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Inspection on 03/08/07 for Murley House Nursing Home

Also see our care home review for Murley House Nursing Home for more information

This inspection was carried out on 3rd August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People using the service benefit from staff who are have a kind and supportive. Staff demonstrated their patience and hard work during the inspection visits. Staff work hard to meet the physical needs of service users. Good relationships have been maintained between people using the service and relatives, staff were described as `excellent`, `hard working` and `very kind`. Visitors to the home are always made welcome and can visit at any time.

What has improved since the last inspection?

The last Key Inspection took place on 10 January 2007 when 3 requirements were made. 1 of the 3 requirements was met at this inspection and another partly met. There are more useable baths provided and a wet room is planned. There were no trailing wires seen from equipment in use that may pose a hazard. The home has created a separate area, Corner House, where increased staffing levels are provided to support people with more complex needs.

CARE HOMES FOR OLDER PEOPLE Murley House Nursing Home Wyvern Road Taunton Somerset TA1 4RA Lead Inspector Sue Burn Unannounced Inspection 3rd August 2007 07:45 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 Murley House Nursing Home DS0000065815.V347923.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. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Murley House Nursing Home Address Wyvern Road Taunton Somerset TA1 4RA 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) 01823 337674 murley.house@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited vacant Care Home 105 Category(ies) of Dementia - over 65 years of age (105), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (105), Old age, not falling within any other category (105) Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A Nurse (RMN) on sub-part 1, RN3 or RNHM, of the current NMC register must be on duty at all times when nursing beds occupied exceed 34. Up to 45 places for Service Users requiring personal care only in the categories OP and DE(E) to be accommodated on Rose Wing. Up to 60 places for Service Users requiring nursing care in the categories DE(E) and MD(E) to be accommodated on Redwood Wing. Date of last inspection Brief Description of the Service: Murley House Care Home is purpose built and is situated in a residential development on the outskirts of Taunton. The registered provider is Ashbourne (Eton) Ltd a subsidiary of Southern Cross Ltd. The home is registered with the Commission for Social Care Inspection (CSCI) to provide a service for up to 105 people with dementia to include personal and nursing care. Murley House consists of three areas: Redwood House provides nursing care for older people with dementia care needs. Corner House provides nursing care for up to 22 people who have more complex needs associated with their dementia. Rose House provides personal care only for older people, including those who have dementia care needs. The main entrance to the home is at the front of the property. There is ample car parking to the front of the home and secure garden areas. The main entrance is kept locked at all times for security of the home and the people. There is a bell on the front door for visitors to make staff aware they are there. The current fees range from: £300.00 to £1500.00 dependent on need. This does not include some items including hairdressing, chiropody and newspapers The home also provides day care for up to 14 people, Monday to Friday. This provision is not registered with the CSCI. This service is staffed separately but share some of the accommodation and facilities on Rose. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was carried out over 3 days by the lead inspector and 3 other inspectors. On two of the days 2 Regulation Inspectors visited the home and the Pharmacist Inspector visited separately. The visit was prompted by a number of concerns that had been raised over time with the Commission regarding staffing levels in the home, which were impacting on the standards of care. Pre-inspection information (AQAA) was requested from the home after the first day of the inspection and is referred to in this report. Surveys were sent to service users, relatives, carers and visiting professionals, it is noted that only 4 responses were received in total and these responses were from visiting health professionals. During the visit inspectors looked at the premises and facilities, observed care practices and daily life, spoke to service users and staff and viewed a range of records. The specific care of a number of individuals was also looked at in detail. The Pharmacist Inspector examined medication management within the home. The home’s Registered Manager left at the end of June and the company has moved an experienced manager, Karen Wilkins, until the newly appointed manager can take up her post on 13 August 2007. A deputy manager and an administrator support the manager. The acting manager, Karen Wilkins, was present during the inspection and received feedback from inspectors at the end of each day. Helen Rushton, Area Manager, was present on the last day of the inspection and also received feedback. Given the concerns raised during this inspection Mrs Wilkins had stopped admissions and Mrs Rushton agreed that admissions would be suspended until further notice and any decision to revoke this would be discussed with the Commission first. The inspectors would like to thank the service users, the acting manager and staff for their welcome and assistance during the inspection. For clarity within this report each House will be identified by the house name, Redwood House (dementia care with nursing) has 38 places, Corner House (High dependency dementia care and mental health needs with nursing) has 22 places and Rose House (Residential care for people using the service who have mild to moderate dementia and who need mainly personal care) has 45 places. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: On the first day of the inspection 3 Immediate Requirements were issued requiring the provider to take action to rectify inadequate staffing levels, to ensure that an identified service user had assessments and care plans completed and to ensure that all significant incidents are reported to the Commission without delay. People using the service needs must be thoroughly assessed before they move into the home to ensure that their needs can be met and staff have full information. An Immediate Requirement was issued during the inspection. