CARE HOMES FOR OLDER PEOPLE
Market Lavington Nursing & Residential Home 39 High Street Market Lavington Devizes Wiltshire SN10 4AG Lead Inspector
Susie Stratton Unannounced Inspection 9:20 23 & 24 May and 14th June 2007
rd th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Market Lavington Nursing & Residential Home DS0000069164.V333379.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. Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Market Lavington Nursing & Residential Home Address 39 High Street Market Lavington Devizes Wiltshire SN10 4AG 01380 812282 01380 710083 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) ANS Homes Limited Mrs Deborah Joan Tilney Care Home 87 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (53), of places Physical disability (2), Terminally ill (4), Terminally ill over 65 years of age (4) Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The 34 bedded residential unit may not admit any service users requiring nursing care. The 53 bedded nursing unit may only accommodate 2 service users with a physical disability and these must be in the age range 52 - 64 years. The 53 bedded nursing unit may only accommodate a maximum of 4 service users with a terminal illness either over 65 years (TI(I)) or under 65 years of age (TI) The 34 bedded nursing unit only may accommodate a maximum of 6 services users with dementia over the age of 65 years (DE(E)) The register manager must always be supported by a designated deputy for the 53 bedded unit who is registered on Level 1 (adult) NMC register and by a designated deputy for the 34 bedded residential unit who either has or is working towards an NVQ IV in care and management. 3. 4. 5. Date of last inspection Brief Description of the Service: Market Lavington Nursing and Residential Centre is registered to provide nursing and care for 87 older people. Although the centre is registered for 87 persons, the registered manager reported that they tend at present to admit to a maximum of 80 persons. Many of the residents come from the local area or the town of Devizes. The accommodation is provided in two separate buildings in a campus arrangement. Residents are informed about care provided in a service users’ guide, a copy of which is provided in each resident’s room and the entrance areas. The building closest to Market Lavington High Street is purpose built and provides accommodation for up to 34 elderly persons who need residential care. The accommodation is over 2 floors, with a passenger lift inbetween. Communal areas are provided on both floors of the home and there is a courtyard garden. The residential wing is registered to accommodate up to six elderly persons with dementia care needs but this is not the main focus of care
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 5 provision. If residents become frail and need nursing care, they will transfer over to the nursing wing. At the time of the first site visit, there were 27 persons resident on the residential wing. The nursing wing is towards the rear of the campus and provides accommodation for up to 53 elderly persons who need nursing care. Some of the rooms are provided in an older building. This building has been extended more than once, these extensions were purpose built. Accommodation is provided over two floors with a passenger lift in-between. Communal areas are provided on both floors there is a courtyard patio area. Residents admitted to the home are often frail and some have highly complex nursing needs. If a resident’s condition improves after they have been admitted to the home, they can transfer to the residential wing. While the home is able to admit up to 2 persons over the age of 52 with a physical disability, their conditions relate to clinical conditions experienced by residents in the rest of the wing. At the time of the second site visit, there were 50 persons resident on the nursing wing. The home was considered to be full, as double rooms were being used as single rooms. There was also a waiting list for people waiting for admission. Both units and each floor of the nursing wing are staffed separately, although in an emergency care staff from either wing will assist other areas. Each floor of the nursing wing has a designated senior sister in charge. There is one kitchen, which serves all the campus, with support kitchens on the first floor of the nursing wing and the residential wing. There are designated catering staff, led by a catering manager. A team of domestic staff are employed. Each unit has its own laundry. On the nursing wing there are designated laundry staff and on the residential wing, laundry is performed by the care staff. There is currently one activities coordinator, who provides activities across the whole site. A maintenance man and gardener are employed. There is one central administrative function, this is provided on the ground floor of the older block. The manager of the Centre is Mrs Debs Tilney, she is supported on the nursing wing by a deputy and on the residential wing by two deputies, who job-share. Deputies are responsible for overseeing staff training and supervision as well as the day-to-day management of their wings. The home is situated in Market Lavington, which is a large village, located six miles from Devizes in Wiltshire. The home is owned by BUPA, a national care provider. The fee range is £398.19 for residential care to £798 for nursing care. Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included visits to the service and takes into account the views and experiences of people using the service. As part of the inspection, 50 questionnaires were sent out and 27 were returned. Questionnaires were also sent out to ten relatives and seven were returned, and three GPs and three were returned. Comments made by residents, their relatives and GPs in questionnaires and during the inspection have been included when drawing up the report. The home also provided information requested by the CSCI prior to the inspection, relating to policies, residents and staff. As Market Lavington Nursing and Residential Centre is a larger registration, the site visits took place over three days, on Wednesday 23rd May 2007 between 9:20am and 2:05pm, Thursday 24th May 2007 between 9:15am and 5:40pm and Thursday 14th June 2007 between 9:30am and 3:30pm. The first site visit was unannounced. The registered manager, Mrs Debs Tilney, was on duty for all three site visits. During the site visits, the inspector met with twenty one residents, and observed care for eighteen further residents for whom communication was difficult. The Inspector reviewed care provision and documentation in detail for eleven residents, two of whom had recently been admitted. As well as meeting with residents and visitors, the inspector met with three registered nurses, six carers, the deputy manager, a domestic, a laundress, the maintenance man, the chef and an administrator. The inspector toured all the building and observed three lunch-time meals and two activities sessions. Three medicines rounds were observed and systems for administration of medicines and the clinical rooms were inspected. A range of records were reviewed, including staff training records, staff employment records, maintenance records and financial records. What the service does well:
At 89 beds, spread over two separate buildings, Market Lavington Nursing and Residential Centre is a large and complex organisation. Despite this, there are effective management systems and the manager knows all the residents and many of their relatives individually. She also knows her staff individually and they reported on how supportive she is. There are systems in place to continually monitor the quality of service provision and all senior staff met with were open to discussion and prepared to change practice if this would improve the service offered to residents. Some of the residents in the home have highly complex nursing as well as care needs and staff were aware of
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 7 interventions needed to meet such needs, working effectively with external healthcare agencies. The home is fully staffed, with an appropriate skill mix to meet residents’ needs. Residents are supported by the home’s effective recruitment systems. Staff are fully supported in meeting residents’ needs by comprehensive training programmes, which relate to residents’ nursing and care needs. Residents and their relatives were complimentary about the service offered. The relative of one newly admitted resident reported that the home was “much better than I though it might have been”. One resident reported “This a happy and well run home”, another “I do not feel I could do better” and another “You can’t find anything wrong with this place”. Residents and relatives commented on the staff, one reported “I am impressed by the staff who are always polite, helpful and can share a joke”, another “I find it clean, tidy and the staff very professional in their work” and another “The care I get is excellent”. What has improved since the last inspection?
Market Lavington Nursing and Residential Centre has been newly registered by BUPA, therefore it is a new registration. However the home itself has been registered for many years. At the last inspection, three requirements and ten recommendations were identified. All had been addressed or showed progress. Care planning documentation has been fully revised. Documentation is being developed, to inform staff of matters significant to the resident in their lives, such as the importance of practice of their chosen religion or how they are to be supported in recreational activities. The new documentation has improved standards of consistency in documentation, although as with all new areas, a few matters still remain to be addressed. Where a resident is prescribed drugs which can have an affect on their daily life, care plans are being developed to assist in the monitoring and evaluation of the effectiveness of such interventions. A review of activities provision across the home has been made and a further appointment was being advertised at the time of the inspection. All staff who have resident contact have been be trained in abuse awareness. When documenting residents’ personal items, the appearance, not the apparent value of the item is now documented. The deteriorating tablecloths and place mats in the residential wing have been replaced. Systems have been put in place to ensure that the plastic container for tea towels in the laundry in the residential wing is regularly wiped out and all debris removed. All non slip bath mats are placed so that they can dry after use. The stained carpets in the nursing wing have been replaced and the scraped walls redecorated. The walls & floors of some of the some of the sluice rooms in the nursing wing and the laundry have been upgraded. All pressure relieving equipment is regularly monitored, to ensure that the weight on the motor relates to the resident’s weight.
