CARE HOMES FOR OLDER PEOPLE
Miranda House Nursing Home High Street Wootton Bassett Wiltshire SN4 7AH Lead Inspector
Tim Goadby Key Unannounced Inspection 15th & 26th September 2006 10:40 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 Miranda House Nursing Home DS0000015930.V311022.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. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Miranda House Nursing Home Address High Street Wootton Bassett Wiltshire SN4 7AH 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) 01793 854458 01793 853951 qualitycarewilts@aol.com Quality Care (Wiltshire) Limited Mrs Gillian Gray Care Home 68 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (68), Mental disorder, excluding learning of places disability or dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (68) Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Persons less than 45 years of age may not be accommodated. No more than 2 persons not less than 50 years in receipt of day care at any one time. 21st July 2006 Date of last inspection Brief Description of the Service: Following a recent expansion, Miranda House now provides care with nursing, and accommodation, for up to 68 adults. These may be people with dementia, or other mental health problems. The homes registration conditions enable it to offer a place to anyone over the age of 45. But the majority of service users tend to be older people. The home is therefore inspected using the standards for this group. The service is also able to offer two day care places for people, aged 50 and over. The home is operated by a private company, Quality Care (Wiltshire) Limited. The responsible individual is Mr Peter Saunders. He lives locally, and has regular contact with the service. The registered manager is Mrs Gill Gray. Miranda House is in Wootton Bassett, near Swindon, Wiltshire. It opened in 1996, and was extended in 2005. The purpose built accommodation spreads over two floors, with passenger lifts between them. Most bedrooms have ensuite toilet facilities. Three double rooms are available. The rest are singles. Baths and showers are provided in various locations throughout the building. There is also a range of communal space, including lounges, dining rooms and a conservatory. Activity areas include a sensory room, which has a range of equipment to offer relaxing and calming experiences. Externally, there is a pleasant, accessible garden. The service also offers adequate parking spaces. Fees charged for care and accommodation range between £589 and £720 per week, depending upon an individual service user’s assessed needs. This amount includes contributions for nursing care, which do not have to be paid by the individual. Information about the home is available from the service itself, or by visiting the home’s website. Telephone enquiries and viewings are welcome. CSCI inspection reports can be seen at the home, and enquirers are also advised of how to access these via the internet. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection was completed in September 2006. The service’s previous main inspection was in February 2006, and a further random inspection took place in July 2006, to focus on specific issues of concern around that time. This key inspection followed up on areas identified at both these earlier visits. Findings from the July inspection are also restated in this report, where they remain relevant. As well as reviewing contact with the service over the months before this inspection, we also considered written information supplied by the service. Five survey forms were completed by staff of the home. Survey forms were also provided for the home to distribute to residents or their families, but none of these were returned on this occasion. Fieldwork took place over two separate visits. The first of these was unannounced, and was carried out by two inspectors, due to the size of the home. The second visit was conducted by the lead inspector, by appointment. This was to meet with the registered manager, to conclude the inspection process and give initial feedback. What the service does well:
Staff are provided in suitable numbers to meet the needs of service users. Rotas ensure that there are good ratios of staff to service users. The deployment of workers on each shift is structured so that all areas of the home receive support. Numbers have been increased to reflect the larger size of the service. This has included extra staff in areas such as the kitchen and laundry, as well as more nurses and carers. Service users maintain contact with their family and friends. Visitors to the home are a regular occurrence. People appear confident in the arrangements, and there is a relaxed and friendly atmosphere towards visitors. Miranda House has clear systems for the assessment of prospective service users. This process also continues to work effectively once someone is admitted. A seven day care plan is used to gain further knowledge about an individual when they have moved in. This then leads on to the longer term plans for their support. Service users can be confident that the assessment and admission process identifies their care needs. Activities are provided which meet the needs and preferences of service users. More staff have been appointed to lead in this area, and they have received suitable training. There is an individual focus for each service user, with
Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 6 relevant information in their care plans. The home’s programme is flexible, with some planned group sessions, and other activities being undertaken more informally, perhaps on a one-to-one basis. Activities staff are enthusiastic about their role. The home is supportive of activities, providing necessary equipment. The service operates openly and transparently within Wiltshire’s procedures for the protection of vulnerable adults. Due to the type of service users that Miranda House supports, there may be incidents which occur due to disagreements or confusion amongst them. The home acts appropriately in recording and reporting all such events. This means that there can be a multiagency approach to deciding upon the most appropriate action in response. Service users can be confident that the home takes suitable steps to uphold their welfare. Positive feedback was received from staff of the home. Five survey forms were returned and completed, all of which commented favourably. Staff who met with the inspectors during the visits to Miranda House were also positive about the service. This included people working in a variety of roles. They felt that the home has stabilised after a period of adjustment, following the opening of the new extensions. They were happy that suitable steps have been taken to support them with increased workloads. What has improved since the last inspection?
