Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 14/09/09 for Netherton Green Nursing Home

Also see our care home review for Netherton Green Nursing Home for more information

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

There is published information about the home, which helps people make choices about where they wish to live. Everyone has an assessment of their needs before they come to live at the home, with the exception of people who have short stays on Saltwells following a hospital admission. This gave people reassurance the home could meet their needs. The home had a friendly and welcoming atmosphere where some people were encouraged to personalise their rooms to reflect preferences and tastes. There were ample communal areas, including conservatories and a `pub` on Primrose unit.Netherton Green Nursing HomeDS0000004886.V377886.R01.S.docVersion 5.2There was good access throughout the building where people were accommodated and a range of aids and adaptations available for dependent people. People were generally well presented and looked well cared for, with clothing, according to their preference. There was an open visiting policy and people were welcomed, so people living at the home were able to maintain important friendships and relationships. Three activities organisers make sure there activities and interesting events, which could be enjoyed with families and friends. The majority of people were supported with their spiritual needs. The majority of care staff had achieved a National Vocational Qualification (NVQ) level 2 in care, which meant that staff should have the knowledge and skills to meet people`s needs. Relatives told us most staff were kind and, "care for the needs of the individual with kindness and patience." Staff made efforts to make conversation with people living at the home, offering choices and assistance at a level and pace that they needed. There were meetings involving people living at the home and their relatives so they could have their say about their home.

What has improved since the last inspection?

There were some improvements to care records on two units, which meant that people`s health and well being was being planned and monitored. There were improved opportunities for activities and socialisation for some people. The home had achieved the 5-star award from the local authority`s inspection of food safety and healthy eating. There was some on-going redecoration and refurbishment on some units. The organisation had recently provided some additional management support to monitor the quality of care provided for people using the service, particularly on Saltwells unit.Netherton Green Nursing HomeDS0000004886.V377886.R01.S.docVersion 5.2

What the care home could do better:

There has been management instability at this home since 2006 and the staffing is also inconsistent. Management and staffing arrangements must provide continuity of good quality care at all times to meet every person`s needs. Improved information must be obtained from the hospital for people admitted to Saltwells so that treatment plans for people`s care and support can be put in place. There must also be improved communication and co-operation between the care staff and therapists so that people can have the maximum benefit from their stay. Clinical practices and health care records must be improved, with timely referrals made to health care specialists to make sure each person`s wellbeing is maintained and safeguarded. Some medication practices were potentially unsafe. Storage, administration practices and records must be improved. There must be an appropriate response to all concerns or complaints. Appropriate safeguarding training must provided for all staff so that people using the service are safeguarded from risks of harm. The planned total refurbishment due to take place over the current financial year has not been completed. The improvements already identified must be provided in a timely manner, with standards maintained and equipment provided for the comfort and safety of people using the service. Comments from surveys included, "Netherton Green (Darby House is badly in need of refurbishment …. The bedroom furniture and furnishings are now very tatty and the whole house could do with updating", "there is a very unpleasant smell when you enter the home". These were recurring themes. The management must be able to demonstrate that there are skilled staff in suitable numbers to meet all the needs of the people living at the home. There must be thorough employment checks in place to make sure the people living at the home are safeguarded. There were numerous comments from discussions and surveys about staffing shortages, "frequently have to wait for attention", "employ more staff each shift", "improve staffing levels at all times, staff seem very overworked." Staff must receive structured supervision, support and training to develop the knowledge and skills to provide good quality care to meet each person`s needs. The quality assurance audits must be more robust so that failings can be recognised with actions taken to improve the service in a timely manner.Netherton Green Nursing HomeDS0000004886.V377886.R01.S.docVersion 5.2Records must be monitored and improved so that risks are recognised and controlled. There were a number of areas relating to health and safety and infection control, which required improvement. Some practices would not safeguard people from risks of infection.

Key inspection report CARE HOMES FOR OLDER PEOPLE Netherton Green Nursing Home Bowling Green Road Netherton West Midlands DY2 9LY Lead Inspector Jean Edwards Key Unannounced Inspection 07:30 14 & 15 September 2009 th th DS0000004886.V377886.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Netherton Green Nursing Home Address Bowling Green Road Netherton West Midlands DY2 9LY 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) 01384 410120 01384 413460 taylorgr@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd Manager post vacant Care Home 120 Category(ies) of Dementia (60), Old age, not falling within any registration, with number other category (60), Physical disability (30) of places Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 60 Physical disability (PD) 30 Old age, not falling within any other category (OP) 60 The maximum number of service users who can be accommodated is: 120 2. Date of last inspection 15 & 16 September 2008 Brief Description of the Service: Netherton Green Nursing Home is a purpose built home consisting of four separate and spacious bungalows set in attractive landscaped grounds. Windmill and Primrose accommodate up to thirty people with dementia, Darby up to thirty frail elderly and Saltwells House is the intermediate care unit for Dudley PCT. Netherton Green Nursing Home is a private home owned by BUPA. All bedrooms are single with toilet and bathroom facilities close by and each unit has a large communal lounge/ dining room, which has smaller partitioned off areas. A kitchenette is situated off the main lounge/dining area, where drinks are prepared, a fridge and microwave are also available. Administration services are situated in a separate administration block where the Manager who has a responsibility for the complex has her office. A central laundry and kitchen are also situated in this block. The home is situated off Bowling Green Road, Netherton. The home has ample car parking and is accessible by public transport. The home had not published information about fees charge. The home should be contacted for up to date information about the range of fees. There are additional costs should as hairdressing and private chiropody, which could be provided within the home on request. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We, the Care Quality Commission (CQC), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. We monitored the compliance with all Key National Minimum Standards at this visit. The range of inspection methods to obtain evidence and make judgements included discussions with the home manager, interim regional manager, quality manager and staff on duty during the visit. We also talked to people living at the home, and spent time observing people without verbal communication skills. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the Commission. We looked at a number of records and documents. The home manager submitted the homes Annual Quality Assurance Assessment (AQAA) as requested prior to the inspection visit. We looked around the premises, looking at communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and peoples bedrooms, with their permission, where possible. Surveys were sent to people living at the home, relatives, advocates, staff and health professionals. Collated views and comments have been included in this report. The quality rating for this service is Zero Stars. This means the people who use this service experience poor quality outcomes. What the service does well: There is published information about the home, which helps people make choices about where they wish to live. Everyone has an assessment of their needs before they come to live at the home, with the exception of people who have short stays on Saltwells following a hospital admission. This gave people reassurance the home could meet their needs. The home had a friendly and welcoming atmosphere where some people were encouraged to personalise their rooms to reflect preferences and tastes. There were ample communal areas, including conservatories and a pub on Primrose unit. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.2 Page 6 There was good access throughout the building where people were accommodated and a range of aids and adaptations available for dependent people. People were generally well presented and looked well cared for, with clothing, according to their preference. There was an open visiting policy and people were welcomed, so people living at the home were able to maintain important friendships and relationships. Three activities organisers make sure there activities and interesting events, which could be enjoyed with families and friends. The majority of people were supported with their spiritual needs. The majority of care staff had achieved a National Vocational Qualification (NVQ) level 2 in care, which meant that staff should have the knowledge and skills to meet peoples needs. Relatives told us most staff were kind and, care for the needs of the individual with kindness and patience. Staff made efforts to make conversation with people living at the home, offering choices and assistance at a level and pace that they needed. There were meetings involving people living at the home and their relatives so they could have their say about their home. What has improved since the last inspection? There were some improvements to care records on two units, which meant that peoples health and well being was being planned and monitored. There were improved opportunities for activities and socialisation for some people. The home had achieved the 5-star award from the local authoritys inspection of food safety and healthy eating. There was some on-going redecoration and refurbishment on some units. The organisation had recently provided some additional management support to monitor the quality of care provided for people using the service, particularly on Saltwells unit. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.2 Page 7 What they could do better: There has been management instability at this home since 2006 and the staffing is also inconsistent. Management and staffing arrangements must provide continuity of good quality care at all times to meet every persons needs. Improved information must be obtained from the hospital for people admitted to Saltwells so that treatment plans for peoples care and support can be put in place. There must also be improved communication and co-operation between the care staff and therapists so that people can have the maximum benefit from their stay. Clinical practices and health care records must be improved, with timely referrals made to health care specialists to make sure each persons wellbeing is maintained and safeguarded. Some medication practices were potentially unsafe. Storage, administration practices and records must be improved. There must be an appropriate response to all concerns or complaints. Appropriate safeguarding training must provided for all staff so that people using the service are safeguarded from risks of harm. The planned total refurbishment due to take place over the current financial year has not been completed. The improvements already identified must be provided in a timely manner, with standards maintained and equipment provided for the comfort and safety of people using the service. Comments from surveys included, Netherton Green (Darby House is badly in need of refurbishment …. The bedroom furniture and furnishings are now very tatty and the whole house could do with updating, there is a very unpleasant smell when you enter the home. These were recurring themes. The management must be able to demonstrate that there are skilled staff in suitable numbers to meet all the needs of the people living at the home. There must be thorough employment checks in place to make sure the people living at the home are safeguarded. There were numerous comments from discussions and surveys about staffing shortages, frequently have to wait for attention, employ more staff each shift, improve staffing levels at all times, staff seem very overworked. Staff must receive structured supervision, support and training to develop the knowledge and skills to provide good quality care to meet each persons needs. The quality assurance audits must be more robust so that failings can be recognised with actions taken to improve the service in a timely manner. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.2 Page 8 Records must be monitored and improved so that risks are recognised and controlled. There were a number of areas relating to health and safety and infection control, which required improvement. Some practices would not safeguard people from risks of infection. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 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 Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 6 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is published information about the home and the home has comprehensive assessment tools. People wishing to live at the home generally have their needs met, although this is not always assured for everyone, especially people who come to the home from hospital requiring intermediate care. EVIDENCE: There were copies of the home’s corporate statement of purpose and service user guide available in reception and there were welcome packs, containing information, in some bedrooms. We were told that the documents had not been produced in alternative formats such as large print, easy read or pictorial formats, which would improve access for people with sensory or other disabilities such as dementia. These documents had been updated but there was no information about the fees charged at this home. This meant that Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 11 people might not have full information to assist them to make decisions about moving into the home. We were told that people who funded their own care had contracts with terms and conditions of residence. However people who had their care funded through Local Authorities or Primary Care Trusts (PCT) did not have contracts / terms and conditions between them and the home. We established that BUPA had a document to be used for this purpose. All persons living at the home should be provided with a contract / terms and conditions of residence, including information about fees, rights and responsibilities, signed and dated by the person or their representative and the organisation. We looked at case files for a sample of people recently admitted to the home and with the exception of Saltwells; each persons needs had been assessed prior to them coming to live at the home. Windmill and Primrose provided care to people with early and late stages of dementia and we were told that the majority of staff on these units had received some dementia care training. The organisation had created a post, Head of Dementia, and appointed the unit manager from Windmill to oversee both units. We noted that in practice this person frequently covered clinical nursing shifts on the unit and did not have sufficient time to initiate, manage and monitor the most current and effective best practice for people with dementia. The 30 beds at Saltwells were block purchased by Dudley PCT. These stepdown beds provided people coming out of hospital with intermediate care for up to 28 days with the aim of rehabilitation to enable them to be fit to return to their home in the community, often with a package of care. We were told that there was had an agreed admission criteria, however the PCT controlled admissions into these beds and routinely staff were not aware of people or their needs until the point of admission. This potentially posed problems with information and the homes ability to make sure there were appropriate staffing levels and equipment in relation to peoples care needs and dependency levels. We were told that not all people sent from hospital had been suitable for Saltwells due to their medical conditions. Physiotherapists and Occupational Therapists were available on Saltwells to assist people from Monday to Friday. A doctor from the hospital also visited people at Saltwells most days. There had been considerable instability in the staffing arrangements for Saltwells, including the resignation of the unit manager and an experienced nurse. There were interim arrangements with the deputy manager allocated to Saltwells, supplemented with bank and agency staff to provide cover for Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 12 nursing duties. During discussions staff told us that training in “intermediate care had not been provided. This had been highlighted at the previous key inspection visit in September 2008. The sample of care records did not include details about what people could do or plans for their needs when they went home such as dealing with their own medicines and ongoing mobility and continence needs. The care plans did not include details of Occupational Therapists and Physiotherapists treatment plans and daily visits. As highlighted at previous inspections there was no close liaison between the staff, occupational therapists, physiotherapists and other health professionals such as dieticians and tissue viability nurses. For example food, fluid, turn charts and wound management regimes did not demonstrate advice was being followed. Staff had limited awareness of the Occupational Therapists, Physiotherapists and tissue viability treatment plans and regimes for individual people. This meant that staff