Inspection on 15/09/08 for Netherton Green Nursing Home

This inspection was carried out on 15th September 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Netherton Green Nursing Home 14/09/09

Netherton Green Nursing Home 04/06/07

Netherton Green Nursing Home 23/05/06

Netherton Green Nursing Home 12/01/06

Netherton Green Nursing Home 08/08/05

Netherton Green Nursing Home 11/01/05

Netherton Green Nursing Home 11/01/05

Netherton Green Nursing Home 11/01/05

Netherton Green Nursing Home 11/01/05

Netherton Green Nursing Home 08/04/04

Netherton Green Nursing Home 07/04/04

Netherton Green Nursing Home 06/04/04

Netherton Green Nursing Home 05/04/04

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Maple Lodge

Heathlands

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Inspirations

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Extracts from inspection reports are licensed from CQC, this page was updated on 17/12/2008.

CARE HOMES FOR OLDER PEOPLE Netherton Green Nursing Home Bowling Green Road Netherton West Midlands DY2 9LY Lead Inspector Jean Edwards Unannounced Inspection 07:40 15 & 16 September 2008 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Netherton Green Nursing Home DS0000004886.V372000.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. Netherton Green Nursing Home DS0000004886.V372000.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 - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability (30), Terminally ill over 65 years of age (30) Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Service users to include up to 60 DE(E), 30 PD, 30 TI(E) and up to 60 OP One service user accommodated on Darby House in the category of OP may also be SI(E) and will remain until such time that the current service users placement is terminated. Two service users accommodated on Darby House in the category of OP may also be DE(E) and will remain until such time that the current service users placements are terminated. One service user accommodated on Darby House in the category of OP may also be LD and will remain until such time that the current service users placement is terminated. One service accommodated at the home may be LD(E). This will remain until such time that the current service users placement is terminated. One service user, named in the variation application dated 13 May 2004, accommodated on Windmill House in the category DE(E) may also be MD(E) and will remain until such time that the current service users placement is terminated. Windmill House to accommodate 30 service users in the category DE(E) who are 60 years and over. 4th June 2007 7. Date of last inspection 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 Group of Hospitals. 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. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 5 The Home Manager should be contacted for information about the range of fees that the home charges. Other additional costs included hairdressing and private chiropody, which could be provided within the home on request. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. We, the Commission for Social Care Inspection (CSCI), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. A lead inspector and two additional CSCI inspectors spent a total of two weekdays at the home, accompanied for part of the inspection by a CSCI pharmacy inspector. 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 recently appointed manager, unit managers, and staff on duty during the visit, discussions with residents, observations of residents without verbal communications and examination of a number of records. We also spoke to relatives visiting the home. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the CSCI. The registered persons had submitted the home’s Annual Quality Assurance Assessment (AQAA) sometime before the inspection visit. We were also assisted by a person with experiences of using care services for older people and we have included their findings as part of this report. We sent resident surveys, relatives surveys, health care professional and staff surveys to the home to be distributed and requested they be returned to the CSCI office in Birmingham. The collated results form part of this report. We toured the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents’ bedrooms, with their permission, where possible. The quality rating for this service is One Star. This means the people who use this service experience adequate quality outcomes. What the service does well: The home was generally pleasantly decorated and furnished with an ongoing refurbishment programme. We were told that the whole home was due to be completely refurbished, on a phased basis next year. There was good access throughout the building where residents are accommodated and a range of aids and adaptations available for dependent people. We saw that all residents, with the exception of people admitted to Saltwells House, have an assessment of their needs before agreement was reached for Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 7 them to come and live at the home. This gave people reassurance the home could meet their needs. The home had a copy of Dudley MBCs multi-agency policy and procedure for the protection of vulnerable adults, and had made sure that all staff have a good awareness of this document, which meant people would be safeguarded from abuse. Relatives told us most staff were kind and, very helpful, they go out of their way to try to help. B - very good, not always the same response from all staff when something is not quite right - but unit manager and nurse in charge excellent. Another comment was, the unit manager - he always does his best. The organisation demonstrated a strong commitment to staff training. The home had a formal training programme with 48 out of 63 care staff with an NVQ 2 or above care award and a further 10 staff undertaking the training to achieve the award. This inspection was conducted with full co-operation of the home manager, staff and residents. The atmosphere through out the inspection was relaxed and friendly. What has improved since the last inspection? What they could do better: Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 8 There was an invaluable intermediate care unit at Saltwells House for people who have been in hospital and need extra support and care to enable them to return to