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 7 The home must complete all assessments after admission and use these to develop care plans unique to the individual that involves the person using the service and/or their representative. These care plans are required to support and enable staff to proved the care for the assessed needs identified. An Immediate Requirement was issued during the Inspection. Care plans, monitoring and recording regarding nutritional needs need improvement to ensure the nutritional needs of service users are met. Alternative/additional snacks are not provided for people needing a soft or high calorie diet sufficient to meet their needs and this is required to be addressed to ensure that all people using the service have access to the appropriate diet. Staff availability during mealtimes is also restricted due to the lack of staff available and has a negative impact on the dining experience for people using the service. Staff awareness must be raised to ensure that call bells are available to people using the service to enable then to summon help when needed. Where this is not practicable a risk assessment must be undertaken and suitable alternative arrangements made. Medication management needs to be improved to ensure the safety of service users. Social and recreational opportunities are very limited, this is due to the size of the home and limited staff resources. This area is required to be addressed to ensure that each person using the service has recreational and social activities tailored to their personal needs and preferences. Investigation into incidents/accidents needs to be more thorough to ensure that appropriate care has been provided and lessons learned where needed. The area manager was asked to re-investigate the care afforded a now deceased resident to ensure that appropriate action was taken following an accident. Staffing levels are not sufficient to ensure service user needs are met and these low levels may place people using the service at risk. Recruitment procedures are not always thorough and robust enough to ensure that suitable staff are recruited and may place people using the service at risk. Moving and handling practices are not consistent with best practice and may cause injury to people using the service and staff. The maintenance of hoists within the home is required to ensure that moving and handling equipment is available when needed. Some maintenance is required on the bathroom in Rose House to ensure it is free from risk of cross infection. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 8 The current storage arrangements for incontinence products require review to ensure that all products allocated are available to the person with identified assessed need. The home must ensure the correct, use, maintenance and risk assessment practices are in place for the safe use of bedrails to ensure people using the service are not placed at risk of accidental injury. Storage of documents in some areas of the home, relating to people using the service, are not secure an din line with the Data Protection Act and may compromise people using the service’s confidentiality. The acting manager is required to inform CSCI, under regulation 37 of the Care Homes Regulations 2001, of any circumstances which would adversely affect the well-being and safety of people using the service. An Immediate Requirement made. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5. Standard 6 does not apply. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users and their families are provided with sufficient information to make a choice about moving into the home. Service users cannot be assured that thorough pre-admission assessments are made regarding their needs and preferences. The home has significant staffing problems that are impacting on meeting service user needs. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 11 EVIDENCE: The Home’s Statement of Purpose and Service User Guide were both examined. The home has a comprehensive written Statement of Purpose and Service User Guide. The Service User Guide is also available in audio format, if needed. Both these documents are written in the corporate style but have been adjusted to reflect the particular service at Murley House. Both have recently been updated and provide all the relevant information, however, it is recommended that the acting manager reviews the Statement of Purpose and Service User Guide to ensure that they contain the correct information regarding care planning and the care provision for end of life care, including spiritual care, so that prospective residents and relatives have an accurate source of information. The home encourages people to visit the home before making any decision and move in on a trial basis of 4 weeks. On the first day of the inspection the care records of a recently admitted service user was examined. The person had been resident in the home for 4 weeks and had complex nursing needs. The pre-admission document had not been fully completed, including critical areas relating to their dementia care needs. There was not full information on file from the referring agency to assist staff. This was faxed through during the inspection visit. An Immediate Requirement was issued requiring that thorough pre-admission information is sought before a person is admitted to the home. On the third day this file was examined again. It was evident that work had been started to carry out assessments and develop the care plans. However there were areas where this had not been completed to a satisfactory standard. The pre-admission documents were not dated or signed, which are essential for legal documents and also to identify when the assessments were carried out as a benchmark for change. A further care record was examined. The pre-admission information was brief and not dated or signed. