered against the home’s statement of purpose (which states who the service is for). Lifestyle and diversity information is acquired as part of the assessment process to ensure ability to meet expectations and needs. A trial period of admission is standard practice. This affords opportunity for prospective residents and their relatives/representatives to assess the quality of service provision. Additionally, it provides additional time for assessment processes to continue to ensure that needs can be fully met. The deputy manager stated this was always explained to prospective residents and their relatives/representatives at the time of admission. Intermediate care is not offered by the home. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 7, 8, 9, 10, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care provision is based on individual needs assessments. Whilst some shortfall in practice and record keeping were noted, overall the standard of care was considered good. Where areas for improvement have been identified there is confidence in management that these will be appropriately addressed. Medication practices are satisfactory. The principles of respect for residents’ dignity and privacy in the delivery of care are put into practice. End of Life plans are being developed and terminal care is provided with sensitivity and respect. EVIDENCE: On the day of the inspection visit residents were well groomed and their dress was appropriate to age and culture. Intimate personal care needs were met behind closed doors, staff respecting residents’’ privacy and dignity at all times. It was evident that some staff had built relationships of trust with individual residents and were skilled in interpreting verbal and non-verbal communication cues. This enabled them to appropriately respond to residents’ needs, feelings and emotional states. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 13 Positive interaction was seen between some residents and care staff during the course of the inspection visit. Staff attended to the needs and wishes of residents. They were supportive in providing assistance with activities of daily living. The atmosphere on all units was calm and friendly. Survey information received from thirteen residents confirmed that most considered their needs were being met by the care they received. Comments included: “They are good girls (care staff) they work hard and look after me”. “Experience and skills of staff vary from excellent to OK”. “Care staff are always caring and concerned with my comfort and needs”. “Night care not always prompt”. “I have been satisfied with my care”. “I feel safe and the carers are very nice”. When asked if staff listen to them, the same residents mostly stated that they felt they did. The home has a multicultural staff group with staff employed from various ethic groups and, for some staff, English is not their first language. Areas of discussion with management included the impact, if any, of this on communication in the home generally and with residents. The deputy manager was of the view that this was not an issue. She was informed of feedback received by the CSCI from a care manager who referred to language barriers at the home at times adversely affecting communication. Also a comment from a resident who stated that staff did not always understand what was asked of them. Discussions with senior staff confirmed that recruitment processes set a minimum standard for language skills. Also training provision included discussions that raised awareness to British culture. This is important given the ethnicity of the majority of residents in this home is White British. Care staff had designated keyworking responsibilities for named residents. The keyworker role includes responsibility for formulating and updating care plans. They are line managed by team leaders who are accountable for the standard of care plans. The new ‘service user plans’ system referred to in the previous section of this report was at an early stage of implementation for existing residents. Work was in progress on the major task of transferring information from old documentation to the new records format. It is recognised that this is a very time intensive process, appropriately involving discussions between team leaders, keyworkers, residents and their relatives/representatives. The two care record keeping systems are currently operating in parallel until such time as all existing residents’ needs are comprehensively reassessed and transfer to the new system is complete. The care files sampled using the new documentation were of an overall good standard. Care plans were generally comprehensive in content, included daily living activities and goals, care objectives and a range of risk assessments. They afforded good insight into residents’ holistic needs. They were signed and dated by staff and had signatures of residents or their Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 14 relative/representative, reflecting their involvement in this process. Discussion took place with a team leader on the importance of ensuring prominent recording of allergies on the new format care plans. The care records sampled using the former care planning format for Individual Life Style Agreements were of variable standard. The need for a more robust system for monitoring the content of these care plans and associated assessments and care notes was discussed with management. These must be reviewed at least monthly, all needs addressed and records maintained up to date. Recognition is given to the hard work that has already taken place for improving these care plans and risk assessments. However, further action is necessary. A system was in place for nutritional monitoring but tools for assessing needs for soft and pureed diets were not used and could not be located. Attention was drawn to shortfalls in care planning and record keeping for one resident specific to a loss of weight. It was agreed that this resident’s needs would be reassessed. It was positive to note prompt follow-up in this matter by the deputy manager. A good recent development is the daily system for alerting team leaders and managers to significant information affecting the health and welfare of residents. This ensures management monitoring and oversight of the care of these individuals. The deputy manager confirmed the policy of six monthly formal review meetings for residents. These meeting were said to involve residents who are able or wish to be consulted and their