CARE HOMES FOR OLDER PEOPLE
Kingfisher House Residential and Nursing Home St Fabians Close Newmarket Suffolk CB8 0EJ Lead Inspector
Jane Offord Unannounced Inspection 3rd March 2006 10:00 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 DS0000024427.V285904.R01.S.doc Version 5.1 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. DS0000024427.V285904.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Kingfisher House Residential and Nursing Home Address St Fabians Close Newmarket Suffolk CB8 0EJ 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) 01638 669919 01638 669929 Four Seasons Homes No 4 Limited Post Vacant Care Home 91 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (33), Old age, not falling within any other of places category (62) DS0000024427.V285904.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st November 2005 Brief Description of the Service: Kingfisher House, Newmarket, is part of Four Seasons Health Care. The house is purpose built to provide nursing and residential care for a maximum of 62 older people. Kingfisher House has two floors with a shaft lift accessing the first floor. The home has a lounge on each floor, a smoking room and a laundry room situated on the ground floor. Both floors have separate dining rooms, which are available for service users to eat their meals. There are 58 single bedrooms and four shared rooms each having the advantage of an en suite toilet and wash basin, shared bathrooms are situated on each floor. A new unit (Spillers) was opened in September 2005 and provides an additional 29 places for people who have dementia. The layout is similar to Kingfisher House in that there are bedrooms and communal areas on both floors. There is a vertical passenger lift for use between the two floors. Currently only the ground floor is in use. Meals are transported from the main kitchen. There is a separate staff team consisting of senior carers and care assistants. DS0000024427.V285904.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This additional inspection was undertaken because of concerns raised during the last inspection and a recent Protection of Vulnerable Adults (POVA) allegation in relation to care in the home. The outcome of the POVA investigation could not be completed on the day of inspection and will be reported in a separate report when completed. The unannounced inspection took place on a weekday between 10.00 and 17.00. The manager was available throughout the day to assist with the inspection process. In the course of the day seven residents files, four new staff files, staff rotas, some policies and procedures and some medication administration records (MAR) sheets were all seen. Part of a medication administration round was observed, a tour of the home was undertaken and a number of residents, visitors and staff were spoken with. On the day of inspection the home was bright, clean and warm although the weather was very cold. Residents all looked comfortable and were well presented. Interactions observed between nurses, carers and residents were friendly and appropriate. What the service does well: What has improved since the last inspection?
Since the last inspection the previous manager has returned to post after a break, in a different post, of nearly a year. They had only been back in post just a month but were keen to remedy some of the areas that were not performing so well or had slipped in standards during their absence. A number of requirements and recommendations from the previous inspection have been actioned. Spillers Wing is staffed and running although only the ground floor is used at present there are plans in place to open the first floor soon. DS0000024427.V285904.R01.S.doc Version 5.1 Page 6 What they could do better: 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. DS0000024427.V285904.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000024427.V285904.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected this time. EVIDENCE: DS0000024427.V285904.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People who use this service can expect to be treated with respect but they cannot be assured that the care plan will cover all the assessed needs or that the medication administration practice will protect them. EVIDENCE: The files of seven residents were seen during the inspection, five of them in Kingfisher House and two of them in Spillers Wing. The files in Kingfisher House had evidence of assessment of needs. Some areas covered included mobility, continence, diet, oral health, personal hygiene, night needs, medication and activities of daily living, which included a falls history. Other assessments on cognition and sensory needs were also recorded. There were scored assessments for nutrition and skin integrity, and moving and handling needs were documented. All the assessments were signed and dated as being reviewed regularly. There was no evidence of a formal procedure in place other than the ‘resident at risk’ report to re-evaluate the needs of a resident in a residential bed whose health has deteriorated and needs nursing care. The care plans did not have interventions for all the assessed needs. One resident who was diabetic and had a Waterlow score of 22 (very high risk) had
