Inspection on 11/07/06 for Laurels Nursing Care Centre

This inspection was carried out on 11th July 2006.

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

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

Other inspections for this house

Laurels Nursing Care Centre 01/06/09

Laurels Nursing Care Centre 11/08/08

Laurels Nursing Care Centre 13/06/07

Laurels Nursing Care Centre 11/01/06

Laurels Nursing Care Centre 12/07/05

Laurels Nursing Care Centre 11/05/04

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

CARE HOMES FOR OLDER PEOPLE Laurels Nursing Care Centre The Laurels 70 Union Street Clapham London SW4 6JT Lead Inspector Sonia McKay & Vashti Maharaj Unannounced Inspection 11th July 2006 08:00 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 Laurels Nursing Care Centre DS0000007030.V303082.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. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Laurels Nursing Care Centre Address The Laurels 70 Union Street Clapham London SW4 6JT 020 7498 7500 020 7498 9833 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) The Laurels Care Centre Limited Mrs Joyce Glenda Tendai Chengeta Care Home 68 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0) Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. up to 21 frail, elderly patients aged 55 years and above up to 47 patients aged 55 years and above with dementia Date of last inspection 11th January 2006 Brief Description of the Service: The Laurels is a purpose built private nursing home for older people, some of whom may have a physical disability or mental health need. The home has three floors with the categories of need being grouped separately on each floor. The ground floor supports elderly people who may have a physical disability. The first and second floors support people with dementia or mental health needs. The home is located in a residential street in Clapham with good links to bus and underground train services. There is a small parade of shops within short walking distance of the home, with larger shops and supermarkets available in Stockwell and Clapham. Privately funded care fees range from £600.00 to £800.00 per week depending on individual care needs. The service is also available to services users funded by a local authority. Prospective service users are given a copy of the service users guide as part of the pre-admission process. A copy of the most recent CSCI inspection report is available in the main reception area. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out in eleven hours over one day. It involved direct observation of the care provided and talking with the registered home manager, nursing, care and ancillary staff on duty, eight of the residents and one visitor. The inspectors also had lunch with a group of residents living in the home. Comment cards were sent to the home before the inspection. Completed comment card were received from: • Sixteen residents • Nine relatives or friends • One General practitioner (GP) • One care manager from the local authority The home manager completed a pre-inspection questionnaire during the inspection. Records relating to individual care arrangements, staff recruitment and training and health and safety were examined and there was a tour of the premises. Four health and social care professionals involved in the purchasing or review of care packages for individual residents provided comments by telephone. What the service does well: One resident said, I eat well and I sleep well! Meals are freshly prepared and meet the cultural needs of all residents. A visitor commented, I have the highest praise for this nursing centre and consider the care of the residents quite admirable. The staff are very attentive and compassionate and on every occasion I have visited I have been met with great courtesy and kindness. A relative commented, The staff are wonderful....caring. A GP commented, I have recently taken over the care of the residents of this home and so far I am very happy with the level of commitment and care of the senior nursing staff. Healthcare is well monitored in most cases and good records are kept of treatment needed and provided. The home manager and staff are keen to improve the service and are open to suggestions from residents, relatives and professional involved. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 6 Staff were observed to be patient and caring and took time to explain what they were doing to the residents they were assisting. What has improved since the last inspection? What they could do better: There is still a shortage of specialist-trained nurses (Registered Mental Nurses). Written plans for the care of individual residents must discussed and agreed with the residents themselves if possible and, if appropriate, a relative or representative. Plans must also be more holistic and include social, emotional and psychological needs. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 7 There must be better record keeping in regard to the care that residents being treated for pressure sores receive and the risk of any resident rolling out of a bed must be assessed and appropriate equipment supplied. The records and instructions for the administration of prescribed medicines must improve and GP advice mist be sought swiftly if a resident refuses to take medications repeatedly to ensure that any detrimental health implications are assessed and recognised. Relevant authorities must be contacted/notified when there are any events or incidents that may affect the health, safety or well being of any resident to ensure that residents are adequately protected. The building exterior grounds are poorly maintained and there is a shortage of outdoor communal space for residents to enjoy. Building security must be improved to ensure that residents living on the ground floor feel secure. A occupational therapist has assessed the home and a number of requirements have been made to improve the lighting, the suitability and number of handrails, the seating and also to assist residents to find there way around the home and to their bedrooms by putting photographs on their bedroom doors. Staff must meet with their line managers more often for supervision meetings to discuss their performance and training needs. There must be a quality monitoring and improvement plan based on the views of the residents and all stakeholders. Steps must be take to ensure that residents who wish to keep their bedrooms doors propped open, so that they can see and hear activity outside of their bedrooms, can do so without compromising their safety in the event of a fire. 