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Each person who uses the service has a care plan, the assessed areas of need were not all reflected in this plan of care and the detail recorded did not ensure that staff were advised of all the care needs identified. The poor management of medicines has the potential to place service users at risk of harm. Staff were observed to treat the people using the service with dignity and respect at all times and residents felt well cared for. EVIDENCE: Ten care plans were examined and the care observed and the care of 2 people was more closely case tracked. On the first day one service user did not have any assessments or care plans completed despite having complex nursing needs. An Immediate Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 13 Requirement was issued and followed up on the third day. Work had been started on these care plans but lacked significant information and detail. Further care plans were examined and were found to have varying degrees of information, some care plans indicated that they were also being reviewed. Some areas of care planning for people with challenging behaviour were incomplete and would not support staff to provide the care needed. Staff confirmed that in some areas of the home the care plans are not read as there is no time. The shift pattern does not include any overlap so that a ‘handover’ of information can be given to the staff coming on duty. No time is made available by the management of the home for staff to review and update care plans. Care plans for those people with high care needs who are currently being nursed in bed were not all reflective of basic nursing care practice for example changes of position, continence care, fluid intake and nutritional monitoring, this may place the person at risk. The acting manager confirmed that care planning is a priority to be addressed to support the needs of people using the service. Care plans recorded the input of visiting health professionals and it was evident that people have access to chiropodists, district nurse, Community Psyciatric Nurses and opticians. Survey results from one visiting health professional indicated that they felt they they are not always kept informed of changes in health and welfare. Another comment stated that they feel the home does not always look at the assessments available to them to ensure identified needs are met. Screening tools for nutrition had been completed but in one instance the record indicated the use of dietary suppliments which it became evident were niether in stock or administered. One nutritional care plan stated the need to encourage fluids but the person using the service did not have drink at the side of the bed. The same nutritional record had not been updated since April 2007. Some records of weight indicated that some people were loosing weight, however no action to address this was evident.(See Standard 15). Social care plans were not fully completed and lacked documentation of social choices and preferences. There was no input by people using the service or their relatives in the care plans seen and reviews had not all been undertaken on a regular monthly basis. Some risk assessments were in place but the care plan did not give guidance to staff in how to minimise the risks identified, these risks included the timescale for staff to ensure the person had a change of position. Another risk assessment highlighted that the person using the service was at an extreme Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 14 risk of falls, but the care plan did not give guidance to staff about observation and monitoring.The peson using the service was seen to almost fall on 2 occasions during the inspection. The daily record of care maintained for each person is not reflective of the care plan, for example, one care plan indicated a minimum fluid intake of 1000 mls, 4 hourly mouth care and daily one to one time. None of these actions were recorded as being undertaken in the daily record or care plan. All care plan reviews examined on Rose House showed a gap in review time between May and August 2007 and none seen evidenced any involvement of the person using the service or their relative/representitve. This is not in line with the Homes Statement of Purpose which states that care plans will be reviewed at least monthly. It was apparent from observation that one person who was assessed within the care plan as needing one to one supervision was not receiving this level of supervsion. Staff confirmed that this was not always possible due to insufficient staff numbers. The management of this person must be reviewed to ensure that the appropriate level and type of supervison is provided. One care plan included details of the care required at night. This was clear and provided suitable direction for staff. On the tour of the home it was observed that some people using the service did not have access to a call bell, the acting manager is required to ensure that all staff are aware of the importance of leaving a call bell with the people using the service, to summon help as needed. Where this is not practicable for some service users a risk assessment must be carried out an suitable alternative arrangements made. Staff were noted to be kind and respectful towards people using the service and were observed knocking on the bedroom doors before entering and treating people with dignity. All people using the service spoken to were complementary about the staff and comments included “ They are wonderful” and a visitor stated that “Some staff are wonderfull”. However one survey received stated that “There is a need for more attention to detail i.e. changing clothes when soiled.” It was observed by the inspectors that the staff had very little time to chat with people using the service as they were so short of staff. The care given appears to be task led and there is no time for socialising or discussion between staff and people using the service. This was also noted by a visiting professional who commented in a survey that “Staffing levels do not facilitate time with clients other than to provide pysical care”. The safe moving and handling of people using the service appeared to be compromised on 3 noted occasions. This may have been due to the low Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 15 staffing levels and the lack of suitably maintained equipment or may be a training issue for particular staff. Staff were observed to move people with an underarm lift which may cause undue distress or risk of injury to both people using the service and staff. Hoists used on the Redwood House were noted to be out of battery charge during the third day of the inspection on 2 occasions and staff were unsure of the correct slings to use for each piece of equipment. The acting manager must ensure that staff are trained and supported to use the equipment available and that the