The provider has supplied proof that service users or their representatives receive written confirmation, following assessment, that Miranda House is able to meet their needs. This means that when people move in they can be confident that the service will be able to provide the care they require. A practice of displaying photos of some service users, as a means of trying to restrict their movement to ensure their safety, has been discontinued. Where any such restrictions are felt necessary, these are now being applied in ways which better uphold each individual’s privacy and dignity. There have been improvements in the management of service users’ medication, so that they can feel more confident in these arrangements. Most of the deficits identified at the inspection of July 2006 have been addressed. In particular, the use of ‘as required’ medication is now supported by clear guidelines about the criteria for administration. Practice in the notification of significant incidents to the CSCI and other agencies has improved, following a dip in the effectiveness of this earlier in 2006. The home has amended its procedure to try and ensure that reports are made more promptly. This helps to ensure that service users receive access as quickly as possible to support which will help ensure their protection. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 7 Decisions about the use of bed sides for any service user are clearly supported in individual records with all the necessary information. This includes an up to date risk assessment, with relevant details about why and how the practice is used. It also includes evidence of consent, or information about who has been involved in the decision if service users are unable to give informed consent themselves. This helps to show that this practice is used safely and appropriately. The use of child safety gates at doorways, to restrict access for service users, has reduced. There is now only one of these, at the office by the front entrance to the home. A documented risk assessment is in place for this. What they could do better:
Guidance on physical interventions remains unclear, and presents the risk that these may be carried out inappropriately. Sampled records lack detail about reasons for interventions, and about how they have been applied. Guidance to report every use of certain interventions has also not been followed. Descriptions of the actual holds to be used with service users remain ambiguous. Some service users are placed at risk by failure to fully assess, plan and monitor care in the area of possible pressure damage to tissue. Risk assessments sometimes fail to address all relevant factors, such as if a service user has diabetes. Once assessments have identified a risk, they are not always linked to a suitable care plan. Such plans need to contain all relevant detail, such as what type of cushion a service user may require, or specific information about how often they are to be turned. If a programme of regular turns is in use, this needs to be properly recorded. Care also needs to be taken that all equipment used with people at risk of pressure damage is suitable to reduce risk. Some deficits in medication practice still need to be addressed, to ensure the safety of service users. The issue of covert administration of medication, for instance, by crushing tablets and/or giving them with food, has not been fully resolved on the ground floor. Information about current practice was unclear during this inspection. Some products for applying to skin, such as creams and lotions, were in use with service users without any information about the reasons. Such products might be prescribed for an individual; or they might be non-prescription items which are used because the service user wishes this. In either case, there must be information about the reason for the product’s use, and information about how and when it is applied. A number of separate issues need addressing to minimise the risks of possible infection within the service. Firstly, in older parts of the home, the rails provided alongside toilets to help less mobile service users have become worn
Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 8 and rusty in places. This means that they cannot be kept hygienically clean. Secondly, a service user identified as having an infection did not have single use hand washing and drying facilities available for staff in their own room. Staff must be able to properly clean and dry their hands before leaving the room, to reduce the risk of cross infection. In addition, it would be good practice to have such facilities available in all service user rooms. Finally, some service users had products such as skin creams kept in their own bedrooms. Some of these were not labelled, or were shown as belonging to a different service user. Communal use of such creams presents a major risk of cross infection. Service users are placed at risk by deficits in the process for the recruitment and selection of staff. Most seriously, in one case a carer had commenced employment twelve days before confirmation was received that their name is not on the national list of those deemed unsuitable to work with vulnerable adults. There were two other examples where it could not be established conclusively from available records whether or not this check of the list had been completed before the staff began working. In two cases, staff were working at the home having had the check of the list completed, but were still awaiting the full information from a criminal records check. In these circumstances, there are restrictions on how staff can be deployed. This should be made clear in the relevant personnel records until the full process is completed. Other deficits included failure to have two written references for one employee, and lack of evidence of qualifications for a registered nurse. Information about previous care employment for two staff was incomplete, and didn’t include written verification of their reasons for leaving. Service users are also placed at risk by deficits in fire safety practices. The required range of safety checks, practices and instruction have not been carried out and recorded at the prescribed frequencies. The home also needs a new overall premises fire risk assessment, reflecting the new layout of the property. This should be linked to the fire procedure, which would also benefit from review. The description of how to make people safe by removing them from hazardous areas, without necessarily evacuating the building completely, could be made clearer. The procedure could also be amended to reduce the time between an alarm sounding and the decision about whether to call the fire brigade. This is especially important for the overnight period. Some action was already being taken on this by the time of the second inspection visit. As a general point, it was noted by the inspectors at this visit that there was a noticeable difference in practice between the two floors of the home. This encompassed a range of issues, such as activities, mealtime support, medication and service user records. It is important to ensure that all service users benefit from an equally good quality of care. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 9 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. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 11 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have their needs assessed before they move into the home and receive written confirmation that these can be met. EVIDENCE: Prospective service users are assessed by senior staff of the home. Relevant input is also obtained from the individual, where possible, their family or carers, and any professionals who have been involved. Mostly service users will be visited in their previous setting. This might be their own home, or a hospital or other care home. If people are transferring from another part of the country, then assessment might have to be done through telephone discussions. When a place is offered, the service user or their representative receives written confirmation that Miranda House can meet the assessed needs. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 12 When a new service user moves in, the process of assessment continues over their first week at Miranda House, using a document known as a seven day core care plan. This consists of making entries and observations under a number of assessment headings for that week. It means that assessment can gather additional information, and also take account of any changes that may arise as a result of the service user’s move. Three records of recently admitted service users were sampled during this inspection. All were seen to be completed in relevant detail, providing sufficient information about the person to enable an effective initial care plan to be implemented. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 13 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 was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have their abilities, needs and goals reflected in their individual plans. Care needs to be taken to ensure that all elements are signed and dated, and that there is clear evidence of regular review. Service users have the majority of their health care needs met effectively. But some individuals are placed at risk by failure to assess, plan and monitor care fully in the area of possible pressure damage to tissue. Service users are placed at risk by failure to have clear guidance for all aspects of the management of medication in the home. Service users are treated with respect and have their privacy upheld. EVIDENCE: There is a primary nurse for each of the areas in the home. They have lead responsibility for the care plans of the service users in that part.
Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 14 Seven care plans were sampled during this inspection, including examples from both floors of the home. All were found to be completed, in the main, to a good standard. Most elements were clear and objective, and directed the care to be given. Care plans covered a range of areas. Alongside information about physical and mental health, they also addressed issues such as activities and communication. Staff were knowledgeable about the needs of service users, indicating their awareness of the information reflected in the written plans. However, evidence of regular review of care was not always in place. Where review has taken place, it is not always made clear who has carried this out – whether it was just by staff of the home, or if other relevant professionals were also consulted. Also, several examples were seen where documents such as assessments were not signed or dated. There are template care plans for some common areas. The relevant individual details can be entered into these. They are also expanded with further information, where necessary. Beyond this, for each service user more specific care plans are also devised, as indicated. Related risk assessments may also be put in place. These cover various topics, such as moving and handling, mobility, falls, pressure area care and dementia. Where assessments identify risk, care plans are usually put in place. However, this was not found to be the case for pressure damage. There were several deficits relating to practice in this area. Some service users assessed as being at high risk of pressure damage did not have a care plan to direct how to reduce that risk. Risk assessment for a service user with diabetes had failed to take account of this additional factor. The individual’s risk had therefore been rated as lower than it really should have been. Pressure risk assessments are linked to an instruction about which mattress a service user should have. But there is no documentation about what chair cushions should be used, or about interventions, such as how often a service user should be moved. In one case, a care plan was in place to reduce pressure damage, but was not clear enough with instructions. It stated that the service user should be turned “as required”, rather than specifying exactly how often to do so. This needs to be made clear in each individual care plan, as it may vary for each person. Where turn charts were in place for service users, some of these were not being completed as required. In two examples there were various periods of several hours where no turns had been recorded. One person was
Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 15 documented on the chart as being on their back, whereas they were actually observed by the inspector to be on their left side. Some service users were observed not to be on the type of mattress which their risk assessment had indicated as appropriate. Instead, they were on a type which does not reduce pressure, and may actually increase the risk of damage if the filling has become hard and lumpy over time. Good practice was seen in relation to the care of a service user with pressure ulcers on their heels. There was a clear care plan in place, along with evidence of regular monitoring. The tissue viability nurse specialist had been involved in the person’s care. Dressings were changed using appropriate techniques for minimising the risk of infection. Some service users may be fitted with catheters to support their continence. Deficits in practice were identified at the first of the two visits for this key inspection. These related to the information which must be kept in records. Advice was given about how to address these, and the necessary actions had been taken by the second visit. A service user with diabetes had a clear care plan for management of this condition. However, this stated that the individual’s blood sugar levels should be maintained within “normal limits”. Current advice is that the limits which a GP or diabetic nurse consider are appropriate for that individual should be stated. People’s rights of access to care plans are set out in the home’s policy. This includes information about the arrangements if it is a service user’s representative who wishes to see the documentation. Miranda House has input from a local GP, and a consultant psychiatrist. Other sources of health advice are accessed as necessary. People’s placement in the home arises because of mental health needs. But most service users also tend to have significant physical health needs. Medication arrangements were checked in detail on both floors of the building. Practice was seen to have improved since the random inspection of July 2006. Administration of medication at lunchtime was observed and seen to be carried out correctly. Arrangements for storage were also seen to be appropriate. Records were being maintained properly, including clear information about any changes to medication. Medications prescribed to be given “as required” were being given in accordance with GP instructions. If a variable dose was prescribed, this was documented. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 16 Service users with diabetes, who needed insulin injections, were receiving these in the arm. Sites were being varied. However, current advice is that arms should be avoided as injection sites for diabetics, especially for elderly persons. The issue of covert administration of medication, for instance, by crushing tablets and/or giving them with food, has not been fully resolved on the ground floor. A letter of August 2006 had been sent to a local GP regarding eight service users. Some feedback had been received, which appeared to indicate that consideration should be given to changing some prescribed items for some service users. For instance, some tablets could be replaced by liquids. But the current administration charts made it clear that there had not been any such changes. The staff member who had written the original letter was not present when this issue was discussed, and other nursing staff were not aware of whether any action had been taken; or if not, why not. Care plans for the individual service users affected also failed to make clear any specific guidance for giving their medication. Some products for applying to skin, such as creams and lotions, were in use with service users without any information about the reasons. Such products might be prescribed for an individual; or they might be non-prescription items which are used because the service user wishes this. In either case, there must be information about the reason for the product’s use, and information about how and when it is applied. Arrangements for privacy and dignity are set out in Miranda House’s policies. There is a stated commitment to upholding service users’ rights in this area. If preferred, intimate personal care can be provided by staff of the same gender. The few remaining double rooms have screens to provide privacy for each service user. Service users were observed to be clean and to look well cared for. This included those who were in bed. Skin was clean, including in creases, hair had been brushed, nails trimmed, and mouths cleaned. Miranda House Nursing Home DS0000015930.V311022.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 was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are provided with opportunities to undertake activities in line with their preferences and abilities. Service users are able to maintain contact with family and friends. Daily lives for service users have an appropriate balance between necessary routines, and individual choice. Service users are offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. EVIDENCE: Activities were considered in detail at the July inspection, and practice was found to be satisfactory. Two part-time activities staff cover Monday to Friday between them, with both present on one day. A third person has been recruited to work all five days, to reflect the increase in service user numbers. All of these staff have now attended training on the provision of therapeutic
Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 18 activities for older people. Some relatives of service users are also involved in providing sessions, as volunteers. Activities and social interaction are addressed in service users’ care plans, with an individual focus evident in each case. For instance, it is made clear whether or not someone is likely to enjoy and participate in group activities. Alternative ideas are suggested for service users who probably wouldn’t do so. Activities that have been provided recently include gardening, music, art and crafts, games and quizzes, and exercise sessions. Outside entertainments are also provided occasionally. On the first day of this inspection visit two sessions took place on the first floor. In the morning there was an art and craft session, and in the afternoon a folk music group performed. Activities staff showed enthusiasm for their role, and a good knowledge of service users as individuals. They spoke about the need to have a flexible approach, as plans might have to change depending on what service users show an interest in on any given day. The owner is reported to be supportive of activities, providing necessary equipment. Some fund raising activities are also undertaken, such as a summer fete. At this key inspection, some service users on the ground floor were seen to be sitting in a communal area unattended by any staff for a time. On the first floor, staff were always present in communal areas. There were plenty of staff around to support and supervise the more restless service users. Individual choice is facilitated wherever possible. People are able to personalise their own rooms by bring in items which are special to them. Previous service users have kept their own pets, where possible. Service users’ care plans include guidance on support they require with diet and nutrition. Nutritional risk assessments are also carried out. During this visit, the lead inspector joined service users having their midday meal in the main ground floor dining room. The food served was attractively presented, and of suitable portion sizes. Any service users needing staff support during the meal had this provided appropriately. Some service users commented positively about food, saying that it is always nice. However, service of the meal did appear quite disorganised. A number of main courses were served, so that some service users were eating, whilst others at the same tables were not. After a lengthy gap, with no obvious reason, and no explanation given, other service users then received a main course at the same time that those who had already had one were given dessert. One service user was almost served a dessert without having had a main course, until other staff pointed out the error. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 19 Also on the ground floor, the relative of a service user was trying to persuade them to remain seated. But they both had to get up twice, to move out of the way of a trolley delivering meals elsewhere. It was later seen in the service user’s records that it is a specific goal within their care plan to try and encourage them to sit still during meals, so that they are more likely to eat enough to remain healthy. The second inspector observed the same meal being served on the first floor. Practice here was much better. The meal was served in an orderly fashion. Staff gave all necessary support to service users. When a service user decided to move to another dining area halfway through their meal, staff noticed this and ensured that the person got their meal back once they had sat down again. A service user who had their meal in bed was supported by a carer who also took the opportunity to chat with the person about things of interest to them. A choice of drinks was not available during the meal, unless service users specifically asked. One flavour of squash was being served. Not all service users can easily express a preference for something else, so alternatives should be offered as a matter of course. The kitchen and food storage areas were viewed. A number of new appliances and pieces of equipment have been obtained in the past year. There is also more space now within the revised layout of the building. Catering staff have been increased to reflect the increased service user numbers. When the kitchen is not staffed, nurses and carers are able to access it, so that drinks and snacks can always be made available for service users. Menus are drawn up over a four week cycle. These reflect the differing needs of some of the home’s residents. Specialist dietary needs are supported, such as people with diabetes, or those with difficulties in chewing and swallowing. The kitchen is notified about the particular needs of new service users as part of the admission process. Lists of individual likes and dislikes are kept in the kitchen, so that all service users’ preferences can be respected. Where necessary, alternative meals can be prepared. Miranda House Nursing Home DS0000015930.V311022.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 was good overall. However, quality in the specific area of management of service users’ behavioural needs was only adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are safeguarded by the home’s policies and procedures for complaints and protection. Service users are placed at some risk by deficits in the planning for management of needs associated with behaviour and mental state. EVIDENCE: There is a complaints procedure in place. This is on display in the main entrance hallway of the home. It is also incorporated into the Service User Guide. Contact details for the CSCI are included. No formal complaints have been received recently. Some minor issues relating to individual service users have been resolved appropriately. Suitable procedures are also in place for abuse and adult protection. These include information about the local multi-agency procedures. Miranda House may support some service users who present with disturbed or aggressive behaviour, associated with their mental health needs. The frequency of such issues can vary. Over the past couple of years, the home
Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 21 has gone through periods when there have been a cluster of such incidents, and other times when they are much rarer. When incidents have occurred, they have usually been recorded and reported appropriately. This has included the consideration of some events under local multi-agency adult protection procedures. The home has worked cooperatively and effectively within the required protocols to uphold the protection of its vulnerable service users. Suitable actions have been taken in respect of specific staff members if allegations have been made about their conduct. Following a dip in the effectiveness of recording and reporting earlier in 2006, when there were sometimes delays in providing all relevant information, practice has improved again recently. The home has amended its procedure to try and ensure that reports are made more promptly. The home’s own management guidelines for service users presenting significant behaviour challenges remain in need of some improvements. A record was sampled at this inspection for a service user known to have been involved in a number of recent incidents. Several elements of the record were unclear. An intervention used with this service user, placing them in a chair in response to certain triggers, was not fully described. Records of its use failed to make clear how or why it was used on each occasion. Some entries did not show how long the service user had been in the chair. Others appeared to show the individual being left in it for lengthy periods of up to six hours. An instruction to monitor the service user every fifteen minutes if in the chair was not recorded as being carried out. The guidance to report every use of the chair had also not been followed. Physical interventions may be required with some service users. All staff have received training in techniques approved for use in the home, and this instruction will also be provided to new employees. However, records referring to physical interventions in the file of the service user mentioned previously were not sufficiently clear about how these were being applied. Records mentioned restraining the person or holding their hands, without specifically recording what type of intervention had been practised, by whom, and for how long. One record stated that four staff had been involved in one care task with the service user, implying an unnecessarily anxiety provoking situation. Descriptions in the service user’s care plan of the physical intervention techniques to be used with them remained ambiguous – for instance, an instruction to use “a friendly come along technique”. During the inspection visits, examples of good practice in the management of complex behaviours were seen. Staff acted promptly and sensitively to defuse
Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 22 disagreements between service users, and to distract individuals and remind them of important matters, such as the state of their clothing. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 23 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area was good overall. However, quality in the area of hygiene and infection control was only adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a comfortable and clean environment, suitable to their needs. Service users are placed at risk by deficits in hygiene practices which may produce increased infection hazards. EVIDENCE: Miranda House is a purpose built care home. Service user accommodation is over two floors, served by lifts and stairs. A security lock system is used on the doors to stairwells and exits, to reduce risk to any service users who are confused. There is a large garden to the rear of the property, and several off road parking spaces are available at the front.
Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 24 The home has a full time handyman. There is ongoing maintenance and redecoration for the older part of the property. Rooms are usually refurbished whilst they are vacant. Work on construction of two extensions, on either side of the original property, was completed in late 2005. One of these is single storey. Variation to the home’s registration was approved by the CSCI, increasing the number of registered places to 68. The majority of service users have single bedrooms. Three larger rooms are available, so that the option to share is possible for anyone wishing to do so. Rooms are personalised to reflect the tastes of their occupants. People are able to bring in their own items of furniture and ornaments. The home provides a range of suitable equipment, such as adjustable beds. As well as increasing the number of bedrooms, the extension to the property has provided additional communal areas, bathrooms and showers, staff office space and break areas, and storage space. There are lounges and dining areas on both floors. The ground floor also has a conservatory, and a sensory room. Externally, Miranda House has a pleasant garden area, which service users enjoy accessing when weather permits. Some space was lost to the building work, but the remaining grounds still provide a valuable resource. All bedrooms have en-suite toilets and handbasins. Bathrooms and showers are also provided at various locations throughout the home. These include various adaptations and equipment suitable to the needs of service users. Following advice discussed during this inspection, the home is to provide a staff toilet on the first floor. This means that the staff on duty in that area will not have to spend so much time away from their duties when they need a toilet break. Service users who commented about the home were positive. Some appreciated the chance to spend quiet time in their own rooms. Others were complimentary about the quality of communal areas, such as lounges. The home was clean and generally well maintained in all areas seen. No unpleasant odours were detected in any part of the building. There are appropriate systems in place for the management of laundry in the home. All items are washed on site, and Miranda House employs its own staff to carry out this task. Extra staff have been taken on since the home increased in size. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 25 Miranda House now has two laundry rooms next to each other. This has provided more space for ironing and pressing of items. The home has also purchased extra appliances because of the increased workload. There are now four washing machines, and three tumble driers. The equipment, and the practices for handling laundry, are suitable for reducing the risks from any items which may be soiled or infected. Laundry staff are kept informed of any service users with known infection risks, so that their items can be handled separately. The kitchen and food storage areas were seen to be kept clean and hygienic. The home now employs a cleaner for two hours each day specifically for these areas. In older parts of the home, the rails provided alongside toilets to help less mobile service users have become worn and rusty in places. This means that they cannot be kept clean effectively, to prevent the risk of infection. One service user identified as having an infection at the time of the inspection visit did not have single use hand washing and drying facilities available for staff in their own room. Staff must be able to properly clean and dry their hands before leaving the room, to reduce the risk of cross infection. In addition, it would be good practice to have such facilities available in all service user rooms. Some service users had products such as skin creams kept in their own bedrooms. Some of these were not labelled, or were shown as belonging to a different service user. Communal use of such creams presents a major risk of cross infection. Additionally, creams prescribed for the use of one person are that individual’s property, and must not be used with anyone else. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 26 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected 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 was adequate. However, quality in the area of staff recruitment was poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported by suitable numbers of appropriately trained staff. Service users are placed at risk by failure to apply all required checks during the recruitment and selection of staff. EVIDENCE: Miranda House is registered to provide nursing care. This means that a qualified nurse is on duty at all times. Staff are allocated to both of the two floors. Each shift on each floor is led by at least one nurse. They are supported by senior carers and other care staff. Suitable staffing levels are being maintained, reflecting the increased numbers of service users since the home’s extensions were opened. There are usually 18 staff on duty for all daytime shifts, and eight waking staff overnight. People are deployed throughout the building to ensure appropriate ratios of staff to service users in each section. The home also employs staff for other key tasks, such as catering, cleaning, laundry and maintenance.
Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 27 Staff training was considered at the random inspection of July 2006, and again during this key inspection. It is clear that training is ongoing for a range of relevant topics, and there are further plans for future sessions. Some learning takes place in house, with designated staff members taking the lead role on particular subjects, such as moving and handling or wound care. Appropriate external sources are also accessed. For instance, a number of staff are attending sessions organised by the group Dementia Voice, and the home is also going to access training from the local professional mental health team. Training in physical interventions has been provided for the majority of the staff team. A further session took place recently, to give instruction to a group of new staff, and another one is be held shortly. Other training which has taken place this year has covered topics including nutrition and health and safety. Training records have not yet been updated to include all information about the most recent courses staff have attended. Induction of new staff is linked to the national training standards for the social care workforce. Carers then also have the opportunity to go on to study for National Vocational Qualifications. The home is above the minimum 50 target for care staff who have achieved NVQs at Level 2 or higher. More staff have also commenced working towards this award. Recruitment records for four staff appointed during 2006 were sampled during this inspection. These showed a number of deficits. Most seriously, in one case a carer had commenced employment twelve days before confirmation was received that their name is not on the national list of those deemed unsuitable to work with vulnerable adults. There were two other examples where it could not be established conclusively from available records whether or not this check of the list had been completed before the staff began working. In two cases, staff were working at the home having had the check of the list completed, but were still awaiting the full information from a criminal records check. In these circumstances, there are restrictions on how staff can be deployed. This should be made clear in the relevant personnel records until the full process is completed. Other deficits included failure to have two written references for one employee, and lack of evidence of qualifications for a registered nurse. Information about previous care employment for two staff was incomplete, and didn’t include written verification of their reasons for leaving.
Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 28 In one case, a reference from a previous employer mentioned some concerns about a worker’s reliability and attendance, although balanced with positive feedback about their standards of care. It would be good practice to document discussions and decision processes about appointments when any concerns have arisen. Steps were already being taken to address some of these issues by the second of the visits which made up this inspection. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 29 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, 33, 35 & 38 Quality in this outcome area was good overall. However, quality in the area of fire safety was only adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The registered manager is suitably qualified, competent and experienced, so that service users benefit from a well run home. Quality assurance measures underpin service developments, and include actions based on the views of service users. Service users have their financial interests safeguarded, but the home’s practice could be enhanced by improvements in recording and checking. Service users are placed at risk by deficits in the home’s fire safety arrangements. Arrangements for protection of service users’ health, safety and welfare in other areas are appropriate. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 30 EVIDENCE: The home’s registered manager is Mrs Gill Gray. She is a qualified Registered Mental Nurse, with long experience caring for elderly people with mental health problems. Mrs Gray has been the manager at Miranda House since 1998. She has also attained the Registered Managers Award. A deputy, senior nurses and senior carers support the manager in her role. Miranda House also employs an administrator. There is regular contact from the home’s proprietor. Miranda House has a quality assurance system which is based around an audit of the service. Outcomes are measured under a range of headings – service user care; information and care development; quality improvement; and organisational fitness. One area is measured every three months, adding up to an overall picture each year. Two sections have been completed for the current year. Each of the main headings has a number of sub-sections. Performance is compared with previous audits. Any reasons for non-compliance are identified. Goals and targets are set. Alongside the internal management checks, feedback is also obtained from external sources, such as comments or complaints received, and inspection reports. A relatives’ questionnaire is also sent out once a year. Service user input to the process is difficult to achieve directly for the majority of the group at Miranda House. But there is a focus on issues which are relevant to them, via the measurement of outcomes. The home attempts to limit direct involvement in the management of service users’ money. Most people have their affairs managed by relatives or other representatives. If any amounts are held in safekeeping on site, there are secure arrangements for this. Appropriate records are also maintained, including the retention of receipts. It is recommended that it would be better to have two signatures for all transactions, and also to have the records audited occasionally. Some service users have money held on their behalf in a ‘pocket money’ account. Care home regulations mean it is generally not permitted for services to pay money belonging to users into an account, other than one in their own name. But this rule does not apply if the money is paid in respect of services provided by the home, as appears to be the case for this arrangement. A child safety gate has been fitted at the door of one ground floor office. This is to restrict service users from entering this area and perhaps removing Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 31 important papers from desks. A risk assessment is in place for the use of this equipment. Bed sides are in place for a number of service users. Sampled records showed that risk assessments and evidence of consent are in place in appropriate detail. These have been kept under review. In another example, a decision has been reached not to use bed sides, because this might increase the risk of harm for that person. So an alternative approach to minimise risk is in place. There is also clearly documented