their own homes in the community wherever possible. Improved information must be obtained from the hospital 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. The systems for making sure people can manage their medication must also be improved. The manager agreed to make sure care records were monitored more closely, especially for residents with complex needs. This was to make sure that staff were aware and meeting their needs such as fluid intake, feeding, turning, and observations to prevent falls. We also made the home aware of some areas of medication administration and recording, which must be improved so that there is assurance that residents receive their medicines as prescribed. Although there were some improvements relating to activities and outings, these must be built on and an individual activities planner put in place for all residents, relating to their preferred individual activities. The records must be kept up to date and show refusals and any alternatives offered. We were told that there was a planned total refurbishment due to take place over the next financial year, which was very positive news. However for there needed to be a repairs, renewal and maintenance plan in place and the registered persons must continue the improvements already identified, in a timely manner. Examples were the need for additional nursing profile beds and comfortable armchairs or recliner chairs for very frail and immobile residents. A comment from a relative reflected the need for this improvement, the place especially the rooms need a bit of a makeover and they needed more staff. The home manager must keep staffing levels under review and make sure that there are sufficient staff to meet the needs of all residents accommodated. We received comments about what home could do better, such as, sometimes appears short staffed, at times people need more attention and more quickly. The person accompanying us with personal experience of care services reported comments from relatives, she felt the food was ok but was usually lukewarm by the time it reached his room. She also told me she was unhappy when dad had a fall last year that she hadn’t been informed straight away. She did go on to say that she had spoken to staff since and that in the main if her dad falls she is contacted immediately but added that it does depend on the member of staff on duty at the time. Whilst I was with the family they buzzed for help as X needed to go to the loo. No one came even by the time I had left the room and the grandson had to try to get his granddad down the corridor to the toilet (there are no en-suites) by which time it was too late. There were a number of areas relating to health & safety and infection control, which also required improvement. We noted that not all recommendations of the PCTs infection control audit at Saltwells House, in March 2008, had been Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 9 put in place. Examples were cleanliness of suction equipment, though not all were in use. Also we saw showerheads touching the floor in a number of showering facilities, which could become contaminated, and would not safeguard residents from risks of infection. 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. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 6 Quality in this outcome area is adequate. 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 people who come to the home from hospital requiring intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were copies of the home’s corporate statement of purpose and service user guide available in reception and we noted that there were welcome packs, containing information, in some bedrooms. We were that the documents could be provided in alternative large print, easy read or pictorial formats, which would improve access for residents and others with sensory or other disabilities such as dementia, at request. These documents also needed to be updated. Examples were that they contained information relating to the previous registered manager who had left for promotion within the organisation. There were also some omissions for example there was no information about the fees Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 12 charged at this home. This meant that people might not have full information to assist them to make decisions about moving into the home. During the inspection visits we saw a nurse from the PCT undertaking assessments of residents dependency levels for reimbursement of fees for care provided by registered nurses. We looked at a sample of new residents case files and requested that the unit manager provide us with all documents relating to each person. We noted that with the exception of Saltwells House, the resident’s needs had been assessed prior to them coming to live at the home. The 30 beds at Saltwells House were block purchased by Dudley PCT, called step-down beds and 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. The home had an agreed admission criteria, however the PCT controlled admissions into these beds. This potentially posed problems with information and abilities to make sure there were appropriate staffing levels in relation to residents care needs dependency levels. There was some evidence that not all people had been suitable for Saltwells House due to their medical conditions. Physiotherapists and Occupational Therapists were available to assist residents Monday to Friday. We were told that a Doctor from the hospital also visited residents at Saltwells House most days. During discussions staff highlighted that lack of training in “intermediate care The sample of care records still did not include details about what residents could do and 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. There did not seem to be any close liaison between the staff, occupational therapists and physiotherapists. For example we noted one resident, with very poor nutritional and fluid intake, who had been sat out of bed, unable to move from the chair unassisted, without any access to a drink nearby, and a fluid chart, with minimal entries of drinks. We discussed this persons care with the home manager, who acknowledged that the fluid charts did not demonstrate adequate nutrition but told us that the physiotherapist had transferred the resident from bed to the chair and had not placed drinks within easy reach. Whilst we accepted this