DS0000024427.V285904.R01.S.doc Version 5.1 Page 10 no care plan to manage the risk of potential skin breakdown. There was a care plan to manage the dressing of a skin tear. This resident was in a nursing care bed. No file seen had written evidence of any pressure relieving equipment being needed or used. One file had a monthly assessment review that stated the resident’s skin was intact but recorded, on the same day, a nutrition assessment review that noted a grade 1 pressure sore had developed, which changed the scoring. One resident admitted from hospital had an assessment from the hospital that showed their needs included an air mattress and use of a hoist. The Waterlow score was 20 (very high risk). The initial assessment done in the home was incomplete and the care plan did not address any pressure area care. The care plan of another resident contained an intervention for personal care stated ‘sit xxxxx on the toilet and wash them’. There were records of visits by the GP and other health professionals. One resident spoken with said they had had a recent health problem that the service had dealt with promptly and they had been admitted to hospital for a short time. Another resident said they had had a persistent cough that the home had got treatment from the GP for and had had the treatment reviewed and changed when it proved ineffective at first. Two files were seen in Spillers Wing. They were chosen randomly and happened to relate to a married couple who are residents there. Neither file recorded that the spouse was also resident in the same home. There were no identifying photographs and one of the admission assessments was poorly completed. There was no life story work in the files although the daily records were better than those in Kingfisher House and did give a feel for how the resident was feeling and behaving rather than just care given. There were some risk assessments in place but there were some omissions. One resident had been used to going out daily and was able to orientate themselves to their new surroundings. In discussion with their social worker it was agreed that daily outings should continue. There was no risk assessment in place to cover that or the fact that the resident had a problem with alcohol and would be able to access local public houses during the daily outing. There was also no risk assessment or care plan intervention to manage the resident’s challenging behaviour. Part of a medication administration round was observed and some MAR sheets in both houses were seen. In Kingfisher House there were photographs with the MAR sheets for identification but there were none in Spillers Wing. Both sets of MAR sheets had signature gaps and in neither house were numbers given of medication dispensed on an ‘as required’ (PRN) prescription that gave a choice of dose i.e. one tablet or two. One prescription for insulin in
DS0000024427.V285904.R01.S.doc Version 5.1 Page 11 Kingfisher House was incorrect as the dose was for 16 units daily and the nurse said the GP had ordered a sliding scale to be ascertained weekly following a blood sugar check. Some medication was dispensed from blister packs by hand rather than using a non-touch technique. The controlled drugs (CDs) register downstairs in Kingfisher House was checked against the contents of the CDs cupboard. The cupboard contained one prescription of morphine patches that tallied with the register. A second entry in the register that showed a further set of patches for a different resident had not been signed for when they were returned to the pharmacy after the death of the resident. Staff were observed knocking on doors before entering rooms. All interactions observed between staff and residents were friendly and appropriate. Residents spoken with said staff were ‘kind and polite’; ‘nothing is too much trouble for them’. The resident’s preferred form of address is established during the admission procedure and recorded in their file. One resident said they had always been known by a different name than their first name and staff respected that. DS0000024427.V285904.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15. People who use this service can expect to be encouraged to maintain contact with family and friends and to receive a well balanced diet. EVIDENCE: The files seen had contact details of the residents’ next of kin, their relationship and when they wanted to be contacted i.e. ‘not between 22.00 and 6.00’. One file contained a list of birthdays and anniversaries important for the resident to remember. During the day a number of visitors were seen around both buildings. Some were spending time in the communal lounges and some were with a resident in their own room. Visitors spoken with all said they were welcome to come and go at any reasonable time. Staff greeted them and were available to give progress details of the resident. One spouse in Spiller Wing said they spent a lot of time there and had been offered meals there if they chose. All residents spoken with agreed that the food was very good and they were always able to have a choice of meal that they liked even if the main menu was not to their taste. The lunch served on the day of inspection looked appetising and hot. Residents cleared their plates with satisfaction. DS0000024427.V285904.