equipment is maintained and available for use when needed. It was observed by the inspector that bed rails on the Redwood House were not used to protect the people using the service, on one occasion the rails were not fully up and could place the person at risk of accident/injury. On another occasion the inspector noted that the care plan indicated that the person would climb over the top of them. This would indicate a further risk to be addressed but no risk assessment was in place or evidence to suggest that alternative arrangements had been considered. The care plan was examined of a person who lived at the home but has now died. The records noted a steady deterioration in the persons condition with staff taking appropriate action to maintain pain control and also maintain contact with the family and GP. It was noted that there was no reference to any spiritual needs or action taken and it is recommended that this area be addressed for future practice. The pharmacy inspector visited on the second day of the inspection and found that for medicines prescribed to be administered with a variable dose, the dose actually administered is not always recorded, meaning that it is not possible to monitor how the medicine is affecting the health of the person. We also found that the home is using medicines prescribed for individuals as “homely remedy” stock. This means that the home may be administering prescription only medicines to people without the authority of a prescription. We found that some medicines with a reduced shelf life after opening were still in use after the end of this reduced shelf life. We also found that some of the sterile products in the home were date expired. We also found that some sterile dressings had been opened and part used with the remainder stored in the dressings cupboard. This remainder is no longer sterile and may present an infection risk if used. We found that the storage facility for some medicine was not adequate and they were not stored appropriately. We found that nutritional supplements were being stored on the floor, which is not appropriate. On the first and third days of the inspection inspectors observed that the morning medication rounds were taking a long time, one did not finish until 11.40am. Others finished from 11am-11.30. This left only a short time before the next round, which could impact on the effects of prescribed medication. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 16 This was due to the pressures of staff time and that the nurse or senior carer needed to stop frequently to assist with tasks, answer the phone or door etc. Prescribed creams are kept together in a box in each house. These boxes are accessible to service users throughout the morning as they are not kept in the medicine cupboard or locked away. There is no record of administration and creams seen did not have an opening/expiry date. This means that there is a risk of cross infection, accidental ingestion, no clear monitoring of administration and that out of date creams may be in use. It was noted on the 3rd day of inspection on the Rose House that medication was left in front of a person using the service for a period exceeding 2 hours. During this time the risk of accidental ingestion by another person was high and no observation could be made to ensure that the service user had the medication administered. The acting manager is required to ensure that medication is administered correctly in line with the Royal Pharmaceutical guidelines. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are some opportunities for social stimulation and residents are supported to join in with organised activities or pursue their own interests. Visitors are always made welcome and can visit at anytime. The meals in the home are of a good quality, further development of the menu is required to support people using the service who have specialist dietary requirements. The home is required to provide adequate staff to support people using the service who require assistance with eating and drinking. EVIDENCE: The inspectors spent time talking with people using the service and observed people reading newspapers, chatting to other people using the service and visitors. The people using the service are advised in advance of the planned activities and some people on Rose House confirmed that activities take place regularly. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 18 On the day of inspection, people using the service were seen to be either in their rooms, in the foyer of the home or in the lounge watching TV. Also on the day of inspection on the Rose House, a visiting musical entertainer was performing in the afternoon and the day care staff planned a small birthday tea party. No activities were planned or observed on the Redwood and Corner Houses. The home has currently employed 2 full time activity coordinators and activities are also undertaken by the staff. Given the poor staffing levels already indicated in this report, activities are limited to time and staff availability. The home has a well laid garden suitable for use by the people using the service, on the first day of inspection it was noted that one person was enjoying the garden but was unescorted, this person was later seen to fall. The care plan for this person highlighted the need for supervision. The garden was not noted to be in use on the remaining days of inspection and people living in Corner and Redwood Houses did not have ready access to the garden as doors were locked or they lived on the upper floor. The acting manager is required to address the activity provision in all Houses of the home to meet specific choices preferences and abilities. Visitors spoken with confirmed that they could visit at any time and were always made welcome by the staff. Some people using the service’s bedrooms were decorated in a manner which reflected their tastes and lifestyles, evidence was seen in some cases of people’s own furniture in their bedrooms. Those people who were able confirmed that they could get up and go to bed within a reasonable time of request. Most interactions observed between people and staff occurred during the serving of lunch and when the tea trolley went round. Staff carried out this interaction sensitively and respectfully. The breakfast and lunchtime meal was observed on the first and third day of the inspection. Breakfast started in each House around 09:00 and continued until about 11am. 2 people were noted to start breakfast at 11am when lunch