explanation we had observed staff going into the residents room and whoever was responsible the result for the resident was likelihood of inadequate fluid intake. The poor food and fluid intake had been the reason for this persons hospital admission. Staff also had limited awareness of the Occupational Therapists and Physiotherapists treatment plans and regimes undertaken with residents. This meant that staff did not have good awareness of their role to continue supporting the treatment plans with residents when the therapists were not available. A relative told us that they had expected more support for the resident, for example with the frequency and distance that they should be walking to improve mobility. The comment Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 13 was that the person was only practicing when they visited and were able to encourage, assist and support them. The home used QUEST, care documentation that the organisation had introduced. This provided residents with a comprehensive assessment, which identified their needs and any associated risks and formed a useful development for care planning and risk management. The majority of pre admission assessments contained comprehensive information, though there were some anomalies, such as inaccurate records of medication regimes. From the sample of records examined, an example was that the dosage of Methotrexate and instruction for frequency of Folic Acid did not correspond with the MAR (Medication Administration) sheet used for medication administration. We discussed the anomaly with the nurse, who acknowledged the recording error in the assessment documentation and confirmed the correct dosage was given according to the MAR sheet. There was also no consistent evidence of the active involvement of residents or their representatives, such as signatures, which would demonstrate good practice. From the sample of care files examined we noted that a number of residents had deteriorated and the comprehensive dependency assessments and scores on admission had been reviewed, with referrals to other appropriate healthcare professionals demonstrating good practice. We noted that the manager was taking action to have one person with very challenging behaviour reassessed to make sure they could receive the support they needed and that they did not pose undue risks to other residents living in the house. We saw recorded evidence of formal reviews taking place, initiated by the home and involving the resident, their representative, and outside agencies or advocates. During discussions with individual unit managers, they could not show us evidence as to how they monitored or revised staffing levels in accordance with residents occupancy and dependency levels. This meant that staffing levels may not be adjusted to meet residents changing and in some instances increasing 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 had unacceptable waits for attention. Windmill House and Primrose House provide care to people with early and late stages of dementia and it was positive that the majority of staff on these units had received some dementia care training. The recently appointed home manager, a RMN told us she had previously used dementia care mapping and was keen to implement initiatives to improve staff knowledge and awareness of dementia and introduce good practice initiatives to these houses. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is adequate. Care planning is adequate to identify peoples needs and provides staff with sufficient instructions to meet residents needs and generally there is assurance that people’s needs will be met. The arrangements for administration of medication ensure residents receive their prescribed medicines most of the time, which means that risks to their health and well being is minimised. Residents are generally treated with respect and their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes AQAA submitted to the CSCI identified what the previous manager considered the home does well, All residents have comprehensive personal care plans individual to their identified needs. We have a comprehensive suite of Policies and Procedures and the Royal Marsden Manual of Clinical Procedures. There are company specialists both regionally and nationally who Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 15 can be consulted for advice and support at any time. Self-care is encouraged. Any pressure ulcers are recorded. The information is collated within BUPA Care Homes and the information is used to identify trends and inform the purchase of appropriate equipment. All residents have a nutritional screen using the MUST nutritional screening tool. Every resident is registered with a General Practitioner of their choice (within the constraints of access to G.P.s). The recently updated Medication policy meets the criteria of the National Minimum Standards and the guidance from the Nursing & Midwifery Council and the Royal Pharmaceutical Society. Privacy and Dignity feature highly in BUPA Care Homes customer service programme, Personal Best. We looked at a sample of residents care records in each of the 4 Houses. There were variances in how well the healthcare screening tools, risk assessments and care planning were implemented, monitored and maintained. All houses had a number of residents with complex needs and a number of people needing to be nursed entirely in bed. Some of these people were not being cared for on a nursing profile beds. The manager told us additional nursing profile beds were on order but acknowledged that there were insufficient of these beds for all residents being nursed in bed. We noted that all residents on each of the Houses had a plan of care and risk assessments, which generally identified their needs. Some examples were that a care plan for a resident living at Windmill house gave staff detailed guidance about how to communicate with her by face to face, speaking clearly, using simple words and closed questions. We saw evidence of referrals to other healthcare professions, for example a resident received support from the Speech and language therapists and the staff were given advice given regarding this persons poor diet and Thick and Easy was prescribed to assist with difficulty swallowing fluids. There was documentary evidence that this person was reviewed on 2/4/08 and discharged by the speech & language