Inspection on 19/09/06 for Moorwood Cottage Care Centre

This inspection was carried out on 19th September 2006.

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

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

Other inspections for this house

Moorwood Cottage Care Centre 17/07/07

Moorwood Cottage Care Centre 16/05/06

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

CARE HOMES FOR OLDER PEOPLE Immanuel Nursing Home 9 Valley Road Chandlers Ford Eastleigh Hampshire SO53 1GQ Lead Inspector Annie Billings Unannounced Inspection 19th September 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Immanuel Nursing Home DS0000066927.V314381.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. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Immanuel Nursing Home Address 9 Valley Road Chandlers Ford Eastleigh Hampshire SO53 1GQ 01325 351100 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) www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited To be confirmed Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47) of places Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users must be at least 50 years of age. A maximum of 9 service users may be accommodated between 50-64 years of age. Bedroom 39 can only be used by a service user, over the age of 65 years, who requires personal care only 16th May 2006 Date of last inspection Brief Description of the Service: Purchased from Ashbourne Healthcare in November 2005, Immanuel is one of a national group of care homes owned by Southern Cross Healthcare Limited, currently trading as Ashbourne (Eton) Limited, and is registered to accommodate up to forty-seven older people. The home can admit up to fortysix service users for nursing care and one for personal care only. Of the fortyseven service users that the home can admit, nine may be between the ages of fifty and sixty-four. The home is situated in a residential area in Chandlers Ford and is near to the local shops and amenities. The home has been extended and accommodation is on two floors offering three communal rooms, thirty-seven single and five shared bedrooms although several are not currently available for use. There is a stair/chair lift to one part of the first floor. The home has a large garden that is uneven in some areas and has an accessible pond, although steps to this area are currently fenced off for safety purposes. A raised patio area is accessible to the residents from the sitting room and there is a large car park at the front of the home. The manager advised that a copy of the statement of purpose and service user guide are made available in the reception area, although this area is not accessible to all service users. The pre-inspection questionnaire states the current scale of charges per week as £500 - £600, with additional charges made for hairdressing and chiropody. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this unannounced inspection on the 19th and 21st September 2006. During the two days, all of the key standards were assessed and twenty-three issues identified at the last inspection were followed up. One of these has remained outstanding from an inspection in January 2005, three from visits on the 12th & 25th May 2005 and thirteen of these have been repeated from an inspection in October 2005. During the visit the inspectors toured most areas of the home, speaking to residents, their visitors and members of staff. Staff files, resident’s personal care plans and other records were examined as part of the inspection process. Additional information was supplied within a pre-inspection questionnaire completed by the service earlier this year. Since the last inspection a new manager has been appointed who took up their post in May 2006, and an application for registration with the commission is due to be made in the near future. Brief discussions were also held with the responsible individual and operations manager of the home, visiting on the 19th September. Following the last key inspection in May 2006, a letter of serious concern was sent to the providers in respect of three immediate requirements issued, and the providers were invited to attend a meeting with the Commission for Social Care Inspection (CSCI) on the 20th June, to discuss all of the serious concerns identified, and an action plan submitted to address these concerns was agreed, including an extension to some completion dates. What the service does well: Service users spoken with said they are well cared for, and that staff treat them well. Three visiting relatives also advised they were happy with the service provided, one giving particular praise to one of the qualified staff for the excellent care given to their relative. Communal rooms are bright, spacious and comfortable. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It is again disappointing that the service does not appear to have taken steps to ensure that all previous issues raised have been appropriately addressed in line with the action plan submitted by the organisation and as indicated at the meeting with the providers on the 20th June 2006. Although some work has been undertaken in several areas, the majority of concerns have not been fully addressed. Further concerns were identified during this visit. The home has been asked to ensure that all new residents are admitted only after a full assessment of their needs is undertaken to ensure that all their needs are met. That each resident has a service users plan of care, which is generated from a comprehensive assessment of their health, welfare and social needs. These plans must give staff detailed guidance to ensure they are aware of how to support people’s needs. Recording systems must be fully and accurately completed to demonstrate peoples’ needs are being met. Three nursing staff must receive further training in the administration of medication and agency staff assessed for competency prior to lone working, to ensure that staff follow the medication policy and procedure. Risk assessments must be fully completed for all identified risks, and evidence available to support the judgements made with appropriate measures put in place to minimise the risks identified. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 7 The home must be kept clean, safe and well maintained. In particular, improvements must be completed to first floor bathroom facilities, and the ground floor bathroom facilities are well maintained. WC’s are kept clean, hygienic and free from offensive odours. All staff must receive training in adult protection and awareness of abuse to ensure that residents are protected. Staffing numbers must be appropriate to ensure the assessed needs of the service users can be met, and staff induction, training and supervision arrangements are put into practice to ensure that staff are adequately trained and supported. Products hazardous to health must be stored safely to ensure that residents are not put at risk. Any potential risks identified must be assessed and prompt action taken to eliminate or minimise the risk to ensure the health, safety and welfare of service users or staff. 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. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Service users cannot be assured that all their care needs have been adequately assessed and would be met. EVIDENCE: Although standard 1 has not been fully assessed, it was noted at the previous inspection that the information given to prospective service users did not make clear who was providing the service. Signage and paperwork systems are all in the name of Southern Cross Healthcare, and not the registered provider, Ashbourne (Eton) Limited. The acting manager agreed to discuss this with their line manager, as the relationship between companies needs to be made clear to service users, to ensure they are aware who is providing the service. This does not appear to have been done, and information seen does not reflect the recruitment of a new manager. The administrator advised that new contracts had been issued to service users to reflect the new provider, but not all had been returned. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 10 A requirement was made at previous inspections to ensure that each new resident had a pre-admission assessment, which assessed, identified and documented all personal, health and social needs. This followed the implementation of new paperwork systems, which clearly had not been fully understood or implemented, and no training for staff made available. This could not be properly assessed on this occasion, as no new admissions were accommodated in the home on this occasion, however, files were examined of three existing service users. There was no evidence of auditing of these files, as many assessments were still not signed or dated, are confusing and give conflicting information. For example, an unsigned risk assessment for bed rails on the 28.7.06 and an evaluation dated the 13.8.06 stating that the care plan for bed rails remains relevant, no change needed as there is a risk of falls, conflicts with other information in the file, stating that bed rails were removed on the 31.7.06. The risk assessment is based on a scoring system, although there is no explanation of this system. An unsigned and undated continence assessment and current care plan refers to catheter care, although other information in the file states this was removed on the 19.5.06. Another assessment says “nil by mouth” yet the care plan states they are able to eat pureed diet, and it is not clear on what had changed. A communication assessment dated the 27.4.06 states “has absolutely no problems with communicating to anyone or being understood”. A later evaluation note states that “communication has greatly improved”. A nutrition (MUST) assessment undertaken identified one service user at high risk, and requests dietary intake monitoring for three days. Inconsistent records dating from the 1.8.06 were still in the service user’s room. Improvements were however identified in some areas, as assessments had recently been undertaken by a speech and language therapist in August, although there was little evidence that advice given was used to inform the care planning process. A follow up visit on the 8.9.06 requests that staff be briefed on comprehension and response. There was no evidence to support this had been done. The manager advised that continence assessments were also planned for the future. Training records confirm that three of the six qualified staff have received training in assessment and care planning, although the manager advised of further planned training on the 28th September for all registered nursing staff. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The care planning process remains inconsistent, and does not ensure that staff have sufficient guidance to support service users’ current needs. Systems are in place to ensure health care needs are addressed but many incomplete records do not demonstrate this. Arrangements for dealing with medication have improved, but continuing errors do not protect the residents. The resident’s privacy and dignity is compromised by the structure and layout of the home, and the staff’s lack of attention to detail in personal care. EVIDENCE: Individual care plans were available in each of three files sampled. Although some are good, and are evaluated monthly they remain inconsistent, and do not all reflect the service users’ current needs. One care plan says the service user is able to weight bear with assistance of two care workers. This is not in line with the original assessment, which states, “can stand and transfer”. No further assessments had been undertaken, although an August evaluation says they can mobilise with one care worker. The care plan also requests that the Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 12 service user is stood 2 hourly due to the “very high risk” of pressure sores. Records seen do not demonstrate this plan is followed consistently. Shoulder exercises are also undertaken, and the care plan states that staff should train each other on how these should be undertaken. There was no evidence of staff receiving training from a physiotherapist, and no risk assessment undertaken. Generally, those residents and relatives spoken with