was served at 1pm, this would indicate that a long time span had elapsed between supper the night before and breakfast. It would further indicate that a full lunch would not always be enjoyed having had breakfast so recently. Several people using the service were noted to sit at the dining table for in excess of 2 hours and one person remained seated at the table until lunch was served. It is recommended that the acting manager ensures that people are assisted to sit in comfortable chairs after they have eaten. One person was seen to spend lunch time pushing a bedside table around the lounge, the table contained that persons lunch which was spilt and wasted. The Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 19 person was noted to have eaten very little and no alternative was supplied or assistance given to support further dietary intake. The staff serving both breakfast and lunch in Rose House appeared very busy and had little time to support and encourage those people who clearly needed assistance. On some occasions people using the service were noted to have gone to sleep at the dining table and not completed their meal, further support had been needed to encourage adequate intake of the meal. The acting manager is required to ensure that adequate staff are available to support those people who need assistance with eating and drinking to ensure adequate diet is taken. Meal times seen in Redwood and Corner Houses were unhurried and staff provided suitable assistance although they were clearly stretched and not everyone received assistance promptly enough to ensure a hot meal. On all of the Houses there was no means of identifying who had eaten and how much. The registered manager is recommended to ensure that mealtimes are a pleasurable social/dining experience. She is further recommended to ensure that staff have means of auditing who has eaten and nutrition records maintained as required to ensure adequate diet has been taken. The dining tables in the home are set fully for lunch. Menus were placed on the tables in large print on the Rose House. People had chosen what they wanted the day before but had forgotten on the day. The inspectors recommended that in the Corner House and Redwood Houses a menu board is used to display the choice available. The meals were well presented and appeared nutritious. However some people using the service stated that the meals were not always served hot. The home caters for specialised diets and all puree diet was served individually to ensure that people using the service could enjoy varying tastes and textures. Examination of care records indicted that several people using the service had evidenced a weight loss, which would indicate further nutritional assessment and action was required. The acting manager is required to undertake a full audit of all people using the service’s weight and use this information to inform staff via the care plans of action to take to promote increased calorific intake and encourage weight gain. The evening meal is prepared by the cook and served by the care staff. It was discussed with the chef that a soft option is not catered for the supper provided around 8pm. It is recommended that a soft diet option is available with each meal/snack provided and with morning and afternoon drinks. One staff commented that on some occasions there is not always enough choice and quantity of food available at the evening meal and supper does not have a soft option. Some people using the service may only have a drink and biscuit from teatime to breakfast time. Redwood House has a small kitchen on each Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 20 floor. There was very little food kept in these kitchens and no crockery. Staff stated that everything was supplied by the main kitchen so if a snack or hot drink was requested or needed then staff would have to go to the kitchen to get this. In a large home with very busy staff this may not always be possible. Staff also confirmed that neither milky drinks nor snacks were served at suppertime in this part of the home. The acting manager agreed to ensure stocks were supplied to each kitchen. There is also no means of keeping porridge hot so not everyone had hot porridge served if they had a later breakfast. It was discussed with the acting manager that nutritious snacks and smoothie drinks be implemented to support those people using the service who have health needs which indicate eating little but often to support their dietary intake. This to be implemented in the near future. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 21 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service and visitors to the home have information available to enable them to make a complaint or raise concerns. The registered person takes all complaints seriously and will respond to all concerns in writing following the organisations procedure. Recruitment procedures undertaken in the home do not protect people using the service from the risk of abuse. EVIDENCE: The complaints procedure is displayed in the main reception area. People spoken to said they knew who to talk to if they had a concern and relatives consulted with were aware of the complaints procedure. The home has recorded one complaint since the last inspection in April 2007. The Commission for Social Care Inspection has received 3 concerns relating to the quality of service delivery by the home since the last inspection, these issues were based around the issue of lack of sufficient staff available. Staff training records examined indicated that many staff had received abuse awareness training, staff also confirmed that they knew how to access the whistle-blowing procedure. It is noted that the whistle blowing policy used by the home does not contain the contact details for CSCI and it is recommended that these to be included. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 22 For the protection of people using the service the home is required to undertake recruitment procedures to check that staff are not included in the Protection of vulnerable Adults list (POVA), have a satisfactory Criminal Record Bureau check (CRB) and have 2 satisfactory references prior to commencing employment. 