relatives/representatives, as appropriate. It was stated that realistically the frequency of reviews could only be on an annual basis due to time constraints. Review meetings for residents funded by care management were arranged by care managers and took place at the home. It was stated that a request had been made to care management for overdue review meetings to be convened for four residents with high care needs. The delay in convening these meetings was related to a shortfall in Surrey County Council care managers. It was noted that the home’s assessment tools did not include pressure sore risk assessments. The deputy manager and a team leader consulted confirmed that district nurses supported the home in carrying out these assessments. It was stated that pressure sore prevention plans were generated by district nurses who supplied all necessary pressure relieving equipment. Although the inspector was informed that pressure sore prevention plans were usually kept in bedrooms, there was no evidence found of such a plan for a resident who was on total bed rest. Discussed was the need to avoid fragmented storage of records and the need to maintain a copy of pressure sore prevention risk assessments and care plans in residents’ files. This comment does not apply to nurses’ treatment plans or records of treatment. It was concluded that there was a need for a more proactive approach to pressure sore prevention on the basis of information and observations at the time of the inspection visit. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 15 Staff must ensure timely referral to district nurses for these assessments and must not delay referals until such time as observing indicators of tissue damage. Residents are registered with general practitioners who visit the home by request. Feedback from residents confirmed a high level of satisfaction with their medical support and treatment. Feedback from a care manager, however, included comment that some relatives felt that referral to GP’s and district nurses was not always promptly dealt with by the home; also pain relieving medication prescribed to be given when needed was not always offered. Records examined confirmed delay in referral to the district nurses for one resident referred to earlier. A complaint record confirmed there had been an occasion when referal had been delayed to the GP for review of medication prescribed for pain management. Also the investigation into this found no record to demonstrate that staff had always offered pain relieving medication as prescribed. It was noted that remedial action had since been taken to ensure medication for pain control is offered and records maintained if declined. Arrangements are in place for residents to access opthalmic, audiology and dental services. Chiropody needs are met by a private chiropodist for which there is an additional charge. Referral can be made for NHS chiropody provided the criteria for this service is met, and arrangements made for transporting residents to and from the NHS chiropody clinic. Staff confirmed excellent support received from district nurses in meeting residents’ short term nursing needs. There are links with continence advisors, and other specialists can be accessed through GP referral. End of Life advanced care planning is included in the home’s new care planning system. An individualised approach was evident and the process seen to empower residents and their families to have some control over decisions about terminal care. Letters and cards sampled from relatives of former residents thanked and commended staff for their care and empathy during their relatives’ final illness. It was concluded from this information and discussions with staff that death was managed with sensitivity and dignity. End of life planning enables expression of wishes concerning spiritual or religious needs, if any, and preference as to how these are met. The importance of including residents’ religion in care records was again discussed, after noting this omission on some records. In the event that a resident is agnostic or prefers not to give this information, this should be recorded. Odour control throughout the home was very well managed and observations confirmed ongoing staff training in infection control. Facilities and procedures support appropriate practice for minimising cross infection risks. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 16 The home has efficient policy, procedure and practice guidance for management of medication. Staff designated responsibility for medication administration had received certificated basic training from the home’s pharmacy supplier since the last inspection. This training provides staff with the knowledge and practical skills necessary to ensure safe medication practices. Storage, recording and disposal of medication was sampled and considered satisfactory. Quality assurance systems ensured daily monitoring of medication practice. Records of discrepancies found now also include details of remedial action. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 17 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): Standards: 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The meals served at the time of the inspection visit were appetising and appeared well balanced. Residents have a choice of food. It is necessary to identify residents who require soft diets and for this provision to be available. Social care needs and wishes are identified and an activities programme on offer. Community links are promoted. EVIDENCE: The day centre on the ground floor operated by Anchor Trust is in a designated area. This service offers a range of activities for older people living in the community. A day centre manager and two part-time activity co-ordinators are employed. The day centre is open to residents living at Keswick to attend at any time and does not provide activities on the residential units. The day centre manager stated that she was happy to assist residents wishing to attend an activity in making their way to the day centre from their units if care staff are busy. The activity co-ordinators were stated to encourage residents, on their units, in maintaining every day living skills. They were said to engage residents, who wished to do so, in domestic activities. Examples of these include laying dining tables for meals and folding and putting away personal laundry. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 18 A small number of residents joined in the activities programme on the day of the inspection visit. A flexible, user-led approach was observed in the operation of the activities timetable. Examples of activities include word games, musical events, bingo and painting and craft sessions. A group from the day centre, which included some residents, were observed in the garden enjoying the morning sunshine, socialising over a cup of coffee. Survey feedback from thirteen residents confirmed that they felt there were generally activities that they are able to participate in. Comments included, “There is an open invitation to attend the day centre but for people with disabilities, joining in is difficult”, also “There is no pressure to join in activities, which is as it should be”. One resident attends two other day centres in the community and was stated to enjoy going on holiday every year. A number of residents received regular visitors and there was no restriction on visiting times. One resident stated how much she appreciated visits by a ‘Pat the Dog’ visitor. She found stroking the dog very comforting, reminding her of her past. It was nice to see displays of photographs around the home taken during recent social events. These had involved residents, their relatives, friends and staff. Examples included a fancy dress fund-raising event for Red Nose Day and, more recently, a garden fete in the home’s garden. Regular coffee mornings take place, which are open to residents and their neighbours living in the community. It was stated that staff sometimes take residents out in wheelchairs to the local shops and for walks. The deputy manager’s attention was drawn to comments received anonymously from a resident who expressed the wish to have this opportunity, which inferred this person was not offered to be taken out. Discussed was the need to ensure that this opportunity is afforded to all. It was good to note that recently some residents were able to spend an enjoyable afternoon visiting Wisley gardens. Residents’ religions or other beliefs were stated to be sought as part of the pre-admission assessment process. As previously commented, some records did not include this information. It was stated that residents are informed on admission that church groups of various denominations hold a Christian service in the home every two weeks. It was not clear from discussions with staff whether residents who are non-ambulant have opportunity to attend this service. It was stated that a Roman Catholic priest also gave Communion in the home. Observation of End of Life Plans that were being put in place confirmed that wishes were explored for meeting spiritual needs with residents, where possible, and with family members. The deputy manager advised that effort would be made to support residents who are non- Christians, in practicing their beliefs and ensuring that cultural needs are met. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 19 An administrator is employed who is responsible for invoicing fees and other additional charges not included in fees. Financial records were not examined during the inspection visit. This was on the basis that they had been inspected and found to be improved at the time of a random focused inspection last year. On the basis of information supplied to the CSCI by management about residents’ finances, it has been concluded that arrangements are satisfactory. Although it was policy to regularly monitor weights, at least monthly, some gaps in weight records were noted. There is a need to ensure that weights are recorded, also action in response to significant variations in weight. Observations confirmed records appropriately kept of fluid and dietary intake for some residents. The menu was displayed in units and included a choice of a cooked breakfast daily. Lunch was a two-course hot meal with two main meal options and dessert and the evening meal afforded a choice of sandwiches or a light cooked meal and a range of desserts. The lunchtime meal on the day of the visit appeared nourishing and well balanced. There was a choice of liver & bacon, cod or salmon in sauce, mashed potatoes, root vegetable and spinach. For dessert bread & butter pudding, yoghurts or fresh fruit was served. The meal was transported to each unit in heated trolleys and served by care staff. This enabled staff to offer residents a choice of meal and portion size of their preference. Comment has already been made on observations of the need to ensure that residents who need soft diets are identified and their needs are met by catering staff. The meal observed was served in a relaxed way; there was a pleasant, unhurried atmosphere in all the dining rooms and dining tables were all nicely presented. Staff assisting residents to eat did so discreetly, giving time for people to enjoy their food. Comments from residents about catering standards were varied. Examples of comments were: “It is not like home cooking, neither can it be, the meals are sometimes excellent and sometimes very poor. Still, we get good variety, plenty of fresh fruit and vegetables, no one need go hungry, there is always plenty available, night and day”. Another resident stated, “The former cook was very good, output by this team not to my liking”. The chef manager was on duty with a kitchen assistant on the day of the inspection. Observations of the state of the kitchen for the time of day indicated significant time management pressures on catering staff. The chef manager was observed to be staying over her time to ensure birthday cakes were cooked and iced for two residents celebrating their birthdays that day. It was noted that there had been a vacancy for a deputy chef for some time. A deputy chef had been recently recruited though not yet in post. The home has been covering this vacancy through use of agency chefs. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 20 The report by the environmental health officer who inspected food safety in February 2006 raised no significant issues of concern. The chef manager confirmed that the extractor canopy hood above the cooker, which was not working, had been reported for repair and this was in hand. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 21 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): Standards: 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to express their concerns and have access to robust, effective complaints procedures. They are safeguarded from abuse and have their rights protected. EVIDENCE: The complaint procedure is included in the service user guide, which is a document that tells people how the home works. There is also a leaflet by the visitors’ book in the reception area entitled, ‘Compliments, Concerns, Complaints’. This invites completion of a short questionnaire by residents and non-residents, enabling them to express views about the home and staff at any time. These can be completed anonymously and sent to the home’s management or senior management within the organisation. On the reverse of the leaflet is a space for contact details of CSCI to be inserted, though not provided on the leaflets displayed. The complaint procedure was prominently displayed in the reception and on units and two binders of thank you notes were in the reception area. The assistant area manager and deputy manager confirmed a corporate review had taken place of the complaint procedure since the last inspection. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 22 Survey feedback from residents to CSCI confirmed that all respondents knew how to make a complaint. They stated that they would speak to care staff, the home manager or relatives if they had a concern. There had been no concerns or complaints received about the home by the CSCI since the last inspection. The home manager, under the home’s complaint procedure, had investigated nine complaints in the same period. Overall records of complaints were adequate, mostly providing a clear description of the complaint, audit trail of the investigation, outcome and action proposed to address any service shortfalls. Advice was given to attach evidence of action carried out to complaint records. Safeguarding and whistle blowing procedures were in place and staff familiar with the same. Internal safeguarding procedures supported local multi-agency safeguarding procedures and guidance. Staff induction records sampled confirmed adult protection awareness was covered and safeguarding training later provided as part of a planned training programme. There had been two safeguarding incident referrals since the last inspection. The deputy manager confirmed that both incidents referred to the safeguarding team were examined and the decision taken for no further action under these procedures. Recruitment practices overall safeguard residents. New staff do not take up post until checks are carried out against the national list barring staff unsuitable to work with vulnerable adults. Staff taking up post before receipt of Criminal Records Bureau (CRB) disclosures were stated to work under direct supervision at all times. A volunteer and the home’s self employed hairdresser and chiropodist were stated to all have CRB disclosures. The inspector confirmed that advice would be sought on whether the home should require an employee, who resigned and was reinstated in post within a matter of weeks, need apply for another CRB and POVA check. It has since been confirmed to the home that this is required. Also discussed with the assistant area manager and deputy manager was the need to review arrangements for supervising contact between student doctors and residents. The students visit from time to time as part of their training course. It was suggested that the sun lounge be used for this purpose which would afford privacy of conversation whilst ensuring adequate supervision. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 23 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): Standards: 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The design features of the premises providing domestic in scale and character living units with their own communal focus, promotes independence and is suited to the home’s stated purpose. There is an ongoing programme of refurbishment and upgrading and the home is well maintained, clean and hygienic. EVIDENCE: The building was purpose built as a care home and the accommodation is divided into seven domestic style living units for six to eight residents. All bedrooms are single occupancy, comfortably furnished and have fitted washbasins. Each unit has a comfortable communal lounge, dining room and kitchenette. The location of bedrooms near to toilets, bathing facilities and communal areas promotes independence and individual choice. Residents and their relatives are encouraged to personalise bedrooms, enabling retention of links with family and friends and the past whilst creating a more home-like Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 24 environment. All areas for use by residents are wheelchair accessible and provision of equipment and facilities maximise independence. The upgrading programme for improving and extending bathroom facilities was nearing completion at the time of the visit. Work was also in progress for extending and improving car parking facilities. New developments since the last inspection include new kitchenette facilities on all units, new furniture and replacement of the emergency call bell system. The call bell system includes provision of pendants that can be worn, enhancing safety and independence. External doors, other than the front door, are alarmed for safety. The front door can be secured so that visitors have to ring the bell to gain access when the reception desk is not staffed. Other new developments include the recently refurbished hairdressing salon on the ground floor and an enclosed garden. Access to this garden is through one of the ground floor units. Although this is not ideal, both in terms of impact on the privacy of residents living in this unit or the constraints on independent access for people living in other units, this is considered a positive development. It is recognised that in planning this garden it had been intended that this living unit be designated for provision of dementia care. Unfortunately this proposal had not been possible to achieve. It had been intended to modify this unit with features that provide a positive environment for dementia care, examples including use of colour and other signage to aid orientation, increasing feelings of comfort and security. This is not so easily achieved in non-specialist environments, as some older people may consider these features patronising. The main garden was well maintained at the time of the visit, with mature trees and shrubs and attractive flower borders. It was well furnished and gazebos afforded protection from sun and wind. The garden was accessible to residents from the reception lounge and through the conservatory. Odour control was excellent throughout the home and all areas nicely furnished and comfortable. Though the home had been relatively recently redecorated and décor was mostly good, some areas were in need of redecoration as a result of the current works programme. The deputy manager acknowledged this and thought this would be included in next year’s development plan. Infection control procedures and practices were also satisfactory. Of the two cleaners planned to be on duty, only one had reported for duty on the day of the inspection visit. Despite the staffing shortfall, overall the home was clean and tidy. Usually there were four cleaners on duty some days and one at weekends. A recent development had been the designation of a senior housekeeper for a trial period. It was stated that the home planned to recruit a laundry assistant for a few hours daily during the week. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 25 Other areas of discussion included the need to review adequacy of bin storage for black refuse bags adjacent to the building, which were overflowing. Also the practice of hanging Kylie sheets, after washing, on clothes lines visible from the road. It was suggested that a trellis be erected by the rotary drier. A large quantity of old furniture that had recently been replaced was stored outside the building. It was stated that a skip was on order. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are safeguarded and supported by staff recruitment practices. Residents’ needs are met by the numbers and skill mix of staff who receive training appropriate to their role. EVIDENCE: The staff team is relatively stable and a number of staff have worked at the home for many years. The staffing establishment includes seven team leaders, three working on night duty. Staffing levels for care staff ensure one care assistant on each unit throughout the waking day. Two additional care assistants are on duty on early shifts, providing support and assistance on units as necessary, and one on late shifts. Night staffing levels total three, which includes the team leader in charge and two care assistants. In addition to managers, cleaners and catering staff, the home employs a maintenance person, administrator, receptionist, day care manager and two part time activity co-ordinators. The staff team was covering a shortfall in care hours at the time of the inspection visit. Three care bank staff are employed and stated to work exclusively at Keswick. Agency care staff were not used. A deputy chef had just been appointed and was not yet in post. Job interviews were scheduled to replace some night staff working out their notice; also for recruitment of a domestic assistant. Consideration was being given to employing an additional Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 27 care assistant for part of the morning shift to assist staff in supporting residents in getting up and dressed. The personnel records sampled demonstrated overall compliance with statutory requirements for staff recruitment and vetting procedures. Comment has been made on a CRB practice query in the complaints and protection section of this report. During the inspection discussion took place with a team leader with designated lead responsibility for staff induction and training. Induction records of new staff were sampled and evidence found of common induction standards covered and of ongoing statutory training. All new staff complete the Anchor Trust BTEC certificated induction programme. The National Vocational Qualification training programme for staff was ongoing and good progress being made in working towards meeting workforce training sector targets. It was good to note that the home had attained the Safe Site Anchor Accredited Award. Anchor’s Dementia Specialist Team had facilitated dementia training for staff. It is excellent to note that 97 of care staff were stated to have received this training. Observations of interactions between staff and residents demonstrated a warm, caring approach and good understanding of needs. Good feedback was received from residents during the visit about individual members of staff who they named and clearly held in high regard for their kindness and competence. Survey feedback from individual residents was discussed with the deputy manager. Some individuals commented that care staffing levels were low at weekends and on Bank Holidays. This was not based on fact or planned, though there were occasions when there had been staffing shortfalls through late notification of staff sick leave. It was thought this perception was gained owing to the absence of other staff. Though not directly involved in care, their absence would reduce the level of activity in the home and opportunity for residents’ interaction with staff. Comments from a resident that night staff do not always answer the call bell promptly was discussed. Also feedback from other residents who stated this could be a problem during the day also. It was reassuring, however, to receive a comment from one resident who stated, “The home is good, I sometimes have to wait for staff but when I was ill they couldn’t have bettered their speed in answering my call bell”. Other comments received were from a relative: “Usually staff appear to have the right skills and experience”, and from GP’s who said, “The residents appear well cared for, staff seem capable and caring”, and “Staff manage the care of older people in a sympathetic and empathetic way”. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 28 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): Standard: 31, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is overall effective and quality assurance systems are in place. Whilst progress was evident in reviewing and updating care plans and risk assessments, some shortfalls remain. The inspection outcomes highlight the need for a more robust monitoring system for care plans during the transition to the new care planning system. Staff supervision records are now maintained, though the frequency of supervision sessions not in accordance the home’s policy or national minimum standards. Requirements include the need to review security and confidentiality of storage of records and fire safety at night. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 29 EVIDENCE: There is a registered manager who is appropriately qualified and experienced to manage the home. At the time of the inspection visit the manager was on leave and the deputy manager was in charge of the home. The management structure includes seven team leaders, three of whom work on night duty. Managers and team leaders have defined areas of responsibility and there are clear lines of accountability within the home and within external management On the day of the inspection visit an assistant area manager visited the home, which was pre-arranged. Also present was an ‘acting’ area manager who arrived unannounced to undertake a statutory monthly visit on behalf of the responsible individual for the organisation. Financial records were not examined during the site visit. Information supplied to the CSCI by the manager and observation during the random focused inspection, indicate that residents’ financial interests are safeguarded by the financial systems. Formal arrangements for staff supervision were examined. Records of formal staff supervision meetings were being maintained. It was evident from the records that whilst some progress had been made in provision of supervision sessions for staff, the frequency of these sessions was not in accordance with the home’s policy or National Minimum Standards. Quality assurance systems include an annual quality assurance survey by an independent company. This had not been carried out since the last inspection. Questionnaires were being prepared to be sent to residents, their relatives and other stakeholders. At the time of the last key inspection the regulation inspector found the overall outcome of this survey to be very satisfactory. It was noted that twenty-nine of the thirty-six standards measured met or exceeded standards. On arriving at the home, the inspector was able to access confidential information about residents whilst the reception desk was briefly unstaffed. On top of the desk was a file with alert sheets containing photographs and personal data about residents whose condition was being monitored. Also other personal information in a communication book for district nurses which was permanently filed on top of the desk. This contained the names of residents referred to nurses or receiving nursing care and personal details of their nursing needs. There was also a trolley beside the reception containing care records, care plans and other personal information. This information was openly accessible on other units throughout the home. Discussion with a team leader confirmed the usual practice of securing the front door when the Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 30 reception is not staffed. This measure, however, does not preserve confidentiality of records, which can be accessed by visitors already in the building. Recommendation was made to the deputy manager and assistant area manager for review of storage of confidential information. A number of records relating to safety were examined during the inspection visit. These included staff training in moving & handling, first aid, fire safety and accidents and risk assessments for moving & handling, fire and health and safety assessments. Recommendations included the need to record names of staff attending fire drills and ensure that the organisation’s policy is adhered to for all staff to participate in fire drills. The need to update the fire risk assessment to address and reduce risk specific to the practice of residents sleeping with bedroom doors open, including an individual on continuous oxygen. It was suggested that the fire officer be contacted for advice and solutions explored for minimising risk. Consideration could be given to the use of a door guard on the bedroom door of this individual who feels anxious if the door is shut, if agreed by the fire officer. Whilst acknowledging this resident is on one hourly observation throughout the night, reduced observation levels increase risk at night with only three staff on duty in this two-storey building which has a complex layout. It was good to note action taken to fit a magnetic door closer, which automatically closes if the fire alarm is activated, on the door of the administrator’s office, since the last inspection. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 31 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 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 2 2 Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 32 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(20(b) Requirement All care plans must be kept under review and reflect resident’s current needs. Timescale of 30/05/06 and 22/09/06 not fully met. For prompt referral of residents at risk of developing pressure sores to the district nursing service. The home must ensure appropriate interventions for pressure sore prevention are included in a care plan. For staff recruitment and vetting procedures to apply to all new staff including former employees. A new CRB disclosure and POVA check is required for a staff member recruited in these circumstances. For residents’ records to be kept secure and confidential. Timescale for action 24/09/07 2. OP8 13(4)(c) 14/08/07 3. OP29 19(1)(a) 31/08/07 4. OP37 17(1)(b) 13/09/07 Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 33 5. OP38 23(4) (c)(i) For advice to be sought from a fire officer on the practice of bedroom doors left open at night when observation levels are significantly reduced. Specifically the fire officer should be consulted on the hazard of leaving a bedroom door open where flammable gas is in continuous use. 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations For assessment of dietary needs of the resident discussed and, if a soft diet is required, for this information to be communicated to catering staff and suitable soft diets made available. For care documentation to fully address diversity needs. For residents’ weights to be recorded and records provide an audit trail of action taken in response to significant fluctuation in weight. For the internal Compliments, Concerns, Complaints leaflet to include contact details for the CSCI in space provided for this information. For review of supervision arrangements for meetings between residents and medical students. For review of storage of black bags to ensure adequate bins available. For consideration to be given to erecting a trellis fence by the rotary dryer concealing Kylie sheets being dried outside from the road. 2. 3. OP7 OP8 4. OP16 5. 6. 7. OP18 OP26 OP26 Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 34 8. OP38 For a record to be maintained of staff participating in fire drills. Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Keswick DS0000013691.V342321.R01.S.doc Version 5.2 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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