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Market Lavington Nursing & Residential Home DS0000069164.V333379.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 Market Lavington Nursing & Residential Home DS0000069164.V333379.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): 1, 2, & 3. The home does not provide intermediate care, so standard 6 is N/A Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents and their supporters are given full information on the home to enable them to decide about admission. All residents are given a comprehensive contract. Residents have full assessment of needs prior to and at admission. EVIDENCE: All residents are provided with the service users’ guide in their own room. The guide is a comprehensive document, which is presented in an approachable style. Copies of the Guide are also available in the front entrance areas, together with general information about services offered by BUPA. Twenty nine of the thirty three persons who responded to this section of the questionnaire stated that they had received enough information about the home prior to admission. During the inspection, it was discussed with the manager, that the
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 11 home’s statement of purpose would benefit from revision, to further detail more information on the range of services offered by the home. All residents are given a comprehensive contract on admission, which they or their representative signs. Contracts have recently been revised by BUPA, to ensure that residents are protected by contracts which comply in full with current regulations and guidelines. Twenty four of the twenty six persons who responded to this part of the questionnaire reported that they had a contract. One relative reported that they had “Good information regarding bank payments”. All prospective residents are assessed by the manager or her delegate, prior to admission. Assessments seen were detailed. Where possible, the home also obtains relevant assessments from other professionals. Where there is limited information available about a prospective resident’s needs prior to admission, further assessments are made on admission. Two of the newly admitted residents met with were unable to recall their admissions process, however one person responded in their questionnaire to state “I was very impressed that a senior carer came a long way to see me at home before I moved here – this was helpful to me” and another said “I came in for a fortnight & enjoyed it so much, I never went home.” Staff spoken with reported that they were informed by the manager of the needs of people who were going to be admitted to the home. This information was given verbally and in writing. This enabled them to properly prepare for the resident’s admission. Market Lavington Nursing & Residential Home DS0000069164.V333379.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): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents are protected by the home’s care planning systems. Residents’ healthcare needs are met. The home largely has safe systems for administration of medicines, but attention is needed to prevent risk to residents for two different matters, in two different parts of the home. Residents’ privacy and dignity are protected. EVIDENCE: The home has recently revised much of its documentation relating to resident care to provide more person-centred care plans. All residents have assessments for needs such as manual handling, pressure damage risk, falls risk and dietary care. All assessments are reviewed regularly. Where needs are identified, the home sets up detailed care plans to direct staff on how individual resident’s needs are to be met. The majority of care plans showed high standards and included apparently small but significant matters to the resident. Residents spoken with informed the inspector of different matters
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 13 which were important to them and it was noted that this was fully documented in their records. For example one resident’s, care plan documented that they liked their bathroom light to be left on at night, with the door slightly ajar, another detailed how they liked their hair to be looked after and another the importance of opening and closing the resident’s curtains. As with any new system, there were still a few matters which needed attention, to fully direct nursing and care. In the residential wing, not all care plans detailed which topical application was to be used and on what area, pressure relieving aids as supplied by the community nurses were observed to be in use, but this was not always documented in care plans and where care staff were supporting the community nurses in monitoring residents with diabetes, care plans did not all state the upper and lower blood levels. On one floor of the nursing wing, one resident who had a complex breathing care need did not have a care plan, although there was evidence in the resident’s room and other records that this need was being met. Several of the residents needed to be supported in taking in fluids by the use of thickening agents. This was documented in their care plans and observations in their room showed that thickening agents were being used in their fluids. As different residents prefer or need fluids thickened to a different consistency, it is recommended that this be directed in care plans. Staff met with all showed a good knowledge of residents’ nursing and care needs. Staff were also generally positive about the new records and they were observed to up-date records as and when needed, during the inspection. In the residential wing, where residents had an assessed risk, for example of putting on weight but intervention was not indicated staff knew why this was, they were advised that in such cases, as the resident had an assessed risk that this should be documented. Staff described in detail how one resident’s needs were to be met when their condition became unstable but this was not documented. On discussion with staff in the nursing wing, it was also identified that two residents’ conditions had changed in parts of their nursing and care needs but their care plans had not been fully evaluated when this had occurred. However it was also noted for one resident on the nursing wing, who had become suddenly unwell, leading to a major change in their nursing and care needs, that a new care plan had been put in place to reflect this and other care plans evaluated, to reflect their changed needs. This had taken place on the same day that the resident became unwell. The home maintains daily records for all residents in which their day to day condition is documented. Where needs were identified in such records, there was evidence that care plans were promptly put in place. Where residents had increased needs, monitoring systems were generally put in place in the form of a frequent care chart. The home have recently introduced a revised frequent care chart. This provided evidence that residents who needed to be offered fluids regularly or have their positions changed to prevent pressure damage, had such needs met. Not all staff are completing all sections of the monitoring