3 staff recruitment records examined evidenced that • 2 of those staff employed at the home commenced employment prior to the home receiving the Protection of Vulnerable Adults (POVA) check. • Risk assessments were not in place for staff who had identified previous convictions. • One reference had not been received prior to commencing employment. • One reference was not received from an appropriate source and 2 references were not from the most recent employer. It is required for the protection of people using the service that all the required recruitment processes are completed before staff commence employment. It was observed at inspection that a member of staff was residing at the home in a spare bedroom, which was registered by the Commission. This practice is highly unusual. The use of rooms for staff residential accommodation is not recorded in the Statement of Purpose and Service User Guide. It is noted that this was a temporary arrangement and the acting manager is recommended to change this situation without delay. Murley House Nursing Home DS0000065815.V347923.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 23 24 25 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is a large building which is well maintained with a good standard of décor, the standard of hygiene is adequate. Service users bedrooms are decorated to reflect their own personal tastes. The gardens are attractively laid out and suitable for people using the service use. EVIDENCE: The homes AQAA states that “ The home is purpose built with large airy spaces and there are various quiet areas around the home for those that want this facility.” Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 24 The décor of the home is pleasant but some furnishings are showing signs of wear and tear, this is with particular reference to the upper bathroom on the Rose House which is in need of refurbishment. Bathrooms noted on the Redwood and Corner Houses also evidenced a lack of use and appeared to be being used as a storage facility for hoists and other equipment. Staff were observed to follow infection control procedures and the home has a team of domestic staff. The homes AQAA states that in the last 12 months “All staff have a better knowledge of infection control “. Cleaning staff on duty confirmed that they had sufficient time and equipment to maintain an adequate level of hygiene although there were times when the numbers of staff were not sufficient. On the 3rd day of the inspection there were 2 cleaning staff on duty. It was noted that 4 areas did have a malodour of urine at the time of inspection. It was noted that each room was clearly named for the person using the service and some people had been supported to decorate the room in their own personal style. Small piece of peoples own furniture were seen. Each room has a sink and vanity unit, call bell and can be heated to the individuals own preference. The inspectors observed that incontinence products were being stored collectively in a cupboard or wardrobe on the corridor of each House. These items are supplied individually following an assessment of each person’s need. The acting manager is recommended to ensure that the products are stored in each persons room and therefore stock is not shared. This practice also impacted on staff time as they left service users to go and find a suitable product for them. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are not adequate to meet the assessed needs of people using the service and may put people at risk. Staff training is required to ensure the safe moving and handling of people using the service. Recruitment practice is poor and may poor people using the service at risk of abuse. EVIDENCE: The homes AQAA states that “The dependency level of the Residents are met with an appropriate skill mix of staff and the off duty is planned in advance to ensure that optimum staffing levels are maintained”. This was found on each day of inspection not to be the case. On each of the days of inspection it was confirmed by the acting manager that the home was short of staff. Agency staff were being used and assistance by staff from another home in the company was evident. On the first day of inspection an Immediate Requirement was made requiring that the acting manager carry out an immediate review to ensure that adequate staffing levels were available over the following weekend .It was Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 26 also required that the home submit a full review of staffing levels, based on the agreed minimum levels and taking account of the current people using the service’s dependency levels. Following the Immediate Requirement the area manager informed the Commission that the staffing levels would be increased by one carer per shift in each area during the day. Admissions to the home were also suspended in agreement with the management of the home, until staffing levels had stabilised. The provider has agreed to notify the Commission if the staffing levels fall below the stated numbers of staff and send worked rotas to the Commission each week. The staffing level is calculated by a dependency of people’s needs and on the first day of inspection the levels did not meet this assessed level. On the 3rd day of inspection there was one qualified nurse and 2 care staff on each of the 1st and 2nd floors of the Redwood House and 1 qualified nurse and 2 carers working in the Corner House House. There were 1 senior carer and 5 carers in the Rose House. This level was achieved by late morning and the Rose House was staffed at varying levels through the morning. It was noted that staff in charge had periods of time when they were not aware of who and how many staff were working on their Houses. Rota’s examined evidenced that staff were available at varying levels each day. Discussion with day and night staff confirmed that staffing levels were frequently low and staff felt stressed and compromised by the lack of time available to them to ensure a good standard of care was consistently delivered. Staff on the Rose House appeared extremely busy, people using the service were noted to be sat at the dining table for periods in excess of 3 hours due to poor staffing levels. One visitor commented “More staff would be helpful”, another person using the service stated “ There are not enough staff especially in the mornings”. The staff of the Corner House and Redwood House were seen to be calm and managing the House in a professional manner. However, people using the service would benefit from more staff being available to ensure the adequate supervision of people who’s needs have been identified as high risk and it would allow staff to spend social time with people using the service. Staff were meeting the physical needs of service users but not their