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. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 8 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 Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5. Standard 6 is not applicable to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have adequate information about the services provided although there should be more information about fees. The home manager completes a comprehensive assessment of the care needs of all persons referred and relatives and some service users are offered a chance to visit the home as part of the process. There are an insufficient number of nurses with specialist training. EVIDENCE: There is an informative statement of Purpose and a ‘service users’ guide’. However, the statement of purpose and service users guide should be revised to include recent staff changes. (See recommendation 1) Contracts do not provide sufficient information about client fee contributions and placement costs. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 10 The information provided to residents and their families must be revised in accordance with the recent changes in the Care Homes Regulations of 2001 due to come into force in September 2006. The service users guide and associated individual contracts must be amended to provide greater detail relating to the standard package of services provided. The terms and conditions (including fee levels) that apply to key services (nursing care, personal care and food) and the payment arrangements (service user contribution/local authority contribution) must be stipulated. The guide must also state whether the terms and conditions (including fees) would be different in circumstances where a service user’s care is funded privately or by local or health authorities and, if this is the case, the reasons for the difference. (See recommendation 2) The pre-admission assessments of two residents who have recently moved to the home provide evidence of comprehensive pre-admission assessment, and in both cases local authority and nursing care needs assessments are also available. As recommended in previous reports, the home manager is now offering prospective residents an opportunity to visit the home before making a decision to move there. Although this visit cannot always be arranged, four new residents have been able to look around the home since the last inspection in January 2006. This enables prospective residents to meet staff and other residents before moving in. This is good practice and should be continued. (See recommendation 3) Long-term residential nursing care and respite care for residents with dementia care needs are provided. The home does not offer intermediate care. Each of the three units has a qualified nurse leading a team of care assistants at all times. Residents living on the first and second floors have dementia. The home manager said that she has recently re-assessed the needs of the residents living on the first and second floor units of the home and people with more advanced dementia are now cared for on the second floor unit. Recruiting a sufficient number of specially trained nurses (RMNs) is still proving difficult and the home does not have enough RMNs to provide 24-hour cover. General nurses (RGNs) are on duty in the absence of an RMN and both the RGNs and the care assistants have undertaken on-the-job training in the care and support of service users with dementia. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 11 This does not negate the need to have an RMN on duty on the first and second floors. This is essential to ensure that service users receive the specialised services for people with dementia offered by the Laurels. The home manager is currently developing a qualified staffing proposal that must be submitted to the CSCI for consideration on completion. (See requirement 1) Laurels Nursing Care Centre DS0000007030.V303082.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of residents are set out in comprehensive individual plans. More must be done to develop plans for social and emotional care and to ensure that residents and/or their representatives agree all plans. Healthcare is generally good, but some areas of recording keeping must be improved. The handling of medications has improved but there are still some areas of poor practice. Residents are treated with dignity and their rights to privacy are upheld. EVIDENCE: Care planning systems have been revised recently and there is some progress in making them more individualised. The care plans identify each medical and personal care need and how these needs will be addressed and met. There is also a record of the health care and advice provided by relevant outpatient or visiting health specialists and health consultations are conducted in the privacy of bedrooms. Care plans relating to physical issues are detailed and are being followed, ensuring residents physical health needs are being met. Although there is Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 13 progress in personalising individual care plans, they are mostly still based on physical health problems and social care, emotional and psychological needs are not fully addressed in some cases. Residents would benefit from a more holistic approach to their planned care. (See requirement 2) Nutritional screening is undertaken on admission and there are falls, moving and handling and tissue viability risk assessments in place. Care plans are reviewed regularly and the home manager monitors the care plans and the frequency of the reviews. Where possible, the initial written care plans are discussed with the resident and their relative/representative and their signatures are obtained as evidence of this. This has not happened in all cases. This is important to ensure that relatives