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 14 charts in a similar manner, this could make assessment complex for managers and staff may need more training and support in ensuring that such records are completed in a consistent manner. Where staff were making records of meals taken in by residents, some charts did not state the meal eaten, just “liquidised diet”. This should be avoided and the actual liquidised diet eaten should be documented, so that there is evidence the resident was given a balanced diet. Where care plans document that a resident had a particular need, for example where a resident with continence care needs had directions in their care plan that they were to be offered the toilet at certain intervals, there are sometimes but not always records maintained to show that staff are complying with the direction in the direction. This is indicated, so that managers can ensure that nursing and care needs are being met and review if the directions continue to be effective. Generally the home has clear systems for monitoring that staff rotate injection sites when administering regular injections, however this had lapsed for one resident and needs to be reintroduced. Where residents had dementia care needs, they all had clear care plans in place, which directed staff on actions to take to meet their needs. For example, one resident’s care plan stated that if a resident showed certain behaviours, staff were to walk away, another resident’s care plan stated that the resident needed care interventions to be performed quickly. Care plans were completed in a non-judgemental language. Records were maintained of complex behaviours, for example when a resident hit out at staff, in the daily record. One resident’s medication record indicated that they had an additional medical health need, they did not have a care plan about this need or specific treatments to be used when this drug was used. Where residents had wounds, there were clear directions in care plans about how the wounds were to be treated, with monitoring systems in place, so that the wound’s response to treatment could be assessed. There was also evidence that the home regularly consulted the tissue viability nurse specialist when indicated. When a resident had a urinary catheter or supra-pubic in place, full records were maintained and the clinical indicator for its use was consistently documented. As much as possible urinary catheters are removed when not indicated. It was noted as good practice that one resident had recently had their urinary catheter removed and was being supported in reachieving continence. Staff reported that they had effective working relationships with local GPS. Clear records of consultations were maintained. One resident who had an unstable diabetic condition had regular reviews of their condition with their GP. Where residents became unwell, records showed that GPs were promptly notified and a visit requested. Of the 34 persons who responded to this section of the questionnaire, 27 reported they always and seven that they usually received the medical support that they needed. One person reported “If anything is wrong they certainly get the doctor in.” Another person reported on
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 15 how they appreciated supports from staff saying “If you need the doctor, they go with you, so you are not alone.” Other healthcare needs are met. The chiropodist visits regularly and an optician was visiting during the inspection. Residents had also been supported in having reviews from the dentist and hearing aid therapist. Residents commented on how staff met their medical needs. One reported “If I’m in pain, I can tell the staff and they give me something for it” and a relative commented “My [relative] has certainly improved since she has been there”. BUPA has a very detailed and comprehensive policy and procedure on the administration of medicines. The residential wing and both floors of the home have their own storage areas for medication. All drugs were safely stored and records of drugs received and disposed of maintained. Controlled drugs were correctly stored and full records maintained. There is only one controlled drugs cupboard in the nursing wing, this means that registered nurses would have to leave the first floor to access the only one, which is on the ground floor, so it is recommended that a controlled drugs cupboard is provided on each floor of the home. During an observations of a medicines round, it was noted that a registered nurse left the drugs trolley unlocked when they went to give a resident their drugs in their room and so the drugs were not secured. As there were no residents who had wandering behaviours, this did not present a very high risk, however it is not good practice and does not conform to BUPA’s medicines policies and procedures. Medicines trolleys should always be locked when not under direct observation. Medicines administration records were in place for all residents. In the nursing wing they were completed in full. However in the residential wing a total of 26 records had not been completed. Where these could be checked, in all apart from one case, the tablet had been given to the resident but the chart not signed, however as many of the non-completed records related to eye drops, it was not possible to assess if residents had been administered these prescribed medications. Non-completion of records indicates that certain staff were not following the home’s policy and procedure on administration of medicines. The manager was advised that she or her senior staff should perform some supervisions relating to medicines administration, to ensure that staff did comply with the home’s policy. Where residents were prescribed a variable dose of a medication, this was documented in the nursing wing but was not in all cases in the residential wing. This is needed so that medical staff can be properly informed of responses to treatment. Where medication instructions had been completed by hand, this was signed and countersigned in all cases. All limited life medications had been dated when opening. Care plans had been developed for residents who were prescribed drugs which could affect their daily life, such as aperients and painkillers, so that their effect could be monitored. Staff were observed to knock before they entered residents’ rooms. All personal care was performed behind closed doors. Frail persons who were
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 16 cared for most or all of the time in bed, were nicely presented, with clean glasses, properly brushed hair and tidy finger nails. One relative commented “The staff are very good about caring” and one resident commented “They don’t treat me as silly”. One relative commented on how understanding and supportive the home were when the spouse of one resident, who was also in the home, died. Another relative commented how staff cared for their relative “the way […] likes things done, their appearance, one carer even does[ …]’s nails. They always give her her dignity.” Market Lavington Nursing & Residential Home DS0000069164.V333379.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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. The home works to provide an environment where residents’ diverse needs can be met. Residents are supported in maintaining close links with family and the local community. Residents reported that they could choose how they spent their days. A range of different meals are provided to residents. Staff are available to support frail persons at mealtimes. EVIDENCE: Market Lavington Nursing and Residential Centre is situated on the high street of the small town of Market Lavington. This means that residents who are able to, can access local facilities such as the library, post office and churches. Where residents are unable to go out of the home, due to its proximity to the centre of the town, it is also easy for people to visit. The home employs an activities coordinator, who concentrates on providing activities to persons in the residential wing in the morning and nursing wing in the afternoon. On the morning of the first day of the site visit, she was running an art class. On the afternoon of the second site visit, she was coordinating a visit from a PAT dog.