confirmed their satisfaction with the service, and said that staff treat them well and are very kind. One relative advised that they had received “brilliant care” and that staff have been wonderful, praising one particular member of staff. One resident said that staff provide personal care in a way that I like, while another spoken to in the afternoon said they would like a shave but there were not enough staff to help him. During the inspection it was identified that there was a problem with the call bell system since the 15th September and was repaired on the 19th September. A notice in the clinical room states that 15-minute checks should be made to those residents without a call bell. No records of these checks were identified. Residents spoken with confirmed that staff generally attend calls quickly, although one advised of an incident a few months ago when the staff member responding to their call looked in the room, and left without asking how they were or what they wanted. Care planning training has been provided to two trained staff and one care assistant since the last inspection. Although staff are working hard to improve the care planning process, and demonstrate a willingness to improve, there was still evidence of conflicting information within three care plans sampled, and other records do not demonstrate these plans are followed consistently, although those spoken with appeared to have a reasonable understanding of peoples’ needs. One resident advised they had difficulty communicating with some staff due to language difficulties, although this was not evidenced during the inspection. Three files were sampled. One resident had been identified at very high risk of pressure sores. Control measures were not stipulated on the risk assessment, although the moving and handling care plan requests that staff “stand 2 hourly”. The care plan also states the resident can weight bear with two care workers, which conflicts with the assessment, and had not been updated in line with more recent evaluations that identifies a need for assistance from one care worker, although no further risk assessment had been undertaken. The “risk of falls out of bed” care plan states that bed rails be used to reduce the risk. An evaluation of the care plan dated the 13th August states that the plan remains relevant, although following a review of the risk assessment the bed rails were removed on the 31st July. The continence care plan has no date or signature, and requests the need for catheter care. Other information within the file states that the catheter was removed on the 19th May. A care plan is in place for exercises to be undertaken with the resident, and states that staff Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 13 show each other how these should be undertaken. This is unsafe practice, as there is no evidence that staff have received appropriate training from a physiotherapist, and no assessment had been undertaken. A further file examined indicated that the resident prefers female staff to attend to personal care. This has not been specified in the care plan. Other information states that the resident often displays challenging behaviour. The only planned care is to record all events. This record was examined and does not provide details of what led up to the behaviour, and no analysis appears to have taken place to identify any patterns, although all incidents have occurred in the evening. Other information on file states, “it is agreed that … will have a cigarette at night before retiring to bed … to alleviate and diminish tantrums”. This is not considered appropriate recording, and does not demonstrate the promotion of independence or choice. Systems are in place to ensure that health care needs are met, but recording tools are still not completed consistently. Daily food and fluid charts were in place in each room visited, but were not properly completed. Records seen indicate that residents receive regular visits from GP’s, dentist and chiropodist when necessary, and this was confirmed by residents and relatives. A third file examined identified the resident as nil by mouth, yet the care plan states able to eat pureed food, although it is unclear what had changed. A recent assessment undertaken by a speech and language therapist makes plenty of information available and the care plan includes reference to the amount of fluid required. Food/fluid intake charts were only available for the 27th and 28th May and these were only partially completed. Other partially completed food/fluid intake charts were seen in several rooms dating back to the 1st August, with no evidence these had been audited or used to inform the care planning process. One resident file contained a malnutrition screening tool that indicated a high risk. The control measures state that dietary intake be monitored for three days. Intake records for this resident dated back to the 1st August, and again had only been partially completed. Observation during the inspection did not demonstrate that residents’ privacy and dignity was promoted. Several bedroom doors were left wide open, with one resident left uncovered from the waist down. One resident advised that their bedroom door was left open all night, but he did not mind. During the first day of inspection an optician clinic was being held for residents in the reception area and visitors’ lounge. This is not considered appropriate, as it does not respect residents’ privacy. This was discussed with the manager, who is aware this is not ideal, but alternative facilities are not available. The qualified nurse on duty explained how medication procedures and recording practice had been tightened up since the last inspection. Monthly audits are now undertaken to include stocks and records. Issues regarding storage highlighted in the previous month’s audit had been partially addressed Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 14 by supplying a replacement controlled drugs cupboard, as the existing lock was faulty. This had been installed by the second visit. Further errors in recording on medication administration records were identified at the last audit, since when a colour coding system has been implemented, which staff said had made a difference. The recording sheets sampled did show improvements in recording although three further issues were identified. One omission in recording, although medication is generally refused by the resident, another where recording is unclear suggesting that co-codamol is being taken five times and not four times daily, as prescribed, and one incident of simvastin on the 6th September taken at 2pm and not 8am as prescribed. Following previous shortfalls in recording of medication, a requirement was made that all qualified staff undertake additional training in medication. This had been partially addressed at the last inspection, and the duty nurse advised that further training had been postponed and only four of six trained staff had completed training. The requirement will remain in place until this has been completed. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Little improvement has been made to ensure that activities are based around residents’ choice, interests and preference. Contact with families is encouraged and the provision of a balanced diet is promoted, but the home must ensure this offers choice and meets the dietary preference of the residents. EVIDENCE: While residents’ interests are now documented within their files, there was little evidence that choice, preference and interests are promoted. Many of those spoken with were not keen to participate in activities, although one resident advised they wished to go out for a walk “to see what’s happening”, but said there are not enough staff, and said, “the rules and regulations won’t allow me to go out”. They were also heard expressing their wish to visit the local pub and markets but no provision had been made, although the manager said they would see what arrangements could be made. It was also noted during the inspection that residents’ had to request doors to be unlocked, to allow them access to the smoking area. Another resident is identified as being from a particular culture, and “prays quite frequently”. No information was available in the file to identify what arrangements were in place to satisfy their religious need. Due to their culture, information available in the file requests Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 16 their head be covered when eating, but was seen in the dining room without a headscarf. Since the last inspection, the list of activities has been moved into the lounge to make it more accessible to the residents, although on the first day of inspection the previous week’s activities were displayed. This had been corrected by the second visit, although there appeared little cohesion between the activities listed and the residents’ interests documented. The range of activities on offer included music and movement, one to ones, quiz, hairdresser, bingo, gardening and musical entertainment. A video player available in the home had been placed in a drawer at the last inspection, and it was suggested that by making this more accessible in the communal lounge, residents could choose to make use of it. This is still stored in a drawer, although the manager advised that residents made use of it, although many would find this impossible without assistance. It was identified at the last inspection that an activities recording sheet has been developed for each service user, but these regularly record “one to ones”, without explanation as to the activity. This is still the case, as those sampled still identify the majority of activity as watching T.V. or one to ones. A music and movement session was observed in the lounge. This was not well co-ordinated, with residents wandering in and out and staff unaware of who was attending. At previous inspections management have advised they were accessing a training course for the co-ordinator to further promote more diverse activities, but this has still not happened, although the manager advised that training had been planned. In addition to this, one of the care staff was to become involved in activities at the weekend. The visiting policy in the home is flexible, and relatives were seen to come and go at different times throughout the visit. The home employs contract caterers and there is always at least one cook in the kitchen at meal times. Lunch was observed on both days, and food was well presented, plentiful and hot. Staff were available to assist if necessary. Staff were observed assisting residents to the dining room at 11.45am, although lunch was not served until 1pm. This was discussed with two residents, who said, “they had to wait even longer for supper”, although another resident said they liked the wait, as it meant they could have a chat before the meal. Many of those waiting for lunch were unaware what was on the menu. Minutes of a recent meeting with catering staff identified the manager had requested this be made available to residents, and although not accessible to many of the residents, had been put in place by the second day of inspection. There is a planned menu, which is varied, although some evidence seen indicates that the differing and specific needs of the residents are not always met. As indicated earlier in the report, conflicting evidence was Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 17 available within files. A previous quality assurance questionnaire identified at the last inspection stated that one resident did not feel their cultural needs were being met. The acting manager agreed to look into this further, as the comment related not only to diet but religious needs not being met. Since then, a similar issue had been raised by a family member, although documented evidence does not support this was handled appropriately. Several of the current residents receive a pureed diet, although previously there was not always sufficient evidence to support the reasoning behind this. This has since improved following recent assessments by a speech and language therapist, although one resident advised that those on pureed diets did not receive a choice. This was discussed with the manager, who was unaware of this. Other comments made by residents included “Food is nicely served”, but still suggested that menus are repetitive. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. An appropriate complaints procedure has been developed that residents and relatives feel able to use. The majority of staff have received training and have an awareness of abuse and the appropriate reporting procedures, which ensures that residents are protected. EVIDENCE: Residents spoken with were aware of the complaints procedure said they felt able to talk to staff and the manager if they had a problem. A copy of the complaints procedure is available in the service user’s guide, and is normally displayed by the front entrance, but had recently been removed during decoration. Two visitors said they were aware of the procedure. The visitors / comments section of one recording tool seen had been completed on two occasions, and staff had responded appropriately about issues relating to lighting and clothing. The relative’s response indicated they were satisfied with the action taken. The complaints log was sampled and identified two complaints since the last inspection. These had been dealt with appropriately, although one has yet to be resolved. Staff training includes ‘Resident welfare’, which covers all aspects of adult protection and provides definitions of abuse and what to do if abuse is Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 19 suspected. Staff spoken with had a good awareness of abuse issues and the reporting procedures. It was advised at the inspection in May 2005 that all staff would have completed this training by the end of that year. This had not been achieved by the inspection in May. Training records show that the majority of staff have now received training although three members of staff have yet to undertake the course. Although two of these are bank staff, the manager is aware this needs to be addressed, but the requirement will be repeated until this has been done. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 20 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, 21, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Systems to ensure the environment remains clean, hygienic and well maintained are ineffective, as action taken to address previous health & safety issues identified has not been sustained, and could put residents at serious risk of harm. Despite some evidence of action being taken to address other shortfalls identified, much of this work remains incomplete and facilities remain inadequate to meet the needs of residents. EVIDENCE: At the last inspection several rooms were uninhabitable due to poor access, lack of appropriate facilities or their state of repair and immediate requirements were made to address serious health and safety issues identified. Although action was taken to address these, the action taken in some areas has reverted to unsafe practice, and it is disappointing that other Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 21 environmental requirements have not been addressed within the agreed timescales. Room 39, which is deemed only appropriate for someone with personal care needs, is now being used to accommodate a staff member. Room 25, currently used as a staff room, still has a badly stained and broken basin, held together with tape. Rooms 33, 34, 35 and 36 do not have appropriate bathroom facilities, although work is underway and rooms 27, 28 and 29 have sustained water damage due to a leak in the flat roof, and are therefore not in use. The electric supply to these rooms has now been checked, and although danger notices were still posted on the doors these rooms were left unlocked on the first day of inspection. The flat roof has not been repaired since the leak in May, although work was commenced on the second day of inspection. A nearby airing cupboard had a notice attached to the internal light switch to identify a danger if lights were switched on, but the room was left unlocked. The manager said this was a precautionary measure, as unexplained water had been found on the floor. A risk assessment was undertaken immediately upon request. Structural cracks are still visible in a number of rooms, particularly on the first floor. A number of vanity units in the older part of the home are in a poor state of repair, and décor looks tired and worn, with many of the bedspreads worn and threadbare, although the manager advised that new ones were on order. A number of other bedrooms are in need of decoration, repair, new carpet or clearance of unused furniture and old mattresses. The manager was advised to keep these doors locked until the work had been completed. The manager advised they had been waiting for the arrival of a skip to enable the disposal of these, and others, seen stored at the side of the premises. One skip had arrived that day but was not large enough to accommodate all. Work has commenced in several areas although much of the work is incomplete. Some areas have been repainted, although tins of paint, filler and tools had been left in an unlocked en-suite bedroom. Although currently vacant, this was brought to the manager’s attention, as the room was accessible to other residents. The first floor sluice has been removed, and was cited on the landing, awaiting refit elsewhere. A new bathroom suite is being fitted, although the appropriateness for the service user group was questioned, as both the bath and WC are low level. A shower and WC are to be fitted in the room opposite, but this work is still in progress. The ground floor wet room layout has been altered to allow residents more privacy, but again this work is unfinished. The ground floor bathroom, previously used to accommodate various pieces of equipment has since been cleared, although the assisted bath was out of order. The manager was unaware of this, and later advised this had been out of order since the last inspection, although new valves have now been ordered. No adverse comments were made by residents in respect of this lack of facilities, although staff said this caused problems meeting residents’ needs. One resident advised that their radiator was not working and they