service, though the home was assured another referral could be made if needed. The persons relative had stated that he is quite happy with care of X We saw that another resident nursed in bed with very limited movement, poor nutrition and a high Waterlow score had a very detailed support plan in place to maintain skin integrity. This person was being nursed on a profile bed with a pressure relieving auto excel mattress and their skin was skin intact. There were a number of areas where there were shortfalls. We noted that there were residents identified with poor nutrition and care plans, which instructed that the person should be weighed on a weekly basis but this had not happened. We were told that 17 residents were being weighed on a weekly basis at Windmill House. We saw on the weekly overview record for 13/9/08 – X poorly not weighed. Other examples were a weight record showed 13/7/08 33.9 kg; 20/7/08 33.6 kg 10/8/08 too frail to be weighed; 9/9/08 refused to be weighed and an entry on 15/8/08 X being weighed weekly then frail Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 16 lately, unable to be weighed on weekly basis there was also a reference appetite remains poor. Another residents care plan indicated they were too frail to be weighed and the MUST (Malnutrition Universal Screening Tool) should be used to monitor weight on a weekly basis, but there were no records to demonstrate this had been done and the trained nurse acknowledged the omission. This meant that staff might not recognise when to seek additional medical advice and support for residents at risk of malnutrition and dehydration. We spoke to a relative who told us that they had made arrangements for someone funded by the family to come in daily to help feed the frail person, nursed in bed. An example was the fluid chart at the inspection visit recorded: between 8:00 - 200 mls tea, and 10:30 - 400 mls tea, a total of 600 mls of fluids, not given by carers. The fluid chart showed further entries at 11:00 100 mls juice and 13:00 - 200 mls offered - 50 mls taken. There were no further entries on the fluid balance chart at 18: 30, which meant that this resident might have only had a total of 750 mls, the majority given by a person employed by the family. The person accompanying us at this inspection reported, X tells me she has progressive MS. She is fed with Nutrison feed via a PEG tube and has spasticity of her limbs but in particular her legs making her virtually bed bound. She told me that today was her day in her chair. The staff alternate her days in and out of bed. X says this is because her bed has a pressure relieving mattress but her chair only has a pressure relieving cushion to protect her sacrum and bottom area. She said she would like to get out of bed every day but she thinks it is easier for the staff to do it on alternate days because she is so difficult to move each time. I did wonder why, if it is what X would prefer, she could not be out of bed every day for shorter periods each day, especially as the only pressure relief she has in her chair is a cushion on her bottom and a sheepskin chair cover. We noted that the home uses colour coded short term care plans for residents with conditions such as urinary tract infections, chest infections and cellulites, which give staff additional guidance to make sure the residents receive the additional care to recover from episodes of ill health. We were told all residents had access to community services such as chiropody, dentistry and the optician. We saw that there were risk assessments in place for the reduction of pressure ulcer development, falls, nutrition and moving and handling, which were reviewed monthly. However we noted that there were no turn charts in place for residents nursed in bed in Windmill House and the turn and fluid balance charts in place at Darby House and Primrose Houses were not appropriately completed, with instances of one chart used for several days. The nurses in charge acknowledged our findings during the visit and we also discussed these areas needing improvement with the home manager at the conclusion of the two-day visit. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 17 The person accompanying us at this inspection made the following observations in her report, I based my tour in “Darby” and was introduced to the nurse in charge. She briefly showed me the lounge area and pointed me in the direction of the rooms but had to dash off as one of the residents was terminally ill and in a lot of pain. The lady needed some morphine pain relief but the nurse explained that they were one qualified down on this unit and in such circumstances she needed to fetch a nurse from another unit to check the dose and administration of the drug. She added that sometimes she has to wait for quite a long time if the other units are busy too. We looked at this persons care and medication records, which substantiated the observations made by this person. We discussed the situation with the home manager who agreed that staffing levels would be kept under closer review. The person accompanying us at this inspection also reported the following observations and comments from relatives, told me she was unhappy when dad had a fall last year that she hadn’t been informed straight away. She did go on to say that she had spoken to staff since and that in the main if her dad falls she is contacted immediately but added that it does depend on the member of staff on duty at the time. Whilst I was with the family they buzzed for help as X needed to go to the loo. No one came even by the time I had left the room and the grandson had to try to get his granddad down the corridor to the toilet (there are no en-suites) by which time it was too late. We looked at the palliative care of a resident nursed in bed. The staff and family were receiving support from the Macmillan nurses. We were told that the home was being supported to trial the Liverpool Care Pathway for end of life care. However we were told by the nurse in charge at Darby house that people cannot go on the LCP unless their expectation of life is 24 hours involvement of the Macmillan nurses - severely deteriorating. The staff should look again at the clinical guidance for the use of the LCP for use of end of life care. The nurse in charge told us that training was still in progress but that the GP contracted to provide care was on