psychological or social needs. One service user required one to one care and close supervision. This was frequently not possible or effective due to the staffing levels. The professionals surveys returned all commented on the low staffing levels. It was observed that some staff on the Corner House and Rose Unit were well trained and coped well with situations as they arose, however, they appeared Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 27 and confirmed that they were stressed by the amount and the needs of the people in their care which was preventing them from enjoying their job. It was identified that the acting manager must ensure that any identified need for agency staff is addressed at the earliest opportunity to increase the time available for staff to be found. The home encourages NVQ training amongst carers and has qualified assessors to support the staff in training. All the staff felt they had received a good induction training into the home, the induction is based on the Skills for Care Common Induction Standards. Staff training was advertised in areas including abuse awareness, health and safety and care Planning. One staff was noted not to have undergone annual Manual Handling training for a period of 18 months. However staff commented that this training could be difficult to attend as recently it had been held over the lunchtime period when releasing staff, without any additional cover, was not always possible. On the 3rd day of the inspection the planned training was cancelled. Recruitment procedures used in the home were noted to be poor and may place service users at risk of abuse (See Standard 18). Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33 34 35 36 37 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The acting manager is not registered with CSCI and so Standards 31 and 32 have not been assessed. The recording of personal finances is recommended to have 2 signatures for all transactions to ensure safe management. Health and safety documentation is well maintained and updated. Not all care records are stored securely and may compromise the confidentiality and safe keeping of this information. EVIDENCE: The home has undergone a change of manager and the current acting manager is Karen Wilkins. She is an experienced manager and employed by the company to manage home’s for short periods when there is not a Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 29 Registered Manager in post. As such standards 31 and 32 have not been assessed at this inspection. However it is concerning that the company had not addressed the significant staffing problems before the inspection and had not made the Commission aware. The policies and procedures examined are relevant and updated and include policies of guidance for challenging behaviour, abuse awareness and gifts for staff. Staff confirmed that they are read as part of the induction process and they have access to them. The financial records were examined briefly and were noted to contain an audit of all transactions and include receipts, however transactions were only signed by one person. To ensure the protection of people using the service and staff it is recommended that 2 people sign all transactions. Accident records were examined, the home does not undertake an audit of accidents as an opportunity to observe for trends and repeated incidences with a view to preventing further accidents occurring. During the first day of inspection it was noted that 3 accidents took place, the acting manager is required to undertake an audit of accidents on a monthly basis. Care plans and details relating to people using the service are stored appropriately in the Rose and Redwood Houses, in line with the Data Protection Act 1988 .Corner House had care plans stored in the dining area which was easily accessible to other people and visitors,. This issue is required to be corrected and all documentation relating to people using the service is to be stored securely and so not compromise confidentiality. On the first day of inspection it was noted that the home had been without a hot water supply for 4-5 days due to repair work on the boiler, furthermore there were inadequate supplies of continence products available in the home the week prior to the inspection. An immediate requirement was made to comply with Regulation 37 of the Care Homes Regulations 2001, CSCI must be notified of all incidents that affect the well-being of service users. Statutory maintenance records were checked. Most records were well maintained and organised. Some records are required to be forwarded to CSCI including • 24 PAT tested items failed and there was no record of the retest or plan of action to replace. • Fire extinguishers are due to be checked annually but were last checked on 21/07/06 • Fire maintenance due annually, this includes maintenance of the fire panel has not been undertaken since 02/02/06 Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 30 Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 1 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 2 2 3 3 3 2 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 2 X X 1 1 Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 32 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(1)(a) Requirement The home must ensure that adequate pre admission assessment is undertaken and details recorded prior to admission to ensure that the persons needs can be met by the home. Immediate Requirement made 03/08/07 The care plan provided for each person using the service is required to provide sufficient detail to enable staff to provide care for all the assessed needs identified. Immediate Requirement made 03/08/07 The care plan is required to involve and include input from the person or their representative in the development of the care plan and involvement in the reviews of the care plan. Previous timescale of 30/07/07 not met Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 33 Timescale for action 03/08/07 2. OP7 15(1) 03/08/07 3. OP7 15(1) 30/09/07 4. OP8 12(1)(a) People using the service are required to have appropriate access to a call bell or means to summon assistance at all times. Where this is not practicable a risk assessment must be carried out and suitable alternative arrangements made. For medicines prescribed with a variable dose the actual dose administered must be recorded. To reduce the risk of infection medicines must not be used once their expiry date has passed. Medicines must only be administered to the people they are prescribed for and not used as stock medicines. Medications prescribed must administered in line with the Royal Pharmaceutical Guidelines, 30/09/07 5. OP9 13(2) 07/09/07 6. OP9 13(2) All medicines must be stored in cupboards that comply with the regulations pertaining to their storage. This is to prevent unauthorised access to these medicines. The acting manager is required to consult people using the service about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation. The registered provider must ensure that all people in the home are provided with opportunities for stimulation through leisure and recreational activities that suit their needs. This should also include 07/10/07 7. OP12 16(2)(n) 30/10/07 Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 34 opportunities for all to access the garden. 