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 18 One frail person commented on how they had liked the visit to their room from the dog. A range of different responses were made in questionnaires about provision of activities, of the 27 people who responded to this section, nine reported that the home always, eight usually, eight sometimes and two never provided activities which they could take part in. Some residents commented that they preferred their own company and stayed in their own room. One reported “the tv satisfies me” another reported that they preferred to be on their own. Residents who enjoyed the activities commented on the quizzes and trips out, one person described the activities organiser as “lovely”. Where frail residents are not able to leave their rooms, a part-time activities coordinator performs room visits, to provide individual stimulation. To respond to this, at the time of the inspection, the home were also recruiting for a second full-time activities coordinator, who would additionally provide a service at weekends and in the evenings when needed. This will improve facilities in the home for activities. A system has also been put in place for regular meetings between the activities coordinators in different BUPA homes in the locality, so that activities coordinators can exchange ideas, skills and gain support from each other. The home actively supports residents in maintaining contact with family and friends. Visitors can come and go when they wish. One relative commented “Any family celebrations are encouraged as well as trips out.” Many of the residents had their own phones in their room and several commented on how this helped them to keep in touch. Relatives felt that the home kept in touch with them. One reported “Whenever …. needs medical attention a member of staff always calls”. The home maintains links with other supports in the community and local churches visit to perform services and provide communion to those for whom it is important. One younger resident was busy for most days of the week, going out to external activities, which suited them. Residents spoken to reported that they could choose how they spend their days, that they could get up and go to bed when they chose. One resident reported “They don’t force you to do anything” , another “No rules and regulations here” and another “You can come and go as you like”. Residents also reported that they could choose if they attended activities or trips out and that it was up to them whether they ate in their own room or the dining room. One domestic was observed to discuss with a resident when they would like some flowers, which were beginning to pass their best, to be removed and disposed of. The new documentation systems are supportive of reflecting residents’ diverse needs. Some of the care plans reviewed were very detailed and related to residents’ past lives as well as their current needs. As would be anticipated in a large home, there were a wide range of comments about the meals service. Of the 31 people who responded to that part of the questionnaire, eight reported that they always, sixteen that they usually and
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 19 seven that they sometimes liked the meals. Comments varied through “I think all meals except breakfast are pretty awful”, “The food’s all right” to “excellent”. Residents commented that they had a choice. One reported “Oh yes, I like the food and I send it back if I don’t like it.” Several people commented on the availability of drinks throughout the day, one reported “Someone is always bringing you nice cups of tea.” It was noted as good practice that catering assistants, as well as taking residents’ drinks, also took time to talk to them. One was observed to spend time discussing racing with a male resident. Menus are reviewed every six months. The chef was in the process of performing a menu review at the time of the inspection. He reported that he had consulted with residents during a meeting, sent out questionnaires and discussed meals with nursing, care and catering staff, to assist him in developing a new menu. BUPA have a menu management folder to support the chef in developing menus. The purpose of this folder is to ensure that residents can have a balanced diet, including five portions of fruit or vegetables a day. The chef also has a folder detailing a wide range of different diets which may be needed by residents, including diabetic, high protein, Buddhist or Vegan diets. The chef meets with residents and their families where a resident has particular or complex needs. He had done this recently for one person who was on a complex medical diet. Three dining rooms are provided, one in the residential wing and one on each floor of the nursing wing. Dining rooms were nicely set out, with cloth tablecloths and flowers on the tables. One person commented “I like all the chatting at lunchtime”. Many of the residents on the nursing wings were unable to access the dining rooms and many also needed assistance to take in their meals. Where residents needed assistance, staff sat with them, encouraging and supporting them. One member of staff was observed to help a resident who had concentration problems to remember to eat their own meals, another was observed to take a meal to a resident’s room and take time to ensure that the resident was settled and had everything they needed, before they left the room. Market Lavington Nursing & Residential Home DS0000069164.V333379.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. The home has a complaints procedure, which functions in practice. The home has effective procedures to safeguard vulnerable adults. EVIDENCE: The home’s complaints procedure is available in the service users’ guide, which all residents have a copy of in their own room and copies are also available in the main entrance hall of the home. Of the 31 people who completed that section of the questionnaire, 29 reported that they knew how to make a complaint. Of the 34 people who responded to that section of the questionnaire, 27 reported that they always, six that they usually and one that they sometimes, knew who to talk to if they were not happy and that the home had responded appropriately. One relative commented on how they had booked an appointment with their relative’s lead nurse after admission and “sorted a few things out”. Another relative commented “We find that we are able to discuss matters with staff – there had been problems with the laundry service & cleanliness of room but these have been resolved”. Several residents reported that they would talk to a specific member of staff, using their name and several said that they had talked to the manager about matters of concern to them. The manager maintains a record of formal complaints. None had been received since the previous inspection. The manager also maintains a folder of compliments and concerns made by residents or other persons. This
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 21 enables her to assess quality of service provision and any trends. A review of this folder showed that issues had been followed up when they are raised. The home has experience of working within local vulnerable adults procedures. No referrals have been made since the previous inspection. All members of staff spoken with showed an appreciation of safeguarding adults and showed an awareness of matters which they should consider. All staff were also aware of the need to promptly pass on matters which were concerning them to managers. Training records showed that staff had been regularly trained in safeguarding adults. Where residents needed restraints such as bed safety rails, full assessments are completed. If such restraints were indicated, regular re-assessment of need takes place and if they are no longer indicated, action is taken to remove such restraints. Market Lavington Nursing & Residential Home DS0000069164.V333379.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents live in a largely well-maintained environment. Residents have comfortable bedrooms and communal areas. There are a range of facilities and equipment to meet the needs of residents with disability. The home is clean and there are systems to prevent the spread of infection. EVIDENCE: Services at Market Lavington Centre are provided in different wings. The nursing wing is over two floors, parts of which are in an older building, which has then been extended more than once. There is a passenger lift between the floors. The residential wing is a purpose-built building over two floors, it also has a passenger lift. There is one central kitchen and administrative area, which is situated in the old building. A separate laundry is provided in the nursing and residential wings.