board but pharmacy support still had to be put in place for out of hours medication stocks. We also noted that this person recently admitted to the home had a sacral pressure ulcer, 3-4. We reminded the staff that a Regulation 37 notification needed to be sent to CSCI for all serious pressure ulcers. In addition we were concerned about the number of residents admitted to the step-down beds at Saltwells House with serious pressure ulcers. The home manager collated some information during the inspection visit and we noted that there had been 11 people discharged from hospital for intermediate care since May 2008 with serious pressure ulcers. Some people had multiple pressure ulcers. For example we looked at the care of one person who was admitted to hospital from home due to self neglect, malnutrition and dehydration, admitted to Saltwells House with serious pressure ulcers on back, hip, right heel and right Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 18 ankle ranging from grade 2 to 3.8, and this person was immobile but meant to be receiving rehabilitation to return home. We saw the care of a person with type 2 diabetes was generally well managed, with very good comprehensive information relating to diet, medication, and heath care monitoring. We were told that one of the trained nurses who works part time at Darby House had completed a higher-level degree relating to diabetes, which was very positive. We discussed the services offered by the diabetic nurse specialist service in Dudley with the manager and recommended that she contacted the diabetic nurse specialist team to provide additional support, information, and appropriate specialist diabetic training for the trained nurses and care staff. There were some issues of concern; the weekly BM testing required as part of the care plan, was not always done consistently and there was no record of action taken to report results which were outside of this persons normal parameters. We saw that a BUPA medication procedure was available, for the general medication management within the service. It contained information about the control and handling of medication for residents who live permanently within the home, however there was no information about how medication was handled for residents who are staying as part of the ‘step down’ service with the Dudley Group of Hospitals. This means that staff can follow a safe written procedure for some residents but not all of the residents are safeguarded with a written procedure. We were pleased to see that there was an ‘Individual Diabetic Regime’ form available with the medication record chart for any resident with diabetes prescribed insulin. This form had been introduced following a medication error in order to prevent it happening again. This demonstrates that the service takes positive action when there is a medication error and tries to ensure it is prevented from occurring in the future. We looked at the medicine records, which were documented either with a signature for administration or with a code to explain why the medication was not administered. We saw two different forms of medication record to document administration. The first medicine record chart was for residents who live permanently at the home, which is printed by the supplying pharmacy. The second medicine chart was for residents who have been admitted from hospital as part of the ‘step down’ programme. The service continues to use the medicine chart from the hospital, and this has caused some problems for the home. For example, we saw a medicine chart that had been written using an abbreviation for a named medication and very often the charts had not been recorded accurately whilst the resident was in hospital. The medicine chart is then returned to the hospital and the home keeps a photocopy and not an original document. These issues cause concern because the home has to accept responsibility for the records kept for the residents and original records should be retained by the home. This was discussed with the manager who Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 19 agreed that changes could be made to ensure the safety of residents’ medication records. The majority of the medicine records seen for the permanent residents in three of the four units were well documented with staff signatures to record that medication had been administered to people living in the service or a code was recorded to explain why medication had not been administered. It was therefore disappointing that we saw poor medication records in the ‘step-down’ unit. We saw one example where the medicine chart had not been recorded for administration on three occasions. It was also unclear from the medicine record at which point the resident was in hospital and then transferred to the unit. However when we found out the date of admission we saw that it was one of the dates where medication had not been recorded as administered. It was therefore not clear from the records if the medication had been given. We saw further records with omissions in documentation particularly on the date of transfer from the hospital to the step down unit. This means that medication was not always recorded for administration in order to ensure the well being of people who live in the service. We saw documentation for the receipt and disposal of medication in the three permanent units, which meant that the service ensured that levels of medication were kept at a safe level. We visited one of the units at 12.20pm and saw medication being administered. However we were concerned to be told by the nurse in charge that this was still the morning administration as it had been very busy and there was nobody else available to administer medication. This means that people on this unit were at risk of not being given prescribed medication at the correct times, which could cause them harm and delays in treatment due to a lack of nursing staff. Overall storage of medication was safe and secure within all four units. Some issues were discussed with the manager. For example, the refrigerator door in one unit did not close and seal to ensure the safe storage temperature for medication, which included insulin. This means that residents may be at risk of being given medication that had not been stored at the correct temperature. The manager informed us that a new refrigerator was on order for that unit. There was