8. OP15 12(1)(a) The home is required to : Provide an audit of people using the service’s weight and ensure that adequate nutritional screening is undertaken and identified needs care planned and appropriate action taken. Ensure that a suitable choice of food is always available and that people with identified nutritional needs are supported with high calorific value foods to ensure adequate intake is maintained. The home is required to ensure that a soft diet option is available at all mealtimes and that snacks are available at all times for people with an assessed need. The home is required to ensure that people using the service are assisted to comfortable chairs after mealtimes have finished. 9. OP18 19 Schedule 2 The acting manager is required to ensure that all recruitment procedures required by Schedule 2 of the Care Homes Regulations 2001are complete prior to commencing employment : • staff must not commence employment at the home prior to the home receiving a satisfactory Protection of Vulnerable Adults (POVA) and CRB check. • Risk assessments must be in place for staff who had identified previous DS0000065815.V347923.R01.S.doc 30/09/07 30/09/07 Murley House Nursing Home Version 5.2 Page 35 • • convictions. 2 satisfactory references must be received prior to commencing employment. The references must be relevant and include the previous employer. 30/11/07 10. OP21 12(1)(a) 23(2)(j) The home is required to ensure the repair and refurbishment of bathrooms to ensure adequate bathing facilities are available. This is to include the upper bathroom in the Rose House to an acceptable standard for use. The home is required to ensure that a suitable standard of hygiene is maintained which will ensure that the home is free from offensive odours The acting manager is required to review the storage of incontinence products to ensure that products assigned for each person are available to them in sufficient numbers. The registered person shall, ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users; The acting manager is required to ensure that dependency levels are regularly reviewed and each House staffed to the indicated level at all times. Immediate requirement made 03/08/07. 11. OP26 16(2)(k) 30/10/07 11. OP22 12(1)(a) 30/09/07 12. OP27 18(1)(a) 03/08/07 13. OP30 18(1)(a) The acting manager is required DS0000065815.V347923.R01.S.doc 30/11/07 Page 36 Murley House Nursing Home Version 5.2 to ensure that staff training in the safe moving and handling of people using the service is available and that supervision is available to support staff regarding moving and handling issues identified. 14. OP37 12(4)(a) The acting manager is required to ensure that the storage of care plans and other documents relating to people using the service are stored securely in line with the Data Protection Act 1988. The registered person shall ensure that the care home is conducted so as— to promote and make proper provision for the health and welfare of service users; That all hoists are maintained in a manner which makes them available for use when needed. 16. OP38 13(4)(c) The acting manager is required to ensure that all bedrails used in the home are used correctly, well maintained and risk assessed for correct use The acting manager is required to undertake a regular audit of all accidents which occur in the home to ensure that any trends, incidences or staffing issues highlighted are identified and the appropriate action taken to reduce the risk of accidents within the home. The acting manager is required to inform CSCI under regulation 37 of the Care Homes Regulations 2001 of any circumstances which would DS0000065815.V347923.R01.S.doc 30/09/07 15. OP38 12(1)(a) 30/10/07 30/09/07 17. OP38 13(4)(c) 30/10/07 18. OP38 37 03/08/07 Murley House Nursing Home Version 5.2 Page 37 adversely affect the well-being and safety of people using the service. Immediate Requirement Made 03/08/09. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP4 Good Practice Recommendations The acting manager is recommended to ensure that the Statement of Purpose and Service User Guide contain the correct information regarding care planning and the care provision for end of life care, including spiritual care to ensure that prospective residents and relatives have an accurate source of information. The acting manager is recommended to ensure that the menu choices are displayed in appropriate format in each House of the home, for example menu board’s and photographs. The acting manager is strongly recommended to implement a system for recording that meals have been taken and how much has been taken to ensure the adequate dietary intake of all people using the service. A system should be introduced to ensure that meals are served suitably hot. 3. OP18 The acting manager is recommended to ensure that the contact details for CSCI are included in the homes WhistleBlowing policy. 2. OP15 4. OP28 The acting manager is recommended to ensure that staff training is undertaken to ensure a minimum staff ratio of 50 of staff achieve NVQ 2. DS0000065815.V347923.R01.S.doc Version 5.2 Page 38 Murley House Nursing Home 5. OP33 The registered person should ensure that any quality audits carried out are robust and supported with an appropriate action plan. Not assessed at this inspection 03/08/07 6. OP34 The home is recommended to develop the recording of all people using the service personal monies to include 2 signatures for all transactions. Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Murley House Nursing Home DS0000065815.V347923.R01.S.doc Version 5.2 Page 40 - 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. 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