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 23 Most of the buildings are well maintained, some corridor carpets have been replaced and walls redecorated in the nursing wing but corridor carpets and walls in the residential wing would benefit from attention, as both were showing signs of scrapes and staining. The carpets were clean and smelt fresh. The clinical room in the nursing wing showed signs of scrapes and damage to the walls in places and should be up-graded. All areas have maintenance books, which staff and the maintenance man reported were accessed on a daily basis and a prompt response given to matters such as light bulbs and dripping taps. Both wings have their own paved garden areas. In the residential wing, there is one lounge on each floor, and a dining room. There is a lounge and dining area on each of the floors of the nursing wing. A smaller, quieter lounge is also provided in the nursing wing. One resident reported about the lounge in their wing, saying “It’s a nice lounge” , another that their lounge was “nice and sunny” and another about a small lounge that it was “nice and quiet” All residents in the residential wing have single rooms with their own en-suite facilities. In the nursing wing, as it is an older registration, there are a few double rooms and a few rooms without ensuite facilities, but all the newer rooms are single, with en-suite facilities. One resident described how much they appreciated having their own toilet, as they had not expected this to be the case in a care home. Rooms generally exceed national minimum standards. Screening is provided in the few double rooms. Rooms are attractively furnished and residents can bring in their own items of furniture if they wish. There are a range of disabled baths and showers provided for residents across all of the home. Some of the communal bathrooms and wcs in the residential wing need attention, as they were showing signs of scrapes to the walls, deteriorating flooring and development of limescale in the wash hand basins. They should be attended to before they deteriorate further. Equipment is provided to meet the needs of residents with a disability. There are full documentary systems in place to ensure that all aids, including wheelchairs, are regularly checked and serviced. Where residents need variable height beds, these are provided. Two residents described their beds as “comfortable”. One person also said “The mattress was cold, so they put an under blanket on for me, they’re useful like that here.” The manager reported that a further delivery of 25 profiling beds was to take place shortly and that this would mean that all residents in the nursing wing would have access to such a bed if they needed one. A range of hoists to aid manual handling are provided, these were observed to be correctly used by staff. Residents at risk of pressure damage were provided with appropriate pressure relieving equipment. All residents had been left with access to their call bell. Most of the residents spoken with commented on how promptly staff responded when they used their call bell, one reported “If I ring my bell, they come, that’s what it’s for”, another “They come quickly when I ring my bell” and one person who
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 24 was not able to use their bell reported on how staff “keep popping in to see if I’m alright” The home has systems in place to support staff in preventing risk of spread of infection. Four members of staff spoken with showed a good knowledge of principals of infection control and commented that the home had a ready supply of gloves and aprons for their use. Single use methods of hand cleansing and drying are available at all relevant wash hand basins. Sterile gloves were available to registered nurses performing aseptic procedures. Of the 30 people who responded to this part of the questionnaire, 21 reported that the home was always, and nine that it was usually fresh and clean. All aids were clean. One person commented “The cleaning is good and done regularly”. A domestic was observed performing her role, she worked carefully, ensuring that all areas were cleaned, including the tops of door-frames. She reported that staff had a ready supply of cleaning materials and equipment. Some of the backs and undersides of bath hoists in the residential wing needed attention as they showed sings of limescale development, this needs to be removed before they deteriorate further. The home has two sluice rooms on each floor of the nursing wing, one of which has a washer disinfector and one on each floor of the residential wing. The sluice rooms were clean and washer disinfectors working properly. All sluice rooms had a supply of gloves and aprons in them. One of the sluice rooms in the nursing wing and both sluice rooms in the residential wings, showed signs of staining on the floor, walls and wash hand basins and some of the walls and doors were scuffed. In order to ensure that surfaces can be properly cleaned and prevent risk of cross infection, attention should be paid to these areas before they deteriorate further. Both wings have their own laundry. Standard systems were in place to separate infected and potentially infected laundry, which the laundress reported that staff comply with. The laundress on the nursing wing showed a good knowledge of the principals of prevention of spread of infection. Both wings had washing machines with a sluice wash programme. In the residential wing, the gap between the washing machine and wall was very narrow and the area behind the machines was difficult to reach. Due to configuration of the machines in the area, cleaning between them and behind them will be complex and it is recommended that the area be re-configured, to ensure that the areas can be easily cleaned. Market Lavington Nursing & Residential Home DS0000069164.V333379.