had no hot water. Staff were having to carry hot water to their room. The manager Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 22 was unaware of this, and agreed to investigate and put appropriate risk assessments in place to ensure safe practice. Uncovered hot water pipes found in ground floor WC’s have been covered in foam as a temporary measure, but need to be boxed in as a long term solution, and inappropriate flick switches in “wet” areas need to be replaced with pull cords. The manager agreed to undertake a risk assessment around this until a long-term solution is put in place. The laundry area was clean, although the housekeeper advised that facilities had been out of action for the past week, and there is still no designated area for ironing. A contingency plan put in place since the last inspection allows staff to utilise laundry facilities at another home, but the housekeeper advised this reduces the number of domestic staff available in the home. On the first day of inspection several areas of the home were in need of cleaning, particularly bathrooms and WC’s, and all washing facilities were still unwelcoming and institutional in décor. Vents in several areas were found clogged with dirt and were ineffective. Many waste bins were overflowing and unpleasant odours detected in several parts of the home. This had improved by the second day of inspection. Communal areas were tidy and well furnished, and fire doors locked as required. Occupied bedrooms have been personalised, and following recent bed assessments undertaken, five additional profile beds and new mattresses have been provided. Other equipment was available where necessary, although wheelchairs and aids seen were in need of cleaning, and a walking frame was found in one room, belonging to another resident. In several rooms it was found that there were air mattresses, lights and televisions plugged into one socket or a series of extension cables at the last inspection. The safety aspect of this practice was discussed at previous inspections, and although the manager said this had been dealt with, one bedroom sampled still contained trailing wires from one extension to another. This was pointed out to the manager, who said they would take action to put this right. The gardens are partially accessible, as one area has an unguarded pond, and access to this area has been restricted. Other grass areas and paths looked uncared for, although grass cutting was undertaken during the inspection. Exterior windows in the older part of the building still need repainting. The garage is currently used as a storage area, and contains a variety of furniture, mobility aids, decorating and other substances that may be hazardous to health (COSHH), incontinence pads and oxygen tanks. This area was again left unsecured on the first day of inspection, despite an immediate requirement made at the last inspection to ensure this area remains inaccessible to service users, but was secured on the second visit. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 23 An improvement programme had been developed by the organisation on the 7th May 2006 to cosmetically enhance the premises and garden, but much of this work has not been undertaken within the stated timescales. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Staffing arrangements do not ensure that staffing levels or skill mix are appropriate to meet the needs of service users. Recruitment procedures are generally robust in the protection of service users. EVIDENCE: The rosters sampled indicate that generally two qualified staff are on shift 8am to 8pm plus four care staff, with one qualified nursing staff member between 8pm and 8am with two care staff, although there have been occasions when only one nurse is on shift, including the first day of inspection. Some staff, including qualified staff, are still working up to 60 hours a week, although signed agreements to work more than 48 hours as indicated in the DTI Working Times Directive (Department of Trade and Industry) are not in place for two of these. The manager told the inspectors that staffing levels are determined on a ratio of 5:1, rather than their care needs, but was unsure where this directive came from. Observations during the inspection, and discussion with residents, evidence that current staffing levels are insufficient to meet the needs of residents as highlighted in other sections of this report i.e. the length of time to seat residents for mealtimes, the lack of staff to undertake personal care tasks and support activities and no increase in staffing levels to accommodate 15 minute checks on residents without call bells. Staff felt there were times when they worked under pressure, with one saying “we Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 25 are very busy”. Sampling of recent accident reports identified a number of resident falls in the lounge, which further indicates a lack of staff monitoring. Staff spoken with said that team work amongst the staff had improved recently, with qualified and unqualified staff working more in harmony with each other. Staff feel this has contributed to a better atmosphere in the home, and said they now feel supported. Staff said that meetings are held regularly, and there was documented evidence available to support this. Comments made by relatives and residents confirmed they are treated well by staff, saying “staff treat us very well”, “staff are very kind” and “staff have been wonderful”, although one resident said they had difficulties communicating with some staff due to language difficulties. Information within the fire risk assessment also refers to staff not fully understanding verbal and written English. The training matrix sampled does not indicate that overseas staff are supplied with training in English language, although this was highlighted at the last inspection. Three staff files were sampled. Two of these contained evidence of a robust recruitment procedure including a criminal records bureau (CRB) check. The third file related to a member of staff on loan from another home, and the recruitment procedure had been undertaken elsewhere. This