and residents are in agreement with the plans for care. Failure to clarify care needs resulted in a complaint being made by a relative recently and the home manager must be vigilant in ensuring good communication with relatives, especially when placements are hastily arranged. (See requirement 3) One recently placed residents health has improved markedly since moving into the home. The hospital social worker commented that he is very pleased with the progress. The residents son also said that he is very happy with the care and attention his father is receiving. Discussion with staff on duty and observation of care provided suggests that staff are familiar with this residents current care needs and although none of the staff can speak fluent Italian, the residents first language, they are making an effort to use key phrases and communicate clearly. A useful and comprehensive communication care plan is in place. There is now one GPs practise to serve all residents. A GP visits once a week, and was at the home on the day of the inspection. The staff keep a log of residents who need to be seen, with details of the issue. The log also details what action has been taken by the GP. A minimum of five residents are seen on each unit at each GPs visit. The home has input from the Care Homes Nursing Support Team who provide continence, tissue viability and falls prevention support. The incidence of pressure sores, their treatment and outcome, are recorded in the service users individual plan of care. Pressure relieving equipment is available. Photographs of individual wound sites are taken every two weeks to monitor and record wound healing. Four residents have pressure sores at the Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 14 time of this inspection. Three residents had arrived in the home with pressure sores after hospital admissions. Of the two residents files checked there are turning charts in place for only one resident. The qualified nurse on duty explained that the resident is reluctant to turn and that staff are encouraging/supporting him to change position instead. To ensure healing he must be encouraged to change position frequently and records of these position changes must be maintained to ensure that this adequate care is provided with the required frequency. (See requirement 4) General health issues are monitored well, and there is good follow-up with input from the appropriate health professionals, for example, the community mental health teams, dieticians and tissue viability nurses. It was noted that a high-backed chair was placed against the side of one residents bed on the first floor unit, possibly to prevent the resident from rolling out of bed. This is not safe and an assessment must be made and appropriate equipment provided if necessary. (See requirement 5) Daily progress logs are detailed and meaningful, and give a good picture of the residents condition. One resident showed a significant weight loss during one month, the home took quick and appropriate action to request a review by the GP and food supplements were prescribed. There are an adequate number of air circulation fans for use in hot weather both in communal areas and in bedrooms and residents have plenty of cold drinks in hot weather. A recommendation is made for the home manager to research current department of health guidance for action to be taken during heat waves and to devise specific hot weather plans for each unit. (See recommendation 4) The specialist Infection Control team offers MRSA awareness training to all staff. The home is also taking part in a study of MRSA and depression in nursing homes. The outcomes of which will be examined during the next inspection. Observation of staff preparing to assist residents with early morning personal hygiene care suggests that staff are sensitive and responsive to individual preferences and mindful to preserve the residents dignity. Staff knock on bedroom doors before entering and address residents by their preferred names. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 15 On relative commented, I know my husband can be awkward when staff assist him with shaving, but I am pleased with the care he is being given. Service users wear their own clothes at all times. The supplying Pharmacy conducted a thorough audit of the homes medication practises in July and found no issues. The pharmacist will also be providing staff with training. The home manager conducts medication audits and takes action to address any issues identified. There is a medicines delivery and collection schedule for the year, which ensures prescriptions are collected on time from the GP so that medicines are always in stock. Storage facilities are good. Temperature monitoring of refrigerators used for storing medicines and storage rooms is carried out daily. This monitoring has shown that one room gets too hot so medicines are in the process of being moved to another room with better ventilation. Medication Administration Record (MAR) charts state whether residents have any special issues, for example, diabetes. Blood monitoring sheets state advised blood test frequency. All records are accurate and monitoring is as advised. Changes in blood glucose levels are followed up well. One resident was taken off all his oral medication due to non-compliance. MAR charts show only one refusal, and then records were no longer completed. The resident did not see the GP until two weeks after the initial refusal. If a resident is refusing medication, MAR charts must continue to be completed to document refusals until medication is reviewed/changed/withdrawn. As the medicines were prescribed for a number of conditions including depression, congestive heart failure, high blood pressure, high cholesterol and stomach ulcers, he should have seen the GP sooner. (See requirement 6) If someone is refusing medication, a risk assessment/care plan must be put in place to monitor the resident for changes in their condition as if all medication is withdrawn abruptly there is a risk of the persons condition deteriorating rapidly. (See requirement 7) Some medicines that are no longer required by the residents, for whom they were prescribed, are being kept as stock items for general use. An immediate requirement was issued for these prescribed items to be removed. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 16 Homely Remedies (over the counter medicines for minor ailments) can be purchased and kept by the home, but any prescribed items no longer needed must not be kept for stock and used for other residents. (See immediate requirement 8) The medication policy in the MAR chart folders are dated February 2005 and needs updating as the procedure for disposing of medicines was changed in May 2005. The updated policy should be in place to ensure that staff have access to the correct information and guidance. (See recommendation 5) All but one resident take their medication regularly, and almost all records are accurate. A stock discrepancy was noted. The number of tablets remaining in a box did not tally with the number according to the MAR chart. The box contained five too many tablets. This could indicate that tablets are being signed for but not given. There must be regular justified stock checks. (See requirement 9) There were small changes to frequency or timing of administration on MAR charts with no date/initials for the change. This led to an incorrect dose, one third of the correct dose, being given for four days. One item was given at night instead of in the morning for six days and one item was out of stock for seven days. The home must ensure that the instructions on MAR charts are correct and that all items are received before the beginning of the cycle. (See requirement 9) One item stored in the medication fridge has a finite expiry date after opening (Calogen, 14 days). The item was dispensed on the 14th June 2006, but had no date of opening. It was not possible to determine if this had been used past its expiry date. The date of opening must be added to all items with a finite life. (See requirement 9) The MAR charts supplied by the pharmacy are all dated May 2006 instead of July 2006. The dates on MAR charts must be accurate as these documents must be kept by the home for at least three years and must provide an accurate history of all medicines administered. (See requirement 9) Medicines and Regulatory Authority Device Alerts were seen from April 2006. There have been alerts issued since then. It is recommended that a separate folder be kept for these alerts, which are distributed by the CSCI, to ensure appropriate action is taken. Drug alerts are not distributed to homes so the home will have to ensure that they are aware of these, from the MHRS website. (See recommendation 6) Laurels Nursing Care Centre DS0000007030.V303082.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents and relatives are increasingly involved in choosing leisure activities to enrich the lifestyles of those living in the home and the range of activities is being increased gradually. Staff will benefit from additional training in facilitating activities for residents of different cultures and varying abilities. Residents can maintain contact with family and friends and are able to exercise choice and control over their lives whilst they have capacity to do so. Residents receive a wholesome, appealing and balanced diet and mealtimes are pleasant and relaxed. EVIDENCE: There are now two activities organisers who provide activities between Monday and Friday. A written programme of activities is available and distributed to residents. There is also involvement and training from the Care Homes Support team. Residents, who had been noted to be socially isolated in annexe suites on the first and second floors during the July inspection, are now supported to spend time with others in the communal areas, thus increasing their access to social Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 18 interaction and activities. Aromatherapy hand massage has been introduced with encouraging results. Activities arranged for June 2006 included: • A daytrip to Battersea Park • Shopping • Arts and crafts • A musical performance by the Pearly King and Queen Activities planned for July 2006 include: • Sing-Along sessions • Hand massage/one to one • Musical videos • Bingo • Reminiscence • Painting • Dominos • Group reading • Community centre Residents are offered an increasing range of activities, and residents and relatives are now being encouraged to become involved and make suggestions. The home manager said that a recent performance by a Pearly King was much enjoyed. On the day of the inspection some residents were flower arranging and others were doing artwork. A television is available in the communal lounge and some residents enjoy having a radio or television in their bedrooms. There is also a library corner on the ground floor. The home manager seeks information about the life histories of new residents from their family members; this enables staff to have an understanding of their interests and hobbies. A social worker commented that the home manager is open to suggestions about activities. This is good practice. There are residents from a number of countries and cultures living in the home. The staff team is also culturally diverse and, in some cases, a member of staff is available to speak to specific residents in their first languages (Portuguese/Yoruba). This is important and should be considered when offering placements in the home, and when developing activities programmes. (See recommendation 7) The activities co-ordinators are enthusiastic and would welcome some additional training on providing appropriate activities for residents with dementia, physical disability and/or sensory impairment. (See recommendation 8) Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 19 Residents are able to make decisions about when to get up and when to go to bed. On the day of the inspection some residents were up and dressed by 8.00am and others were still in bed. Residents can maintain the friendships and family relationships whilst living in the home and can entertain their visitors in their bedrooms or in the communal areas. Some residents are able to go out to local shops with a member of staff, and other residents go out with their relatives or friends. A visitor commented, On every occasion I have visited I have been met with