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is excellent. This judgement has been made using available evidence, including visits to this service. The numbers and skill mix of staff support the residents. Staff were competent and familiar with residents, as there was a low turnover in staff. Staff are fully supported to develop their skills by the home’s training programmes and up-take of training opportunities by staff is high. Residents are fully supported by the home’s safe systems for recruitment of new staff. EVIDENCE: Market Lavington Nursing and Residential Centre employs a range of staff. A team of registered nurses and carers work on each floor of the nursing wing, with a senior registered nurse leading each team. The nursing wing staffed in accordance with minimum staffing levels. The home always exceed this level. The residential wing is headed by a two managers who job share, they manage a team of care staff. As well as nursing and care staff, hotel services, maintenance and administrative staff are also employed. The home has a very low turnover in staff, there has been no turnover in registered nursing staff for two years and limited turnover in care and ancillary staff. There was evidence that some staff have left employment in the home but have returned to work there, as they appreciate its atmosphere and the supports given. Of the 30 people who responded to this part of the questionnaire, 17 reported that staff were always and 13 usually available when they needed them. While a few
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 26 residents did comment that there were some times of the day when staff were less available, this was certainly not reflected by the rest of the residents and many commented on how available staff were, one reported “They’re always here”. The deputy manager leads on training and is supported by BUPA’s training systems. BUPA have an extensive induction programme, which complies in full to all standards. The deputy manager reported on how supportive the new programme was in helping staff to understand their role and develop their practice. The programme can be used flexibly, so that staff can work through it at their own pace, depending on their past experience and skills base. The deputy manager acts as mentor for all new care staff, with associate mentors, supporting her, for example where the new employee works night duty. Ancillary staff have their own induction programme and are supported by the relevant head of department. All care and nursing staff work at least four shifts supernumerary when they start employment. Following induction, training is supported and over 50 of care staff are trained to NVQ 2 or above, with a rolling programme for newly employed staff who do not have an NVQ qualification. A range of other training opportunities are offered. Training is offered in-house or externally, depending on the topic and skills offered by staff the home. Where a training need is identified, BUPA’s training department can be contacted and they can research the area and provide training across homes in the locality. The home has also contacted suppliers, for example of PEG feed systems, to provide training and local specialists, such as the continence advisor. Where staff are employed whose first language is not English, the home has links with a local college, to support staff in developing English language skills. All staff have an individual training profile. These provided evidence of the wide range of opportunities offered. Records also showed that the up-take of training opportunities is high. Staff spoken with showed knowledge about the types of care needed by residents. One carer reported “I like this job, you get lots of training” another carer said “There’s plenty of training” and described her self-study book. New systems for staff employment records were being developed at the time of the inspection. The files of three recently employed staff were inspected, they were clear, easy to audit and fully maintained. All three records included criminal records checks, proof of identity, at least two references, past employment history and a health declaration. All staff are interviewed using an interview assessment tool, which was individually completed for all staff. All staff are given a job description and terms and conditions of employment, which they sign. Where staff are employed from aboard, the necessary documentation was in place. Three records of staff who had been in employment for a longer period inspected, were also up-to-date, with evidence of sickness monitoring systems and relevant correspondence between staff and the home. Market Lavington Nursing & Residential Home DS0000069164.V333379.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. The manager of the home is an experienced manager and registered nurse, who is able to discharge her duties in full. BUPA has systems for reviewing quality of care and making arrangements for improvements in care, when identified. Residents are supported by the home’s systems for ensuring that their financial interests are safeguarded. Staff are supervised, to support them in their roles. There are systems in place to ensure the health and safety of residents, staff and visitors. EVIDENCE: The manager of the service, Mrs Tinley is an experienced manager and registered nurse. Reviews of previous inspection reports show that Mrs Tilney
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 28 consistently ensures that requirements identified during CSCI inspections are addressed within timescales and recommendations taken into account. Many of the residents spoke highly of her and remembered her coming to meet with them, prior to admission. This was reflected by staff, who felt that they would be able to come and discuss matters with her and that she knew them personally. Mrs Tinley is aware of how to ensure that staff are performing at standards required to meet residents nursing and care needs. A review of files showed that she takes prompt action to investigate and act on any issues relating to staff performance, within BUPA’s disciplinary procedures. Mrs Tinley also ensures that she maintains her nursing skills and knowledge-base, so that she can effectively supervise her clinical staff. She showed a detailed knowledge of up-to-date nursing practice in relation to elderly and terminally ill