file contained two references from the same source. This was discussed with the manager, who said they would have requested a third reference. Evidence of a CRB was not available in the file, although the manager gave assurances this had been received. The pre-inspection questionnaire confirms that only one of fifteen care staff has completed a National Vocational Qualification (NVQ) to level II, although a further seven are underway. NVQ funding was discussed with the manager, who said they needed to clarify the organisation’s policy on NVQ. The stafftraining matrix supplied still identified a number of shortfalls in core training, in addition to medication, first aid, and infection control training which are not identified within the programme of training. Three of the six qualified staff and the manager do not have a current moving and handling certificate but are responsible for monitoring care practice in the home. This concern was discussed with the manager, who advised that a further course was planned for the following week. Moving and handling practice observed was sometimes unsafe, with residents transported in wheelchairs without footplates, one resident using an inappropriate walking frame and moving and handling equipment left unattended in corridors without brakes applied. Induction training has previously not been well recorded, but this should now improve with the introduction of new induction workbooks. Some evidence was available to support staff receiving formal supervision. The manager agreed these were not all up to date, and intends to develop a Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 26 programme of supervision once the new deputy manager had completed training in October. A requirement repeated at the last inspection for qualified staff to undergo additional training in medication administration has not been met. The nurse on duty advised that the training booked for other qualified staff members had again been delayed. The requirement has therefore been repeated. Since the last inspection additional training in care planning has been undertaken by two trained staff and one care assistant, and eight staff have attended training in the control of substances hazardous to health. Discussion with the manager identified their intention to introduce additional training in dementia, palliative care, promotion of continence and infection control, which they intend to develop into a training and development plan for all staff. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 27 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Although progress is slow, changes in management are beginning to impact on the home, but systems in place to protect the health, safety and welfare of residents remain ineffective. Service users’ finance is well managed, although receipts are not always available. EVIDENCE: Since the last inspection a new manager has been appointed, who advised that much of their time has been taken up with project management of refurbishment work and chasing contractors, although following the appointment of a deputy manager, they hoped to spend more time on developing and improving care systems and practice. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 28 Staff and residents confirm that new management is having a positive effect on the home. All those spoken with said the new manager was approachable and effective. Staff said they felt well supported, and they were working more as a team and there had been a marked improvement in staff morale. Discussion with the manager confirmed they had received appropriate support from the organisation, although local budgets and organisational processes sometimes delays prompt action in addressing issues. Residents meetings are held regularly, and an annual quality assurance questionnaire is given to all residents to allow opportunities to feedback on the service. These were sampled at the last inspection and confirmed that action had been taken to address issues raised. The home is required to audit the service on a monthly basis, to ensure the service being run in the best interests of service users. These have been completed regularly since the last inspection but have not highlighted any of the additional maintenance issues identified. Records indicate that systems and equipment are tested and serviced regularly, and a record of accidents kept. A monthly audit record is sent to head office, but there is no system for identifying patterns locally, although the manager had an awareness of recent incidents identifying a lack of monitoring in the lounge. The home is required to report any significant accidents or incidents to the commission, although there have been occasions since the last inspection when this has not been complied with, as in the instance of the call bell system failure and the recent laundry breakdown. Systems for monitoring health and safety in the home are still clearly ineffective as defects within the environment have either not been identified during monthly audits or brought to the attention of the manager. Several health and safety issues have not been addressed adequately, or risk assessed to ensure that appropriate control measures are put in place to minimise any risk to staff and residents. Shortfalls identified earlier in this report in the assessment and care planning process and apparent lack of staff monitoring, recording and training do not ensure the health, safety and welfare of service users and staff, although there was some evidence that steps are being taken to address these. A premises and fire risk assessment was sampled. This refers to some staff not fully understanding verbal or written English, but no action appears to have been taken to ensure they respond appropriately in the event of a fire. Inappropriate storage in the garage, including the storage of oxygen cylinders, has not been assessed or referred, and reference made to smoking areas, although it is understood that the home has a no smoking policy. Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 29 The pre-inspection questionnaire confirms that service users finances are largely managed with the support of their families. Personal allowances are looked after and stored securely by the home. Three records were sampled, and were found to be accurate and well maintained, although receipts were not available for chiropody services in two of the files viewed. Immanuel Nursing Home DS0000066927.V314381.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 X X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X 1 X X X X 2 STAFFING Standard No Score 27 1 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 1 Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The responsible person must ensure that new residents are admitted only after a full assessment of their needs is undertaken; this must include risk assessments of any area of identified risk, with detailed evidence to support any action taken to minimise the risk; this assessment must only be carried out by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. This is a repeated requirement from the inspection on the 25th October 2005 and 16th May 2006 2. OP7 15 and Schedule 3 The registered person must ensure that each resident has a service users plan of care, which is generated from a comprehensive assessment of his or her health, welfare and social needs. Care plans must demonstrate DS0000066927.V314381.R01.S.doc Timescale for action 01/11/06 01/11/06 Immanuel Nursing Home Version 5.2 Page 32 the daily care to be provided for each service user and give staff detailed guidance on how to support peoples’ needs, in consultation with the resident (or their representative) included in the planning or revision of the care plan. This is a repeated requirement from the inspection on the 16th May 2006 13(2)Sche The responsible person must dule 3(i) ensure that staff adhere to the procedures for the receipt, recording, storage, handling, administration and disposal of medicines This is a repeated requirement from the inspection on the 25th October2005 and the 16th May 2006 4. OP9 13(6) The responsible person must ensure that all nursing staff receive further training in the administration of medication This is a repeated requirement from the inspection on the 25th October 2005 and the 16th May 2006 5. OP15 Schedule 4(13) The responsible person must ensure that the fluid and food intake output is recorded accurately for all residents who require these observations This is a repeated requirement from the inspection on the 25th October 2005 and the 16th May 2006 01/11/06 01/11/06 3. OP9 01/11/06 Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 33 6. OP18 13(6) The responsible person must ensure that all staff receive training in the protection of vulnerable adults This is a repeated requirement from the inspection on the 16th May 2006 01/11/06 7. OP19 23 The responsible person must ensure that the home is clean, safe and well maintained; a risk assessment of the whole home including areas of working practice must be completed by a competent person This is a repeated requirement from the inspection on the 25th October 2005 and the 16th May 2006 01/11/06 8. OP21 23(j) The responsible person must ensure that bathroom facilities are appropriate to meet the needs of service users; and other existing bathroom facilities are accessible and well maintained. Improvements must be completed to the wet room to ensure service users privacy, and hot water pipes covered in the ground floor WC’s. Flick switches in WC’s to be replaced by pull cords and ventilation units cleaned regularly. This is repeated requirement of inspection of 25th January 2005 and 12th/25th May, 25th October 2005 and the 16th May 2006 01/12/06 9. OP26 13(3) The responsible person must ensure that all bathrooms and toilets are kept clean, hygienic DS0000066927.V314381.R01.S.doc 01/11/06 Immanuel Nursing Home Version 5.2 Page 34 and free from offensive odours This is a repeated requirement from the inspection on the 25th October 2005 and the 16th May 2006 10. OP27 18(1)(a) The responsible person must ensure that staffing levels are appropriate to meet the assessed needs of the service users This is a repeated requirement from the inspection on the 25th October 2005 and the 16th May 2006 11. OP30 18(1)(c) The registered person must ensure that a staff training and development plan is implemented for the home. The plan must demonstrate that all new staff undertake induction and foundation training that meets the specifications of the Sector Skills Council This is a repeated requirement from inspection of 12th/25th May, 25th October 2005 and the 16th May 2006 12. OP30 18(1)(c) 01/11/06 The registered person must demonstrate that all staff receive the required statutory training, and any necessary additional training, to ensure that they are proficient in their duties This is a repeated requirement from inspection of 12th/25thMay 25th October 2005 and the 16th May 2006 01/11/06 01/11/06 Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 35 13. OP36 18(2) 01/11/06 The registered person must demonstrate that all staff receive regular documented supervision to ensure that they are proficient in their duties This is a repeated requirement from inspection of 12th/25thMay, 25th October 2005 and the 16th May 2006 14. OP38 13(4) The registered person must ensure that products hazardous to health are appropriately stored The registered person must ensure that unnecessary risks to service users and staff are identified and prompt action taken to eliminate or minimise the risk This is a repeated requirement from the inspection on the 16th May 2006 01/11/06 15. OP38 13(4) 01/11/06 16. OP38 37 The responsible person must ensure that Regulation 37 notices are completed and always sent to the commission following any accidents or incidents in the home that may affect the welfare of residents This is a repeated requirement from the inspection on the 25th October 2005 and the 16th May 2006 01/11/06 Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 36 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Immanuel Nursing Home DS0000066927.V314381.R01.S.doc Version 5.2 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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