great courtesy and kindness. There is a portable payphone available that can be wheeled to bedrooms as required. The home employs two chefs and kitchen assistants who prepare a range of wholesome meals in a well-appointed catering style kitchen. The records of the meals served show that a variety of meals have been prepared. Menus include options suitable to meet the age and cultural preferences of residents, for example, Caribbean and Italian options and old favourites. Breakfast and lunch are served in the communal lounges on each of the three units. Breakfast consisted of cereals, porridge and tea. Lunch consisted of liver and bacon, with roast potatoes, fresh carrots and green beans or fish in white sauce with mashed potatoes and cream caramel, fresh fruit or sugar free yoghurt for dessert. Residents can opt for a sandwich if they prefer and can request snacks in between meals if they wish. One resident enjoys a good breakfast and often has three small bowls of porridge. Staff on the unit are pleased to note that the resident, who was underweight, is now gradually gaining weight. The lunch served on the day of the inspection was well cooked. Portion size was adequate and the meals were served hot. Residents needing assistance with eating their meal are helped by patient and respectful staff, who were observed to talk with residents and explain what they were doing. Service users who need a soft or puréed meal are served a puréed or mashed version of the menu available. One service user said, I eat well! another said, Some meals are better than others, I like the Caribbean meals. Staff eat the same meals as the residents are served, but eat their meals during breaks in the staff room. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the home manager has responded to formal complaints appropriately, complaints and concerns raised verbally have not been fully addressed on some occasions. There is evidence that the manager and staff take direct action to protect residents from abuse, appropriate authorities have not been notified on several occasions. Failure to follow adult protection procedures could lead to residents being inadequately protected. EVIDENCE: There is a complaints policy and procedure that meets the standards and regulations and the home manager has kept records of any complaint and complement made. There is a hard-backed book on each unit for staff to record any complaints/concerns raised verbally by residents and relatives or representatives. This is good practice. However, staff have not used the records correctly and in some cases the books are being used for ‘communication’ between staff. To ensure the effectiveness of this record the senior on each unit and the home manager must check the books frequently and the responsible person must monitor these records to ensure that appropriate action is being taken to Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 21 address complaints according to the procedures in place and to identify any trends. (See recommendation 9) There have been four complaints in the last 12 months. One of which, in regard to lost items of clothing belonging to a resident, was substantiated. One complaint was made via the CSCI, although the complaint was unsubstantiated, the outcomes highlighted the need to discuss ‘care needs’ thoroughly before admitting a new service user and to ensure effective communication with relatives who are involved in the care of residents. (See requirement 3) There are policies and procedures to safeguard residents from abuse and a social worker commented that the home manager and senior staff are proactive in identifying, investigating and addressing adult protection issues. However, examination of records during the inspection suggests that the home manager has not notified all relevant authorities on some occasions. For example, a resident had made an allegation in July 2006, and although the home manager had investigated immediately and ascertained that the allegation was unfounded she had not notified the local authority or CSCI. It is essential that appropriate authorities be notified when any allegation is made against staff members. (See requirement 10) There has been a further series of incidents of sexually inappropriate behaviour. The CSCI and placing authority had not been informed. A member of the care home support team became aware of the incidents and advised the home manager of appropriate action to take, including completing detailed incident reports of these events, and notifying the local authority, adult protection co-ordinator and the CSCI. The CSCI was not notified of these incidents. (See requirement 10) All staff attended ‘abuse awareness’ training in May or June of 2006. Further training is scheduled for August 2006. Staff should be made aware of the need to notify the CSCI and local authority of any allegation, incident or accident as part of this training. (See recommendation 10) Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the building is clean and reasonably well maintained on the inside the exterior grounds are poorly maintained and security is a concern. There is a shortage of accessible open-air communal space. Occupational therapy assessment of the building, fittings and furniture has highlighted the needs for remedial action to ensure that these areas meet the needs of current and future residents. EVIDENCE: The home is purpose-built and provides residents with accommodation on three floors. The ground floor building surrounds a small central courtyard garden that is accessible from the ground floor lounge and hallway. There is ramped access for people who use wheelchairs. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 23 The first and second floors have their own separate communal lounges and dining areas. Each floor of the home is separated by security keypad access. A relative commented, As there is no garden I would like the home to make more use of any outdoor space available, with tables and chairs so that tea can be served in warm weather. A care manager commented, The home is very clean and staff are very helpful, however, in my opinion, the residents would benefit from having a bigger garden. (See recommendation 11) The new home manager has recently increased the communal areas on the second floor by converting one of the bedrooms into a second communal lounge. This provides service users with more options. The external grounds are not well maintained and the perimeter hedges are too tall. This provides secluded areas close to the building and there have been instances of smashed windows and nuisance behaviour by youngsters. This is potentially very worrying for residents in ground floor bedrooms, some of who express concern and feel vulnerable on occasions when young people congregate outside their bedroom windows. The security of the exterior of the building should be reviewed to ensure that residents feel/are secure. (See requirement 11) An occupational therapist has recently supplied the home manager with a report detailing the findings of an inspection of the home, as required in previous inspection reports. The report makes a number of observations and recommendations on improving the building to meet the needs of current and future residents: • Lighting is poor in some area and bedroom door numbering is complex. Relatives and residents have said that they often get lost in the building. This is not ideal for a home offering services for elderly people who may be confused or have dementia or sensory impairment. There is a need for improved handrails and lighting in some communal areas and bathrooms and a need for chairs of different heights with suitable cushions in all areas of the home. • A specific and prioritised plan of action is now needed to ensure that the necessary changes identified are implemented. (See requirement 12) The home is generally clean and tidy and well decorated. Bedrooms and bathrooms are fitted with fixed cord call-alarm for service users who need Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 24 emergency assistance. A test call was placed from a toilet and a member of staff responded by attending the room within two minutes. However, some service users may not be able to easily use the call alarm system. A preferable system would have the option of a pendant alarm call as an alternative method for service users unable to access the wall mounted cords. (See recommendation 12) Service users bedrooms are generally personalised and homely and relatives and friends are encouraged to assist by bringing things in. Staff are now also assisting residents to personalise bedrooms in the absence of assistance from relatives. There is now only one double bedroom. Service users have profiling beds, pressure relieving mattresses and some, but not all, have bed rails if they are needed. (See requirement 5) Bedroom doors have locks of a type that can be opened in an emergency by staff, but these locks are not of a type that would allow the resident to lock the door when they left their room. This type of lock should be available unless a risk assessment suggests otherwise. (See recommendation 13) Each of the bedrooms has a small en-suite bathroom facility consisting of a W.C and a hand-basin. Some bedrooms have an en-suite shower facility also. Communal bathrooms have been refurbished recently and a programme of redecoration is in place for bedrooms and communal areas. Bedrooms are usually re-decorated when a room becomes vacant. Aids, slings, hoists and assisted toilets are installed. There are records of professional tests of hoists and slings in use. The home has a passenger lift between floors. The lift is operated by keypad code. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there is an inadequate number of specialist trained nurses the numbers and skills mix of staff available are adequate. Staff are well trained and residents are protected by the homes policies and procedures for recruitment. EVIDENCE: Staff duty rotas record that a qualified nurse is on duty on each unit at all times and there is a record of when staff have worked in the home. There is a shortage in mental health qualified nurses in the home. This must be addressed. The home manager is currently re-assessing the skills mix required on each unit of the home in terms of the need for general nursing and dementia care nursing. (See requirement 1) The current daytime staff ratio and skills mix for each unit is: • Ground floor: One trained nurse and three care assistants • First floor: One trained nurse and five care assistants • Second floor: One trained nurse and three care assistants The current nighttime staff ratio and skills mix is: • Ground floor: One trained nurse and one care assistant • First floor: One trained nurse and two care assistants • Second floor: One trained nurse and one care assistant Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 26 The home employs an administrator, a nursing sister in charge, RGNs, RMNs, senior carers and carers. There are two activities co-ordinators, domestic operatives, chefs, kitchen assistants, laundry assistants and a maintenance person. If necessary, additional staffing is provided by a local home run by the registered provider and many staff have worked in the home for many years. The recruitment records of staff examined during the inspection suggest that adequate checks are made on all staff. Checks include obtaining work histories, evidence of training and nursing qualification, identity checks, POVA first and enhanced CRB (Criminal records) check and satisfactory references. The pre-inspection questionnaire completed by the home manager states that 60 of the care staff have attained an NVQ (National Vocational Qualification) at level 2 or above. There are fifteen registered first level nurses and four qualified first aiders. Domestic staff are also undertaking an appropriate NVQ qualification. Staff have access to internal training provided by the registered provider and to training offered by the Care Homes Support Team. All staff receive structured induction in accordance with Skills for care training targets and a wide range of service specific training is available. The training plans for 2006 include: • Supervision for nurses • Adult abuse awareness • Infection control • Food hygiene • Health and Safety • Health and safety management • Dementia care • Diabetes care • First Aid • Manual handling • Fire training • Nutrition and wound healing Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home manager is qualified and competent and has good leadership skills that have helped to drive forward overall improvement. Although there is evidence of greater consultation and some quality monitoring, systems are not fully developed. The financial interests of residents are safeguarded and most areas of health and safety are addressed. There is a need to improve fire safety and building security and to ensure that staff are supervised more often. EVIDENCE: The home manager has recently joined the team and is registered with the CSCI. The manager is an RMN/RGN and also has the RMA and extensive experience in nursing care. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 28 The inspection was well facilitated by the home manager and all staff on duty, who presented as professional and keen to develop and improve the services provided at the Laurels. There is evidence of good leadership and organisation, and improvement in many areas. The manager has an open, positive and inclusive management style and she communicates a clear sense of direction. This improvement would be swifter if there were a deputy manager in post. Staff are yet to be supervised with the required frequency. (See requirement 13) The home manager has also recognised the need to involve residents and relatives more and recent discussion meetings have been successful. Resident questionnaires have been distributed but have not yet been reported on. These are steps towards effective quality monitoring, although an overall annual development plan is not yet in place. (See requirement 14) Although the specific date of this inspection was not disclosed the home manager and staff made an effort to advise all stakeholders of an impending inspection and to distribute the CSCI questionnaires. This is evident from the large numbers of responses received by the CSCI. Copies of recent meetings with relatives and residents were also provided to the CSCI. Professionals involved in the care of individual residents commented positively about the approach of the manager and staff and most remarked on the recent improvements. Although there are three requirements that are not fully met from the previous inspection, there is good progress and the manager has definite plans for full compliance in place. The director of nursing, who visits the home each week, supervises the home manager and conducts inspections in accordance with Regulation 26 on behalf of the registered provider. Reports of these monthly inspections are maintained in the home and supplied to the CSCI. The home administrator manages the financial affairs of residents whose personal allowance is supplied by the registered provider or the relatives of the residents. All cash and financial records are stored securely and receipts are retained for items purchased on behalf of any resident. The cash balances and financial records for two residents examined were in good order. There are records of routine environmental health and safety checks conducted by a member of staff. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 29 A pest control contract is in place and operatives attend the home regularly to conduct checks and set traps. However, there is a recurrent problem with mice. Pipe work and radiators are fitted with guards to prevent contact burns. Each room is centrally heated with individually controlled thermostats. Hot water temperatures are thermostatically regulated at each hot water to prevent scalding. Water utility authorities inspected the premises in October 2004 and confirmed that the home complies with the Water Supply (Water Fittings) Regulations of 1999. The security of the exterior of the building should be reviewed to ensure that residents feel/are secure. (See requirement 11) The local authority inspectors carried out an inspection of the food hygiene arrangements in June 2006. The report of this inspection makes the following requirements: • The need for improved food safety management and hazard analysis • Freezer door handles need replacement and an area of the kitchen needs to be redecorated • A washing up sink must be cleaned thoroughly The report recommends: • That the manager undertake formal training on how to carry out a food safety management procedure effectively • That kitchen staff retain ingredient information and take extra precautions to ensure the safety of any specially prepared meals for anyone with a specific food allergy The home manager has responded swiftly to the report and has taken action to address each requirement. The London Fire and Emergency Planning Authority (LFEPA) inspected the home in June 2004. The registered manager confirmed that action has been taken to meet the requirements made in their report. The fire alarms, fire fighting equipment and emergency lighting are tested professionally on a regular basis. A fire evacuation drill was carried out in June 2006. Some residents do not like to have their bedroom doors shut. This is understandable but it is also is major fire risk. Risk assessments have been completed and the home manager is obtaining appropriate self-closing door guards. These must be fitted quickly to ensure the safety of all residents in the event of a fire. (See requirement 15) Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 2 3 2 3 2 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 X 2 Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 31 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 OP27 OP4 Regulation 18(3) (18(1)(a) Requirement The registered person must ensure that at all times a suitably qualified registered nurse is working at the care home (an RMN must be on duty at all times on the first and second floors). Although there is some progress the previous timescales of 30/11/05 and 28/04/06 are not met. The registered person must ensure that service users social care needs are set out in an individual plan of care. Although there is some progress the previous timescales of 30/09/05 and 31/03/06 are not fully met. The registered person must ensure that the individual care plans are drawn up with the involvement of the resident and are agreed and