information about this decision. Risk assessments are in place on a range of health and safety topics. There is evidence of recent review of these. Sluice rooms have chemicals kept in them, as would be expected. During the inspection it was observed that these doors were not locked. If potentially hazardous materials are to be kept in these areas, the doors should be secured to prevent service users having access. The fire log book showed a number of deficits in the required range of safety checks, practices and instruction. Tests of the alarm system had not been carried out every week. Staff instruction records, which must be completed once in every three months, were not fully in place for the period of April to June 2006. Fire drills must also be recorded once in each three month period, but this had not been done for January to March 2006. The property’s fire risk assessments address various areas of the building and the possible hazards which may arise. An overall premises risk assessment should now be produced, reflecting the new layout of the property. This should be linked to the fire procedure. The procedure would also benefit from review. The description of how to make people safe by removing them from hazardous areas, without necessarily evacuating the building completely, could be made clearer. The procedure also instructs staff to investigate the source of an alarm, and to establish whether or not there is a fire, before deciding whether to call the fire service. No distinction was made in this advice between day and night time. Given the size of the home, the process of finding out the cause of an alarm and reporting back could take several minutes, which may give time for a fire to develop. Consideration should be given to seeking appropriate advice about whether the procedure needs amending, especially for the overnight period. Some action was already being taken on this by the time of the second inspection visit. Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 32 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 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 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 33 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 OP8 Regulation 12-1 14 15 Requirement Pressure area risk assessments must be completed in full for all service users, addressing all relevant risk factors. All persons assessed as being at risk of pressure damage must have a suitable care plan in place. This part of Regulations also applies to the above Requirement. Where service users need to have their positions changed regularly to prevent pressure damage, turn charts must be completed fully and contemporaneously. Timescale for action 30/11/06 1 OP8 17-1a Sch31&3m 17-1a Sch31&3m 30/11/06 2 OP8 30/11/06 3 OP9 12-1 13-2 15 There must be suitable individual 30/11/06 guidelines to support any use of covert administration of medication. These must be devised with input from all relevant persons, and kept under regular review. (Timescale of 30/09/06 partly met) COMMENT: Practice in this area Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 34 has improved. Guidance is still unclear for some ground floor residents. 4 OP9 12-1 13-2 15 From now on, if a service user is 26/09/06 prescribed or has asked for the use of a topical skin product, there must always be a care plan in place to direct its use. There must be clear, objective guidelines for staff management of potential disturbed behaviour from service users. In particular, any use of physical interventions must be applied appropriately, to ensure suitable individual approaches. (Timescale of 30/11/05 not met) COMMENT: Continued failure to comply with this requirement by the next inspection may result in further enforcement action. 5 OP18 17-1a Sch3-3p,q 13-3 16-2j 13-3 16-2j This part of Regulations also applies to the above Requirement. All rusty and deteriorated toilet rails must be disposed of and replaced. All service users with known infections must have single use methods of hand washing and drying available at the sinks in their own rooms. All topical skin products must be labelled with a service user’s name and used only for that named person. 30/11/06 30/11/06 5 OP18 12-1 13-6,7,8 6 OP26 31/01/07 7 OP26 30/11/06 8 OP26 13-2,3 26/09/06 9 OP29 19-9,10 Sch2-7 From now on, new employees 26/09/06 must not commence work in care positions until a satisfactory result has been received from a
DS0000015930.V311022.R01.S.doc Version 5.2 Page 35 Miranda House Nursing Home POVA First check. 10 OP29 7;9;19 Sch2 Staff records must contain evidence that all required recruitment checks have been completed for all employees. 30/11/06 11 OP38 23-4 From now on, all required fire 26/09/06 safety checks, practices and staff instruction must be carried out and recorded at the prescribed frequencies. 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 OP7 OP7 Good Practice Recommendations All service user records should be clearly dated and signed. Monthly review of service user care should be clearly evident in all individual records. The input of other professionals to review should also be shown. Pressure area care plans should be made specific to each individual, stating how often the service user is to be moved and when. Equipment which does not reduce pressure ought not to be used. Limits for the blood sugar levels which a GP or diabetic nurse considers are appropriate for a service user should be stated in their care plan. Service users who regularly need administration of medication by injection should have a wider range of injection sites used, to help prevent tissue damage. A choice of drinks should be readily available for service
DS0000015930.V311022.R01.S.doc Version 5.2 Page 36 3 OP8 4 5 OP8 OP8 6 OP9 7 OP15 Miranda House Nursing Home users during mealtimes. 8 OP15 There should be a review of mealtime arrangements on the ground floor to ensure a more effective process for serving all service users at a similar time. It would be good practice, as an infection control measure, for all service users to have single use methods of hand washing and drying available at the sinks in their own rooms. Recruitment records should include written evidence of the decision process where potential concerns have arisen about any employee. Staff training records should be updated to provide clearer evidence of the current position. Records relating to service users’ money should be double signed, and also audited periodically. A securing system should be placed on sluice room doors if potentially hazardous materials are to be kept in these areas. The home’s fire procedure should be reviewed to ensure greater clarity about the approach in place, and to link it with a new fire risk assessment for the extended premises. 9 OP26 10 OP29 11 12 13 OP30 OP35 OP38 14 OP38 Miranda House Nursing Home DS0000015930.V311022.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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