persons. One member of the care staff described Mrs Tilney as “A very, very good boss”. BUPA has standard systems for auditing of quality of service provision. The home regularly performs internal audits on a range of areas, including health and safety, menus, accidents and pressure damage. Results are submitted to relevant management departments within BUPA. BUPA also sends out questionnaires to residents, their supporters and staff. These are collated into a report and where relevant, the manager is required to develop an action plan, specifying how improvements can be made in service provision. The home is regularly visited by a manager from within BUPA and a report made. Market Lavington Nursing and Residential Centre operates individual accounts for residents. This service is managed by the home’s administrator. There is a clear audit trail for all matters relating to residents’ personal moneys. Full records are maintained of moneys paid in and debited from their individual accounts. All receipts are kept. These accounts are regularly audited, including unannounced audits, by BUPA. Where residents hand in valuables for safekeeping, full records are in place and safe storage systems available. Staff are regularly appraised and supervised, starting with an appraisal after three months of employment, on completion of induction. Supervisions detailed areas for development and are cross-referenced to the training needs analysis. Supervision records seen were individually completed and signed by both the supervisor and supervisee. New training records recently introduced will facilitate the deputy manger being able to see at a glance if all staff have been regularly supervised. Due to the introduction of the new documentation systems, many of the recent supervisions had related to supporting staff in developing skills in client-centred approach when developing and evaluating care plans. The home has clear systems for ensuring health and safety. All staff are regularly trained in the area. Two staff members lead on manual handling. BUPA has distance learning training packs in areas such as infection control and food hygiene, to support staff. All staff are regularly trained in fire safety.
Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 29 Full maintenance systems are in place to ensure that equipment such as hoists, lifts and fire protection equipment is regularly serviced in accordance with manufacturers’ instructions. Records seen were clear and maintained in full. As noted in Standards 19 & 26 above, work is recommended in some bathrooms, wcs and sluice areas in certain parts of the home, to ensure that fully systems are in place for the prevention of spread of infection. The Environmental Health Department’s report was held on file and there was full evidence that all areas had been addressed. All accidents are reviewed by the manager and reports made on trends, if identified. It was noted as good practice that the manager asks staff to report on residents’ conditions 24 and 48 hours after an accident. The home has a health and safety committee, which meets three monthly. Where matters are identified, for example, some cracked paving stones were noted by the manager in the patio garden, actions plans are put in place to address the matter. Market Lavington Nursing & Residential Home DS0000069164.V333379.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x 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 3 3 3 3 x x 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 3 3 x 3 Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) (c) Requirement Care plans must always be drawn up where service users have a nursing or care need. Care plans must direct actions to be taken to meet this need to ensure that the service user’s health and welfare is met. Care plans must always been revised when nursing or care needs change. All staff must at all times conform to the home’s policies and procedures on the safe storage and administration of medicines. Timescale for action 31/10/07 2. OP9 13(2) 31/07/07 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 OP1 Good Practice Recommendations The home’s Statement of Purpose should be revised to include more detail on the range of services provided.
DS0000069164.V333379.R01.S.doc Version 5.2 Page 32 Market Lavington Nursing & Residential Home 2. OP7 3. OP7 4. 5. OP9 OP9 6. 7. 8. 9. 10. OP9 OP19 OP26 OP26 OP26 Care plans should all include details of service user care, such as topical applications, pressure relieving aids being used, upper and lower levels of blood sugar levels for diabetic service users, the amount of thickening agent needed by a service user or actions to take when changes in weight have been observed Staff should complete the home’s monitoring documentation in relation to changes of position, meals given, supporting service users in re-achieving continence and rotation of injection sites and in the same way. A second Controlled Drugs cupboard should be provided on the first floor of the nursing wing so that registered nurses do not have to leave the floor to check such drugs. Regular supervisions of staff on the residential wing in the administration of medicines should be performed to ensure that staff are complying with BUPA’s policies and procedures. Where a service user is prescribed a variable dose of a medicine, the amount administered should always be documented. Deteriorated corridors, communal bathrooms, wcs and clinical rooms should be re-floored and redecorated, as needed to improve facilities. All limescale should be promptly removed from the backs and undersides of bath hoists and hand wash basins, before they deteriorate further. Deteriorated walls and flooring in sluice rooms should be improved, before they deteriorate further. Consideration should be given to the re-configuration of the machines in the laundry in the residential wing, to ensure that the areas around the machines can be easily cleaned. Market Lavington Nursing & Residential Home DS0000069164.V333379.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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