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. People who use this service cannot be assured that the present POVA policy and staff training will protect them from abuse. EVIDENCE: The POVA policy was seen and did not reflect the most recent county guidelines as issued by the Vulnerable Adult Protection Committee, Suffolk. Training records seen showed that staff had not had recent POVA training and staff spoken with confirmed that. The manager said they were aware that that training had lapsed during their absence and they were looking to start a rolling programme of training, including POVA, as soon as they could. Recently appointed staff had had POVA training in their induction. Documents relating to induction were seen and showed that POVA was part of the training. One member of staff spoken with said they had not received POVA training but when questioned were able to correctly identify what they would do in a potential POVA incident if it related to a member of staff. They were far less clear on what action to take if it related to a visitor or relative of a resident. DS0000024427.V285904.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use this service cannot be assured that the maintenance of fire equipment will protect them or that they will have drinking glasses regularly changed and washed. They may also find some problems around having their own clothes returned from the laundry and find some furniture in Kingfisher House needs replacing. EVIDENCE: This inspection was not specifically to look at the environment, however a previous requirement was to ensure that fire doors functioned correctly. During the day it was noted that one door at the top of the stairs to the first floor in Kingfisher House did not close properly after being passed through. This was one of the doors noted from the last inspection as not functioning correctly at that time. One resident commented that the bedside tables were very worn and it was noted in other rooms that the tables were scratched and chipped. One resident and family spoken with said the glasses supplied to the rooms for drinking water were not changed daily and could be left for up to a week. The
DS0000024427.V285904.R01.S.doc Version 5.1 Page 15 glass in their room on the day was very dull and smeared. Their visitors said they often washed a glass when they visited, as the resident was unable to do so. This matter was raised with the manager who said the routine was to change glasses daily. They would follow up on whether this was happening. Other relatives spoken with on the day said they had concerns that laundry went astray and their relatives own clothing was not always returned from the laundry. Sometimes they would visit to find their relative in clothing that did not belong to them. They found this distressing. DS0000024427.V285904.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29. People who use this service can expect there to be adequate numbers of staff to meet their needs in Kingfisher House but as the service in Spillers Wing develops the staffing needs to be kept under review. People cannot be assured that all the required checks are undertaken when recruiting new staff. EVIDENCE: Staff rotas were seen and explained by the manager. In Kingfisher House there are two trained nurses on twenty-four hours a day. The ground floor has, in addition, four carers on an early shift, three carers on a late shift and three carers to cover nights. The first floor has five carers on an early shift, four carers on both late and night shifts. Staff and residents spoken with all said there was enough staff to meet the needs of residents at present. Residents said they rarely had to wait long when they rang a bell. Spillers Wing have senior carers and carers. Each shift has a senior carer supported by two other carers for the fourteen residents they have at present. The manager said the induction of the carers is a little different from that given to carers in Kingfisher House and includes caring for people with a diagnosis of dementia. A senior carer spoken with said they had had an induction that included fire awareness, POVA, medication and dementia care. There is concern that if a resident is accompanied out of the service for any reason the service is left with two carers for thirteen residents for a period of time. This needs to be managed and monitored. The files of four newly appointed members of staff were seen. One file showed the POVA 1st check had been received five days after the starting date of the