did not have good awareness of their role to continue supporting the treatment plans with people when the therapists were not available. People told us that they had expected more support, for example with practicing the frequency and distance that they should be walking to improve mobility. A relative commented that the person was only practicing mobility skills when they visited and were able to encourage, assist and support them. The home used BUPA QUEST, care assessment and care planning documentation. When used appropriately it provided a comprehensive assessment identifying each persons needs, associated risks and formed a useful care planning and risk management tool. The majority of pre-admission assessments contained comprehensive information, though there were some anomalies, such as inaccurate or inconsistent information about the level of risks and care needed. There was improved evidence of the involvement of people or their representatives in the assessment but not in risk management and care planning. People were not aware of information in care plans and risk assessments and there were no signatures on care plans, which would demonstrate good practice. There was some evidence that as peoples needs changed or deteriorated their assessments were reviewed, with referrals to appropriate healthcare professionals demonstrating good practice. For example a person with very challenging behaviour had been referred to mental health specialists with medication reviews so that risks were minimised as far as possible. However referrals and reviews were variable across the four units and notably referrals had not been made appropriately to diabetic or tissue viability nurse specialists on Darby. During discussions with people in charge on each unit, they could not show us evidence as to how they monitored or revised staffing levels in accordance with peoples occupancy and dependency levels. This meant that staffing levels may not be adjusted to meet peoples changing and in some instances increasing Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 13 needs and dependency levels. We received comments from surveys and discussions with relatives, staff and others that at times the home was short staffed and people waited unacceptable lengths of time for attention. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans, risk assessments and treatment regimes do not ensure each persons needs are fully understood and met. The arrangements for the administration of medication do not ensure that every person at the home receives their medicines as prescribed by their doctor. People are usually treated with respect and courtesy, with rights to privacy and dignity maintained. EVIDENCE: The homes AQAA cited what the home does well, All residents have comprehensive personal plans produced with the help of QUEST assessment tool, which are reviewed monthly and updated as necessary. The Royal Marsden Manual is available to staff. Regional and national specialists are available for consultation. We record and report on the treatment of pressure Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 15 on service, as well and success and document actions taken to alleviate the risk. All residents nutritional needs are assessed using a recognised nutritional assessment tool. All residents are registered with their choice of GP. Resident care is focused on being person centred, supported by the Personal Best Programme. Monthly audits are conducted by the regional manager assessing many aspects of care to allow continual quality investment and improvement. This is in addition to the Reg 26 and also detailed audits on specific aspects of care done at home level (medication, care planning etc.). A regular overview on the quality of resident care is provided by the regional manager, regional director and the Quality and Compliance team. The Key Operating Guides have been developed to ensure best practice in selected aspects of care, giving the required information at point of delivery. There are comprehensive policies and procedures which are regularly reviewed. We were not able to verify all of the good practices claimed. There were improvements to care records on some units compared to the last inspection. Each person had a plan of care and risk assessments, which generally identified their needs and there were improvements to special care records on some units, notably Windmill. There were some examples of care plans for people recently admitted to Windmill written in a more person centred style. These provided guidance for staff about personal preferences for personal care, choice of clothes and sleeping arrangements, such as number of pillows, lighting and checks to be carried out. Daily records on this unit were descriptive and useful. The Quality and Compliance Manager who had been called in to assist the home with improvements, specifically on Saltwells told us that they were working to make assessments and care plans more appropriate for people using the intermediate care facilities for short periods of time. We saw one persons records, which had been completed in a person centred style; unfortunately the person was referred to throughout the documentation by their first name, which was not their recorded preferred name. We noted that the home used colour coded short term care plans for people with conditions such as urinary tract infections and chest infections so that staff had additional guidance to make sure the person received the additional care to recover from episodes of ill health. These were being used to good effect on Primrose but they were not in use on every unit. For example we could not find short term care plans for people who had chest infections on Windmill or Darby. We were told people were sent from hospital for admission to Saltwells frequently in the evenings, which meant that the nurse on night duty had to complete the admission, assessments and care planning at a time when there was reduced staffing levels. We also saw evidence that there were frequently two instead of three care assistants on night duty on this unit. There were three admissions on the evening prior to this inspection visit. This had the potential for care records to contain inconsistent information and for people to receive care and attention, which was not the highest quality. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 16 We saw some evidence of referrals to other healthcare professions, for example speech and language therapists and dieticians, staff were given advice assistance with difficulty swallowing fluids and poor nutrition. The homes service user guide stated that people had a choice of GP. This was within the constraints of geographical borders. However almost everyone was transferred to a GP practice contracted to the home and we were not shown clear evidence of how realistic it was for people to make a choice of GP. There was some evidence that people had access to other community healthcare professionals such as dental, optical, auditory and chiropody services but this was variable across the units. We looked at the end of life planning for one person on Darby. The planning process had improved since the last inspection. The person and relatives had been involved, supported by MacMillan nurses. The Liverpool Care Pathway for end of life care was in place with prescribed medication available to make the person as comfortable as possible. We spent two hours on Primrose observing how the staff promoted the wellbeing of people with dementia. None of staff on duty had heard of dementia care mapping, including two staff nurses and the head of dementia. This technique looks at the way people with dementia behave and their interactions, in order to improve how they can be cared for. We saw that people were treated with respect and staff communicated with them appropriately, ensuring they positioned themselves so eye contact could be made, giving people time to answer questions and using gestures to help them understand. Generally attention was paid to personal care and grooming and people were dressed appropriately for the weather and efforts were made to co-ordinate clothing, promoting dignity. However we noted that some men did not have socks or shoes on, which could pose risks to their stability when walking. We revisited this unit on the second day of the inspection and everyone had appropriate footwear. On Darby we frequently heard staff address people as chick or my darling. People may feel being addressed in this way would not show them respect and dignity, as this was not documented as a preferred term of address in their personal care plans. There were a variety of views from people spoken to in the various houses. Some people told us they had to wait for attention because staff were very busy. This was confirmed by our observations, especially on Saltwells when someone requested to leave the breakfast table several times and waited more than an hour in total. Other people commented, ‘Treated very well, staff always help when needed,’ and a visitor said, ‘Staff are good, very nice, no concerns. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 17 We looked at the care of a sample of people with diabetes. Though there was some good information relating to diet, medication, and heath care monitoring, this was not evident on every unit. We were told at the previous inspection that one of the trained nurses who works part time at Darby had completed a higher-level degree relating to diabetes, however the home had not used this expertise to cascade best practice. At the previous inspection we discussed with the management the services offered by the diabetic nurse specialist service as part of Dudley PCT. We recommended the diabetic nurse specialist team should be contacted to provide additional support, information, and appropriate specialist diabetic training for the trained nurses and care staff and we were concerned that no action had been taken. The nurses and staff we spoken to confirmed that they had not received clinical updates or training relating to diabetes or other conditions requiring specialist care. There were serious issues of concern that some people with diabetes and other conditions were not appropriately referred for specialist advice and their health needs were not effectively met. There were examples that a person no longer at the home was not referred for diabetic screening or assessment from a specialist tissue viability nurse when a pressure ulcer developed, resulting in the need for surgery. Another person had been admitted to Saltwells with diabetes and other complex needs, including poor appetite and Clostridium Difficile, a highly contagious condition. They did not have a care plan for diabetes or nutrition and the infection control measures were not cross referenced into care plans for personal care. Additionally the special care records did not demonstrate adequate food and fluid intake, positional changes or proactive management to prevent pressure ulcers. Records were also inconsistent regarding the frequency of blood glucose monitoring required as part of the care planning, and there were no records of action taken to report results which were outside of normal parameters for each person. We reviewed a sample of the care for people with pressure ulcers on three units. Although there was comprehensive guidance in the QUEST assessment and care planning documentation, the implementation and the clinical practice was inconsistent. The organisations guidance was not followed diligently and though on some occasions advice had been sought from the advanced nurse practitioner attached to the GP surgery, referrals were not routinely made to the tissue viability nurses for specialist advice and support. There were healthcare screening tools, care plans, wound dressing charts and photographs. However some records showed inadequate dressing regimes such as, inaccurate Waterlow and MUST scores, inconsistent measurements of wounds and poor photographic records. There was a record with the date of next reassessment recorded as PRN (as and when needed), which was imprecise and placed reliance on the individual judgment of each nurse. One person admitted to Saltwells with a grade 4 pressure ulcer on their heel should have had the wound assessed and redressed every 3rd day but the charts Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 18 showed the procedures were carried out at erratic intervals such as at 8 days, 5 days, and 4 days without any explanation. There were records to show that this person had been assessed by the tissue viability nurse but no action had been taken to follow the advice, to obtain a repose heel protector or elevate the affected leg on a foot stool with heel to floor as a minimum. The nurse in charge acknowledged she had not seen the tissue viability nurses report. Specialist dressings should have been prescribed for this person and from the records it was unclear whether these were being used as there were no dressings prescribed for her. We were told that the specialist dressings, originally prescribed for another person no longer at the home, had been used. We were shown that a new prescription for the correctly named person had been provided, dated on the second day of this inspection visit. This was improper use of medication / dressings prescribed for one person and used for another person. It was a very serious concern that there were failures to manage pressure ulcer wound care holistically and effectively, as this posed risks of serious harm to peoples health and well being. Other improvements needed to be implemented such as; evaluations of risk assessments and care plans must accurately record changes and daily life records should accurately reflect care provided. The care records for people with PEG feeds should include instructions for correct position whilst feeds are in progress and checks to show that the PEG tube has been rotated 360 degrees every 24 hours and moved gently to avoid the risk of buried stump syndrome. The pressure settings on pressure relieving mattresses should be recorded for each person, with regular documented checks to show the correct pressure is maintained. The nurses in charge and management team present acknowledged our findings during the visit. A new camera was provided on the second day of the inspection visit to enable clear, accurate photographs of wounds to be taken with measuring strips to provide an effective audit trail of wound care. The pharmacist inspector visited the home on 14th and 15th September 2009 to check the management and control of medicines within the service. We visited two out of the four units. We found that there had been some improvement in the management of medication on one unit (Darby), however the second unit (Saltwells) was found to be poor and was placing the health and wellbeing of the people who use the service at risk. We were concerned that the time period between the morning and lunchtime medication rounds on both units had not been addressed since the previous inspection. For example, we saw that the morning medication administration began at 9am but did not finish until 11.30am.We were informed that the reason for this was due to lack of staff on one of the units and due to interruptions from visiting doctors on the second unit. We were informed that the lunchtime medication administration began at 2pm, which did not ensure that there was an adequate gap between doses to ensure the safety of people at the home. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 19 The Medication Administration Record (MAR) chart used on Saltwells was not the same as used on the other units. It was the same chart used when the person was in hospital. This had caused some problems for the service and we found it difficult to see when the chart was used by the service and when it was used by the hospital. This also caused further concern because we saw evidence that medication was not always recorded as administered to a person between transfer from the hospital to the service. This increases the risk of harm to the health and wellbeing of people. We discussed this with the acting unit manager who informed us that the service was in the process of re-writing new MAR charts when the resident was admitted to the unit. We found that sometimes the directions for the administration of medication documented onto the MAR chart did not match the directions recorded on the labelled medication. For example on Saltwells, we saw a painkiller recorded onto the MAR chart as one to be taken four times a day, however the label on the box of medication sent from the hospital had no directions and stated ‘Hospital use only do not give out on discharge’. This increased the risk of a medication error. It was concerning that we saw two people on Saltwells had not received their medication as prescribed. One persons medication was recorded on the MAR chart as out of stock for the morning of 14th September 2009. However, we were informed by the acting unit manager that the receipt records documented that there was a supply available in the unit. This supply was located and the medication administered 4 hours later. A second person had not been given two of their medications as prescribed by a medical practitioner. We found that the MAR chart records had not been signed for administration or a code documented to give a reason why it was not given. We found evidence to show that the medication had not been given. We spoke to the nurse in charge who could not give an explanation for this. There was no record to show if a Doctor had been informed. This increased the risk of a medication error and increased the risk of harm to people living in the service. Medication was not always checked to ensure it was taken safely by the person before the medicine chart was documented. For example, we saw an agency nurse on Saltwells documenting that medication had been given to a person before it had been given. We also witnessed that the nurse asked a care assistant to take the medication to the person in their room and the nurse signed the MAR chart without witnessing the correct administration of medication to the correct person. This meant that people who live in the service are at risk of not receiving their medication as prescribed and increases the risk of a medication error, which increases the risk of harm to their health and wellbeing. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 20 During our observations on Primrose unit we saw the nurse giving medication to people, standing above them, though he always gave them a drink with their medication. We considered that the evidence found at this inspection relating to health and personal care, including the management of medication did not meet the requirements issued at the previous inspection and breached The Care Homes Regulations 2001. We collected evidence of the breaches under our legal powers and informed the management we would consider further enforcement action to obtain compliance for improvement to safeguard the health and well being of people using the service. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are some social opportunities but each person cannot always be assured that there will be appropriate activities for them. People are encouraged and supported to maintain important relationships and friendships. There are choices of nutritious meals throughout the day and night but not everyone consistently receives support to maintain an appropriate nutritional diet. EVIDENCE: The homes AQAA stated, we ensure that all personal plans are individual and based on choices and preferences of the residents. Should they choose to do so, residents are encouraged to handle their own finances. We encourage the personalisation of the residents personal space, giving somewhere they can really feel at home. We have developed our menus to allow resident choice and preferences. We employ an open visiting policy, taking into account residents wishes. The menu master helps ensure every menu within the home is customer led and nutritionally balanced. The Nite Bite menu allows our residents to choose what to eat when they feel like it, providing healthy choices at any time through the night. We provide picture menus to help open Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 22 up choice. We encourage the involvement of residents and staff in the development of menus. We have a structured activities programme, with a dedicated activities organiser. We encourage a weekend activities programme. Not all of the statements made in the AQAA could be verified. We saw preferences for daily routines, should as rising, retiring and bathing, recorded in personal care plans but choices for people generally appeared to depend on staff availability and the daily life records completed at each shift change, did not provide evidence of how and when personalised care was given. We saw well completed activity records on some units. Each unit with the exception of Saltwells, had an activity organiser employed for 30 hours each week. The activity organisers role was to identify each persons’ interests and plan activities around interests, capabilities and choices. Some care records contained lifestyle care plans and a map of life but there was considerable variance as to how well these records were completed and maintained. Saltwells had no planned activities. We were told that it was not part of the contract with the Primary Care Trust, though we were told people could attend entertainment at the other houses. We did not see evidence that this happened in practice and some people told us that they were bored. There was a “pub” on Primrose, complete with bar and piano. We were told that people could use the area to visit with their friends and families for a drink. We did not see evidence this area was routinely used to promote socialisation. Whilst visiting this unit activity workers were discussing plans for trips to Wetherspoons pub for Christmas dinner, shopping at Merry Hill, and a Halloween party. A person living on Primrose told us, the hairdresser comes here and I have my hair coloured. She also told us, have lots of entertainment, very nice, fantastic singers. The activity lady - had changed, she does my nails, need doing again, she was off last week, will do them when she comes in. We saw the activity organiser painted this persons nails after, asking her what colour she wanted. We noted during throughout our Short Observational Framework Inspection (SOFI) at Primrose that the television was on in the lounge, with no one watching. The televisions in the lounge and conservatory were still on, tuned to different channels, later in morning. This meant staff were not attentive to individual needs for stimulation and the competing noise would add to confusion of people with dementia. We saw that someone cared for in their bedroom had a CD player and TV in the room but neither was being used and this person had no stimulation. Activities organisers told us that there was no budget for activities and staff held fundraising events for equipment and trips. We were later told by the interim regional manager that all BUPA homes had a budget allocation for Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 23 activities; however the home manager was unaware of this. We saw minutes of a relatives meeting on Darby. The relatives were mainly concerned with state of décor. The minutes mention the Spring Fayre with relatives thanked for their donations. There were comments that more stimulation was needed for residents. People told us Just sit here all day, not much going on, play the odd game of dominoes, but no good for me as have arthritis. Get up when want to and go to bed when want to. Can go in the garden if you want to, staff will take you out. We saw some evidence of church services held at the home and one person received visits from the local Roman Catholic Church, so that they could continue to practice their faith. One person told us she used to be in Salvation Army, and though some people come from a church visit, they only stayed about 20 minutes. She had asked for Salvation Army to visit the home but this had not happened. We spoke with the home manager who acknowledged that improving the way peoples spiritual needs was an area the home needed to develop. We saw that some people had been encouraged to personalise their bedrooms, but this varied considerably from unit to unit. There were inventories of personal possessions in care records but the majority were not fully completed, signed, witnessed and kept up to date. The home had a four weekly menu, regularly updated and offering a choice at each meal. The home had achieved a Five Stars Award for food safety and healthy eating at the last Environmental Health inspection. There was a night bite menu; these were meals and snacks available throughout the night, which could be pre-ordered for people who do not sleep well, especially on the dementia units. At the previous inspection this initiative was being well used but when we asked how many people were having night bite meals, we were told none were being ordered. On one unit we saw staff giving out drinks, asking people what they wanted and asking people what they wanted for breakfast and lunch. However at lunch time on Primrose unit a trolley full of cups filled with orange squash was wheeled to dining room, this practice did not promote choice if the expectation was that everyone on this dementia unit would all have the same drink. We received a variety of comments about the food. One person told us, staff make nice birthday cakes, everyone has one when it is their birthday, staff took me out for meal on my birthday. We have parties at valentines and Easter. On Darby we were told Food good on the whole, have what you want, and ‘Food is good.’ Another person said, If you want a drink in the night you can have one, night staff are about all night. A person living on Primrose said ‘don’t like dinners apart from fish and chips on Friday. People on Saltwells told us, breakfast is good, dinner not as good. Meals are good, better than hospital food. Have to wait a while for breakfast, lukewarm Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 24 when you get it. We observed people sitting at breakfast tables for about 30 minutes before given their breakfast. Other people told us Food is plentiful, can have what you want, have full breakfast if want. ‘Food good, for breakfast have cereal and cooked- only problem is have to get up about 7.30am if want a full breakfast. Food is great, but sometimes have to wait a long while for it. We also looked at food and fluid records for people with poor appetite or at risk of malnutrition and dehydration. These had improved on three units since our last inspection but were poor on Saltwells as highlighted at the Health and Personal Care section of this report. The evidence of compliance for these standards was mixed and the organisation must develop strategies to ensure that people experience consistently good quality standards in the outcome areas in this section. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 25 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot always feel assured that any concerns and complaints are listened to with action to investigate using systems to record findings and outcomes. The arrangements in place to safeguard people living at the home are not always effective. EVIDENCE: The homes AQAA cited evidence of what the homes does well, BUPA care homes is currently reviewing its current complaints policy. The current policy has agreed timescales for managing complaints. The information that accompanies the policy is prominently displayed in the home. The policy includes a three tier framework including the home, the regional management team and the national Quality and Compliance department. BUPA care homes has robust allegation of abuse and neglect policies, allowing staff to raise concern within the home or to the senior staff outside the home. The POVA procedures are well documented should the need arise. BUPA care homes have a national team of Quality and Compliance experts available to provide advice and help when needed. Training is available regarding to all aspects of protection. The home had a corporate complaints procedure, prominently displayed in each house and in the administration block. People spoken to generally told us that if they had any concerns they would discuss them with the Unit Manager or the Home Manager. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 26 However during safeguarding strategy meetings it emerged that a relative had discussed a number of concerns with the management of the home relating to unacceptable practices, including staff being very rude. Although the relative had stated she did not want to take this aspect of her concerns / complaint further, the home manager failed to report this matter appropriately or take any action to discover information regarding this potential verbal abusive behaviour. This omission was acknowledged by the management of the home. The homes AQAA told us that there had been eight formal complaints in the past 12 months, five were resolved within 28 days, three were upheld, and there was one awaiting investigation. We looked at the complaints log at the home but were unable to find evidence of every complaint indicated. We were told by the interim regional manager that the only one not recorded was an ongoing complaint, with investigations in the safeguarding arena. She stated this will be recorded in complaints log when the process is completed. We were assured there were records elsewhere but not on complaints forms. The AQAA cited 2 safeguarding referrals made in the last 12 months but according to our records show that there were 4 safeguarding referrals in relation to this home in the past 12 months. Additionally there were 2 regulation 37 notifications, which should have been considered for referral to safeguarding, given the nature of injuries reported. We looked at how the home was managing safeguarding training for staff. We could not find satisfactory evidence that all staff had received safeguarding training. On Primrose one member of staff had seen a video and another staff had attended training this year. Other staff had not received any safeguarding training. A staff member said, we have fact sheet sent to us, had to sign to say we had read it. Another person said, is training on abuse, don’t think I’ve done it. A number of night staff told us they had not received safeguarding training. The staff spoken to were able to tell us what they would do to report obvious evidence of abuse. The organisation had recruitment policies and procedures but the sample of staff recruitment records looked at showed that these had not been followed diligently at all times. This meant that there were not sufficient safeguards to show that people were safe to work with vulnerable people. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 27 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24,26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a warm, comfortable environment for people living there. The systems in place for maintaining infection control are not sufficiently robust. EVIDENCE: This large home was set back from the road in a very pleasant open gardened area. The four bungalows each provided 30 bedrooms, lounges, dining rooms and conservatories, with shared bathing and toilet facilities throughout. The main reception, administration area, main kitchen and laundry were located in a separate building in the centre of the complex. All four units were purpose built so the layout was appropriate for the people using the service. The entrance to each unit was controlled by an electronic key-pad system, which was frequently changed. Visitors were requested to ring the door bell and then they are ‘buzzed’ through by a member of staff. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 28 The grounds were safe and tidy, a number of rooms in all units have patio doors which lead out to the gardens. As it was a warm weather on the days of the inspection, a number of people had these doors open, which led to attractive garden areas. The units were generally pleasantly decorated, and were kept clean and tidy. We saw there was a programme of refurbishment ongoing during the inspection visit. Two in-house maintenance staff were stripping wallpaper in Saltwells and the walls in the bedrooms had been freshly painted. There was some evidence of redecoration in some of the other units. A contractor had been employed to repaint the corridor areas. We were told at the previous inspection in September 2008 that the home would be completely refurbished and redecorated. This had not happened and we were told that the organisation had decided to redirect the planned resources to another home. Each unit had a variety of aids and adaptations such as grab rails assisted baths and wheelchairs. All units had a full nurse-call system in place which appeared to be in full working order. There was evidence of personalisation in the some peoples bedrooms, such as photographs, pictures ornaments and smaller items of furniture, though this was not evident on Primrose. We were told that all bedrooms on Saltwells were due to have new bedside tables, the same style as those seen in Windmill. Some of the curtains were in poor condition but we were told new curtains were on order and would be replaced in all bedrooms at the same time. We saw that a married couple had recently moved into the home and occupied two bedrooms, and staff had turned one a second bedroom into a lounge for the couple so that they could spend time together, with privacy. The majority of bathroom and toilets we viewed were clean or in the process of being cleaned. There were posters showing people how to wash their hands properly and there were disposable gloves and aprons in the bathrooms and toilets. However we noted that a bathroom on Darby with worn enamel on the inside of the bath exposing a small area exposing the metal which had rusted. The majority of sluices/dirty linen areas also appeared clean. Whilst looking around Saltwells unit, clean laundry was being delivered from the main laundry which served all four units. The member of staff was observed placing the clean laundry in the store and removing all dirty laundry appropriately. The kitchen and laundry were not visited at this inspection. However, on previous inspections these were found to be in good working order and no issues had been identified. We noted that none of the radiators or hot water pipe work was guarded in any of the four units. Although we were told they were all thermostatically controlled and there was evidence in the maintenance records of them being checked regularly, written risk assessments must be put in place and regularly reviewed for each person. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 29 There was a malodour on entering all four units; however it was more significant on Primrose and Windmill. The main corridor in Primrose had been decorated to stimulate the senses of people with dementia and had paintings of shop fronts, canals and trees. There was also a ‘pub’ with bar and piano, but this had not been used for a while and was being used to store some equipment. Additionally, a store room had been turned into a ‘snooze room’ with stimulating lights and soothing music but it was unclear how often this was being utilised. The decoration in the dining room of this unit looked shabby and tired, with the wood on chairs very worn. We saw evidence that infection control measures were not being managed effectively. There was some alcohol gel positioned around the units, however the dispenser by the entrance of Saltwells was dirty. One person on this unit had been identified as having a positive diagnosis of Clostridium Difficile, which was highly infectious. Personal protective equipment, such as gloves and aprons, and hand washing facilities were not immediately available on entering the bedroom. There was no signage identifying the infection risk and the door to the room was open. We observed a member of staff enter the room wearing a blue apron and gloves, indicating food handling, and leave without following infection control procedures. We also saw that the top of container of hibiscrub hand wash solution hand was not clean and there was no pump dispenser to avoid contamination. Appropriate measures were put in place after we discussed our findings with the management. We found used continence pads placed on top of the clinical waste bin in the sluice area on Windmill. Additionally, a dirty laundry was draped over the frame of the dirty laundry hamper but there was no bag in-situ. We also noted on Darby unit that a bag of used continence pads was placed on top of the clinical waste bin; and there were not protective gloves or aprons readily available in the sluice room. There was shower area on this unit, which did not look clean, with a shower curtain, with appeared dirty and mouldy. In addition the same shower room had a number of slings to be used with the hoist, which were also dirty. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 30 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The number and skill mix of staff do not always ensure that people receive consistently good standards of care. The recruitment processes do not always provide sufficient safeguards for people living at the home. There is a training programme in place but staff do not always have the knowledge and skills to meet peoples needs. EVIDENCE: The homes AQAA stated, BUPA care homes has comprehensive human resource policies and procedures to aid staff management and recruitment. We endeavour to maintain agreed staffing levels at all times. We perform appropriate CRB, POVA and NMC PIN checks on all staff. There is a training matrix specific to the home that identifies the training requirements of staff. We have a good level of staff retention. We have a unified style and format for staff files. We have an improved skill mix. All mandatory training is up-to-date. Comprehensive whistle blowing policy. BUPA care homes has received IIP accreditation and it has been reviewed since 2003. We were unable to verify all of the claims made in the homes AQAA. We were not shown evidence as to how the home manager or unit managers monitored or revised staffing levels in accordance with peoples occupancy and Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 31 dependency levels. This meant that staffing levels may not be adjusted to meet each persons changing and in some instances increasing needs and dependency levels. We received comments from surveys and discussions with relatives, staff and others that the home was frequently short staffed and people had to wait unacceptable lengths of time for attention. We observed that medication was not administered in a timely manner on two units affecting the efficacy of some medication. We also saw that clinical procedures, such as wound care were not carried out diligently. This is highlighted at earlier sections of this report. We made similar findings at the previous inspection in September 2008 and this did not appear to have significantly changed. Each unit was staffed with a qualified nurse on all shifts, six carers on morning shifts, four carers on late shifts and two carers on night duty. Primrose and Saltwells had an additional nurse on early shifts. We were told that there were 93 people requiring assistance of two staff for personal care and mobility and 61 people requiring assistance with feeding, though these numbers fluctuated due to the nature of admissions to Saltwells unit especially. The people with dementia, especially at Windmill and Primrose units also needed continual supervision. We received many comments such as the staff are very busy and sometimes we have to wait. This was confirmed by observations at peak activity times during the inspection visit. We were told during the inspection visit that the home was experiencing difficulties retaining and recruiting experienced staff, especially trained nurses. This contradicts the AQAA statement, we have a good level of staff retention. The homes AQAA included the information that 15 staff had left the homes employ in the previous 12-month with significant nursing staff resignations very recently on Saltwells unit. Some staff told us lot of staff on holiday, not covered, can’t get the staff to cover, Staff turnover high across the units, and Sometimes staffing is hard, allocated staff then one rings in sick, very hard to cover, stopped using much agency. Comments from people using the service included, Staff work hard, not enough by far, and Staff are beautiful, lovely, wonderful co-operation, would give them a medal if I could. We were told at the previous inspection that the organisation was trying to recruit a new unit manager for Primrose house, without success. The solution has been to promote the unit manager from Windmill house to be Head of Dementia. Both units were now staffed trained nurses on a shift-by-shift basis with the head of dementia overseeing both Primrose and Windmill units providing management overview. However in practice this person frequently covered clinical nursing duties. The home had improved the number of care staff qualified to National level two qualification or above, from 48 to 63, out of a total of 84 permanent care staff. There were organisational recruitment procedures and the recruitment and selection of staff was generally conducted to make sure appropriate checks and clearances were obtained, such as satisfactory references and Protection of Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 32 Vulnerable Adults (POVA) and Criminal Records Bureau disclosures. However the records told us that not all nurses registration PIN numbers had been checked and the profiles for agency staff had not been obtained. These were requested during our inspection visit. We observed an agency nurse, on her first shift at the home, administering medication on Saltwells in an unsafe manner. The record from the agency did not contain evidence of POVA or CRB clearances, or the Nursing and Midwifery (NMC) registration PIN, or evidence of up to date mandatory training. We also saw a young person on work experience from a local school being directed by activities organisers to sit unsupervised reading to people in their bedrooms. There was no evidence of checks for this person. This meant that the management were not diligently following organisational policies and were not making sure that staff were safe to work with vulnerable people. We were told that all new staff had a two-day induction during which they were additional to care staff numbers. The AQAA stated that 70 care staff had undertaken the Skills for Care Induction although we did not evidence during this inspection. We requested an up to date training matrix but we were told that the central system was not all up to date. The management could not demonstrate the system, so she was not aware of which staff had attended training and which staff required training or refreshers. During discussions with staff on duty it was evident that there were deficits in training, especially clinical training for nurses in areas such as tissue viability, diabetes, Parkinsons, strokes, epilepsy and other conditions. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 33 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management arrangements do not provide sufficient safeguards for people living at this home. There are systems for consultation with people living at the home, with views sought and acted upon. EVIDENCE: The home has had three new home managers since April 2007 and has been without a permanent Registered Manager since November 2006. In June 2007 we were told that the home manager would be submitting an application to be registered with the Commission. In September 2008 a new home manager had been recruited and told us she would submitting an application with 4 weeks. This manager was transferred to another home within the organisation and the current home manager was recruited in March 2009. An application for Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 34 registration had not been submitted at the date of this inspection. This meant that the service had not had stability and development of satisfactory standards of care to meet the needs of the large numbers of vulnerable people living at the home. The organisation must ensure an application to register a manager for this home is submitted as a priority. We were told that the home manager had the support of an interim regional manager, who was present for the majority of the inspection. The organisation had also recently provided additional support from the Quality and Compliance team and a quality and compliance manager was also present for part of this inspection. There were vacancies for managers on two units and the person managing Primrose and Windmill was finding it very difficult to oversee both units, especially as he was also covering clinical nursing shifts. A new deputy manager had been appointed since the last inspection but was covering the vacant unit managers post on Saltwells. The management of the home told us that there was a structured staff supervision system. The majority of staff told us they had not received supervision. One staff member told us they were meant to give supervision but did not know what form this should take and had not received training to supervise staff. Another member of staff told us, Don’t have supervision, do handover, don’t have time to do supervision. The manager told us there were supervision records but we did not see evidence of these at the inspection visit. The home had a quality plan, which reviewed all areas of the home at least annually. We were told that there were audits of the incidence of care plans, medication and pressure ulcers; and quarterly audits of accidents and complaints. The regional manager visited the home at least monthly and produced Regulation 26 reports about the conduct of the home. We were told that there were also random audits, from which action plans were produced and monitored by the organisations Quality and Compliance team. Although there were some improvements, the quality audit systems had generally failed to identify and rectify the findings of poor outcomes for people seen at this inspection visit. Annual surveys were undertaken, with results collated and published. The organisation used a system where staff were rewarded with “Personal Best Awards” customer service awards, which were nominated by people or relatives for care beyond expectations. We saw a number of staff wearing their badges. Records must be improved, such as health care screening, risk assessments, medication and staff records. There was insufficient evidence that staff received mandatory training appropriate to their roles, such as fire training, drills twice each year, moving Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 35 and handling, first aid, food hygiene, health and safety and infection control training. We were told that training was being booked where there were gaps, though were not shown records to evidence this assurance. We looked at a sample of heath and safety, fire safety and maintenance documentation, which was satisfactory and well organised. We also looked at accident records and Regulation 37 notifications. There were 340 recorded accidents since September 2008. There was no effective accident analysis and evaluation. This meant that there was no system to identify trends and risks, which could be controlled or minimised to maintain each persons health and safety. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 36 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 2 2 X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X X 2 X 2 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 1 2 Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 37 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 OP7 Regulation 15(1) Requirement To ensure that there are health care assessments, risk assessments and care plans, which include all of each persons assessed needs, the active involvement of the person / or representative; and are updated to accurately reflect all changes to health and needs. This is to ensure care for each persons health and well being is properly provided at all times. 2. OP8 12(1) To ensure that special care records such as food, fluid balance charts, turn charts, and wound care records are maintained, with care provided appropriately recorded and monitored and updated. This is to ensure peoples health and well being is maintained 3. OP8 12(1) To ensure that people with poor nutritional intake and / or weight loss are monitored using a recognised screening tool as frequently as required by their DS0000004886.V377886.R01.S.doc Timescale for action 01/11/09 01/11/09 01/11/09 Netherton Green Nursing Home Version 5.3 Page 38 risk assessment and care plan. This will ensure that staff take required actions to promote peoples health and well being. 4. OP8 13(1) To ensure that staff make timely referrals to health care professionals for specialist assessment, support and advice, with action taken to diligently follow instructions for each persons care needs. This will ensure that staff take required actions to promote peoples health and well being. 5. OP9 13(2) To ensure that the records of the receipt, administration and disposal of all medicines for the people who use the service are robust and accurate to demonstrate that all medication is administered as prescribed. This is to ensure that the people who use the service are safeguarded. 6. OP9 13(2) Medicine records for the administration of medication must be accurate and document administration of medication or a reason for not administering the medication in order to ensure that the people who use the service are safeguarded. Medication must be administered at the correct time of day as prescribed by a medical practitioner to ensure that people who use the service are safeguarded. 01/11/09 01/11/09 01/11/09 7. OP9 13(2) 01/11/09 Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 39 8. OP9 13(2) To ensure that all staff who administer medication are assessed as competent and their practice must ensure that people living at the home receive their medication safely and correctly. This is to ensure that the people who use the service are safeguarded. 01/11/09 9. OP16 22 To diligently record and report all 01/11/09 complaints, with actions clearly identified to demonstrate robust investigations of all concerns or referrals to other appropriate agencies as necessary; and ensure these records are available for inspection. This is to ensure that the people who use the service are safeguarded. 10. OP18 13(6) All staff must receive appropriate 01/12/09 safeguarding training and the homes and Safeguard and Protect procedures to protect vulnerable people must be implemented and followed diligently at all times. This is to safeguard all persons living at the home from risks of harm. 11. OP27 12(1) To demonstrate that the number of staff on duty are skilled and trained and in sufficient numbers to meet all of the needs of each person using the service. This is to ensure that the health, well being and safety of people living at the home can be assured at all times. 01/11/09 12. OP29 19(1) To ensure that all staff employed DS0000004886.V377886.R01.S.doc 01/11/09 Page 40 Netherton Green Nursing Home Version 5.3 at the home are recruited following robust recruitment procedures, with documentary evidence to demonstrate diligent compliance with The Care Homes Regs 2001, Reg 19(1). This is to safeguard people living at the home from risks of harm. 13. OP31 9 To ensure that an application is submitted to register the manager. This is so that the home is managed to safeguard everyone using the service. 14. OP33 24 To ensure quality monitoring systems are effective and demonstrate that positive quality outcomes are consistently achieved for all persons living at the home. This is to safeguard the health, well being and safety of people living at the home. 15. OP36 12(1) To ensure that there is an effective structured staff supervision system, which demonstrates staff are supported, developed and monitored to provide safe, high quality standards of care. This is to maintain and promote the health and well being of people using the service. 16. OP38 13(4) There must be a swift response to provide essentials, such as pressure relieving equipment needed to care for people effectively. This is to safeguard people from Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 41 01/12/09 01/11/09 01/11/09 01/11/09 risks of harm. 17. OP38 13(4) To take action to provide all persons accommodated with equipment that is suitable to meet their needs, such as nursing profile beds, comfortable chairs. This is to promote peoples health and well being and minimise risks of harm There must be robust monitoring systems in place with action taken to ensure high standards of infection control and that all equipment is appropriately maintained. This is to protect from people are from risks of cross infection 19. OP38 13(4) Risk assessments must be put in place for all unguarded radiators and hot water pipes with regular documented reviews for each person. This is to safeguard people living at the home from risks of harm 01/11/09 01/11/09 18. OP38 13(4) 01/11/09 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 OP1 Good Practice Recommendations It is recommended that all information required by the Care Homes Regulations 2001 be provided in the Statement of Purpose and Service User Guide, specific to DS0000004886.V377886.R01.S.doc Version 5.3 Page 42 Netherton Green Nursing Home this home; and this should contain information about fees be easy to read and understand for people needing to use the service. This is a previous unmet good practice recommendation. 2. OP6 Accurate assessment information should be obtained prior to admissions for intermediate care, in good time to ensure care needs are planned for and can be effectively met. The care records for people with PEG feeds should include instructions for correct position whilst feeds are in progress and checks to show that the PEG tube has been rotated 360 degrees every 24 hours to avoid the risk of buried stump syndrome. The correct pressure setting for pressure relieving mattresses should be recorded in each persons care records with regular documented checks. It is recommended that there is a documented protocol available which describes the care to be given to people who could become agitated or aggressive. This must include details for the administration of medication prescribed ‘when required’ for behaviour management. This is a previous unmet good practice recommendation. The services offered by the diabetic nurse specialist service in Dudley should be contacted to provide additional support, information, and appropriate specialist diabetic training for the trained nurses and care staff. This is a previous unmet good practice recommendation. Blood Glucose (BM) testing should be consistently undertaken as directed by the care plan and a record of action taken to report results outside the persons normal parameters be maintained. This is a previous unmet good practice recommendation. Inventories of personal possessions should be fully completed, signed, witnessed and kept up to date. Consideration should be given to offering several small nourishing meals each day at more frequent intervals than DS0000004886.V377886.R01.S.doc Version 5.3 Page 43 3. OP8 4. OP8 5. OP8 6. OP8 7. OP9 8. 9. OP14 OP15 Netherton Green Nursing Home the usual mealtimes, which may also relieve the pressure on staff trying to feed residents with very poor appetites. This is a previous unmet good practice recommendation. 10. OP19 The plans to ensure the environment meets the needs of everyone living at the home should be implemented in a prioritised timescale. A review of the suitability of equipment including beds and footstools should be undertaken. This is a previous unmet good practice recommendation. That regular robust documented accident analysis should be undertaken ensuring that accident records are fully completed, with the unit clearly identified and risk assessments reviewed and revised in accordance with any changed needs. 11. OP22 12. OP38 Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 44 Care Quality Commission Care Quality Commission West Midlands Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Netherton Green Nursing Home DS0000004886.V377886.R01.S.doc Version 5.3 Page 45 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!