signed by the resident whenever capable and/or a representative (if any). The registered person must ensure that records are kept of actions taken to treat pressure DS0000007030.V303082.R01.S.doc Timescale for action 30/11/06 2. OP7 15(1) 31/10/06 3. OP7 12(3) 15 31/10/06 4. OP8 12(1) 13 31/08/06 Laurels Nursing Care Centre Version 5.2 Page 32 5. OP8 OP22 12(1) 13(4) 6. OP9 OP8 12(1) 13(1) 7. OP9 OP8 12 13(2) 8. OP9 13(2) 9 OP9 13(2) 17 sores (turning charts). The registered persons must ensure that appropriate measures are taken to reduce the risk of residents falling or rolling out of bed. The registered person must ensure that if a resident repeatedly refuses to take medications prescribed for serious health conditions GP advice is sought swiftly. The registered person must ensure that risk assessments and specific care plans are devised for situations when a resident refuses to take essential prescribed medications to ensure appropriate health monitoring is in place. The registered person must ensure that prescribed items that are no longer required are disposed of and not kept for stock. To ensure the health and safety of residents through accurate handling and administration of prescribed items. Immediate requirement. The registered person must ensure the safe storage and administration of all medicines by: • Ensuring that all medications are administered as prescribed • Recording (on MAR charts) when dosages and administration times change • Ensuring that the opening date of medications with a finite expiry date are recorded • Ensuring that prescribed medications do not run out of stock DS0000007030.V303082.R01.S.doc 31/08/06 31/08/06 31/08/06 18/07/06 31/08/06 Laurels Nursing Care Centre Version 5.2 Page 33 • • Ensuring that a justified stock check is conducted regularly Ensuring that all MAR charts are correctly dated and retained for the required period 31/08/06 10. OP18 37 11. OP19 OP38 23 12. OP22 23(2)(a) 13. OP36 18(2) 14. OP33 24 The registered person must ensure that appropriate authorities are notified of any allegation made against any member of staff or of any event or incident that affects the health, safety or well-being of any resident. The registered persons must seek advice on making the exterior grounds more secure and ensure that the grounds are well maintained. The registered persons must ensure that action is taken to address the recommendations made in the occupational therapists report of an inspection of the premises conducted in March and April 2006. The prioritised action plan must be sent to the CSCI Southwark office. The registered person must ensure that all care staff receive formal supervision at least six times each year. Although there is some progress the previous timescale of 03/03/06 is not met. The registered person must ensure that effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. DS0000007030.V303082.R01.S.doc 31/10/06 31/10/06 31/10/06 30/11/06 Laurels Nursing Care Centre Version 5.2 Page 34 15. OP38 12 13 23(4) The registered persons must ensure that fire doors are closed and where necessary selfclosing devises (that shut doors in the event of a fir) are fitted to the bedrooms doors of residents who wish to keep their bedroom doors open. 30/09/06 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. Refer to Standard OP1 Good Practice Recommendations The registered person should revise the statement of purpose and service users guide to reflect recent staff changes. The registered persons should revise the service users guide and service user contracts to ensure that the additional information required by changes in legislation (coming into force on 1st September 2006) are added. The registered persons should continue to encourage prospective service users to visit the home themselves before making the decision to move in to the home for a trial placement. The registered persons should research/obtain current department of health guidance for action to be taken during heat waves and devise specific hot weather plans for each unit. The registered person should ensure that the medication folders available on each of the three units of the home contain a copy of the updated medication policy and the out of date policy and procedure should be removed. The registered persons should maintain a folder for Medicines and Regulatory Authority Device Alerts to ensure appropriate action is taken. Drug alerts are not distributed but can be obtained from the MHRS website. The registered person should make specific plans on how the home can meet the cultural needs of all residents and carefully consider how staff can communicate with residents who may not speak English as a first language. The registered persons should provide the activities coDS0000007030.V303082.R01.S.doc Version 5.2 Page 35 OP2 3. OP5 4. OP8 5. OP9 6 OP9 7. OP12 8. OP12 Laurels Nursing Care Centre 9. OP16 10. 11. OP18 OP20 12. 13. OP22 OP24 ordinators with training on facilitating activities for residents with dementia, physical disability or sensory impairment. The registered persons should regularly read the records of concerns/complaints that are maintained on each unit of the home and staff should be advised of the correct method of recording any issues raised. The registered persons should include local authority adult protection procedures and protocols in staff abuse awareness training. The registered persons should seek advise on/consider ways in which the perimeter forecourt and exterior garden can be made accessible to residents, including those who use wheelchairs, as a communal area with seating. These areas should be designed to meet the needs of all residents including those with physical, sensory and cognitive impairments. The registered persons should consider installing a caller alarm system with a pendant call alarm option for service users who find wall mounted call alarms inaccessible. The registered persons should fit bedroom door locks that can be locked from the outside if a service user wishes. Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Laurels Nursing Care Centre DS0000007030.V303082.R01.S.doc Version 5.2 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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