DS0000024427.V285904.R01.S.doc Version 5.1 Page 17 staff member and there was only one reference in the file. The files all contained the correct documents for identification of people but not a recent photograph. The photographs were photocopied passport photos and the passports were, in some cases, up to ten years old, near expiry. DS0000024427.V285904.R01.S.doc Version 5.1 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36, 38. People who use this service cannot be assured that the staff receive supervision or that the Control of Substances Hazardous to Health (COSHH) regulations are complied with. EVIDENCE: Staff files seen contained no documentary evidence of supervision appointments or records. Staff spoken with said they had not had supervision for a considerable period of time. The manager agreed that the supervision programme had lapsed during their absence but they had plans to restart the programme as soon as possible. The sluice in Spillers Wing was found to be unlocked and accessible to the residents and there were bottles of cleaning agents stored in there on an open shelf. DS0000024427.V285904.R01.S.doc Version 5.1 Page 19 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 1 X X X X X X 1 STAFFING Standard No Score 27 3 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 1 X 1 DS0000024427.V285904.R01.S.doc Version 5.1 Page 20 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. 2. Standard OP7 OP7 Regulation 15. 13 (4) (c) Requirement A resident’s care plan must include interventions for all assessed needs. When a resident has a Waterlow or nutrition score that puts them in a risk category an appropriate care plan must be generated. Details of specialist equipment used in the prevention of pressure sores must be recorded in care plans. A robust procedure must be developed to highlight the needs of residents whose health deteriorates and requires a transfer from residential care to nursing care. Care plan interventions must respect the dignity of the resident. Risk assessments must be generated for activities that residents undertake that could result in harm. Residents’ files in Spillers Wing must contain an up to date photograph of the resident. MAR sheets in both parts of the home must have all boxes
DS0000024427.V285904.R01.S.doc Timescale for action 03/03/06 03/03/06 3. OP7 17(1)(a) Sch.3(3) k-n 13 (6) 03/03/06 4. OP7 30/04/06 5. 6. OP7 OP7 12 (4) (a) 13 (4) (c) 03/03/06 03/03/06 7. 8. OP7 OP9 17 (1) 13 (2) 31/03/06 03/03/06 Version 5.1 Page 21 9. OP9 13 (2) 10. OP9 13 (2) 11. OP9 13 (2) 12. OP9 13 (2) 13. 14. OP9 OP18 13 (2) 13 (6) 15. 16. OP18 OP19 13 (6) 23 (4) (c) 17. OP26 13 (c) 18. OP26 16 (2) (e) 19. OP29 19 (1) completed with a signature or a recognised code if medication is not administered. This is a repeat requirement from the last two inspections. MAR sheets in Spillers Wing must have identification photographs of the resident attached. The dose administered with a PRN prescription that gives a choice of dose i.e. one tablet or two must be recorded. When a prescription is changed by a GP the MAR sheet must be updated to reflect the new instructions. The CD register must be maintained as required by law with returned CDs being signed out by a nurse and the pharmacist. Medication must be dispensed using a non-touch technique. The POVA policy must be updated to reflect the most recent guidelines issued by The Vulnerable Adult Protection Committee, Suffolk. All staff must receive POVA training. Automatic fire doors must be maintained in good working order. This is a repeat requirement. A system must be developed to ensure that residents have clean glasses supplied daily to their rooms for drinking water. Care must be taken to ensure that residents have their own laundry returned to them and are not dressed in clothing that does not belong to them. The staff files must contain a recent photograph of the member of staff for identification
DS0000024427.V285904.R01.S.doc 31/03/06 03/03/06 03/03/06 03/03/06 03/03/06 30/04/06 31/05/06 03/03/06 03/03/06 31/03/06 31/03/06 Version 5.1 Page 22 20. OP29 19 (1) 21. 22. OP36 OP38 18 (2) 13 (4) (a) purposes. Evidence that all the checks required in Schedule 2 have been undertaken must be retained in the staff files. A programme for staff supervision must be reinstated as soon as possible. The sluice in Spillers Wing must be kept locked when not used and chemicals stored in a locked cupboard. 03/03/06 30/04/06 03/03/06 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. 2. 3. Refer to Standard OP7 OP19 OP27 Good Practice Recommendations Life story work for the residents of Spillers Wing should be undertaken to help staff meet their needs when they have difficulty expressing them. Consideration should be given to renewing some of the degraded furniture in Kingfisher House. Staffing levels in Spillers Wing should be monitored as more residents are admitted to ensure there is adequate staffing to meet the specialist needs of the residents. DS0000024427.V285904.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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