evidence that the service was undertaking regular checks on people’s medication. The manager informed us that monthly checks were being done using a new BUPA check list called the ‘Quality and Compliance – BUPA Care Homes Monthly Medication Audit’ to ensure that people were being given their medication. We saw a ‘Medication Audit Plan’ dated 9/9/08 for one unit, which was stuck on a medication cupboard door. The overall score had been assessed as ‘RED’ which we were informed by the manager was not a good outcome. However the staff on the unit had completed all of the action points within an agreed timescale. This was commended as good practice. The dates of opening of medication were not always recorded which would have been Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 20 useful to ensure that checks on medication could be undertaken and ensure that they had been given as prescribed by a medical practitioner and is seen as good practice. We looked at one resident’s care plan relating to medication, which was prescribed to calm and control their behaviour. It was written as ‘Take one 5ml spoonful three times a day when required’. The medicine record documented that it had been administered on 8/9/08 at 2200 hours. The care plan seen did not document or provide details on how the person’s behaviour should be managed and at what point the medication should be administered for the benefit of the person’s health and well-being. We also looked at the daily notes for the 8/9/08 and there was nothing documented about why a calming medication had been administered. This means that the care plan and daily notes did not contain specific written information relating to medication and the specific healthcare needs of the resident. We saw that staff treated residents with respect and protecting their privacy for the majority of time during the inspection. During discussions staff demonstrated a good understanding of how to protect residents privacy and dignity. However there were a few examples where the home should consider how to improve care practices. We heard a carer in Primrose House tell a male resident he was naughty, which we discussed with the home manager and she acknowledged was not appropriate. A person with personal experience of care services for older people accompanying us also drew our attention to a situation at Darby House. She noted in her report, I was quite shocked when passing the open door of one gentleman’s room. He appeared to be quite poorly and was lying totally naked and uncovered on an airflow mattress/profiling bed. I pulled his door closed a little and a passing carer pointed out that he was always pushing his bedclothes off and did not like to wear clothes, which was “his choice”. She added he had had a stroke and also pulled his incontinence pads off. A relative going in to a room next door told me not to close the door as the staff liked to keep an eye on those too poorly to get out of bed. We revisited Darby House with the home manager and found the situation as described. The acting manager acknowledged that the situation did not maintain the persons dignity and privacy and took immediate action to rectify the situation. She assured us that she would raise the issue of poorly residents bedroom doors being left open for the convenience of staff observing them at the unit managers meeting and staff meetings. We noted that the care documentation included end of life care plans and relatives expectations but these were generally not completed on the sample of residents care records examined. One of the unit managers told us that this was a sensitive area, which was often difficult to discuss, especially with relatives of very poorly residents. Whilst we acknowledged the sensitivity of the subject, the lack of information may result in residents final wishes not being met and this may have important significance, especially for people with Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 21 strong spiritual or cultural beliefs. We recommended that staff receive training to give them the skills and confidence to discuss and record final wishes for residents end of life plans. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 22 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 adequate. There are some social opportunities for residents for some residents. Residents are encouraged and supported to maintain important relationships and friendships. There are choices of nutritional meals throughout the day and night. Some residents may not consistently receive appropriate levels of support to maintain good levels of nutrition and hydration, which may pose risks to maintenance of their health and well being This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA submitted by the previous home manager told us, We have a structured activities programme tailored to the individual needs and preferences of our residents. The home has an open visiting policy taking account of residents wishes. Residents may handle their own finances should they wish to do so. We encourage the personalisation of residents individual space with their personal belongings. A full and varied menu is available in the home. The BUPA Menu Master helps us to ensure the menu meets the nutritional needs of the residents. The evidence the home claimed it had to show what it does well was, Menu records, Personal plans, Activity records, and lifestyle care plans and Map of Life completed on admission. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 23 We noted that unfortunately not all of the evidence claimed in the AQAA could be verified. Examples were that very few map of life were completed, which would have given the staff a good insight into the holistic needs of the person. On the occasions they were completed they were done well and staff were knowledgeable about the persons background and showed more understanding of their current needs. This was particularly important for people with dementia or lack of verbal communication. We were told that the home employs 3 activity workers, however one person had only recent returned to work after and extended absence to recover from surgery. We saw some activity records but the records ceased to have entries after the end of June 2008. We were told that the managers had met with Bowling Green Residents Association who had lottery funding available, which the home could access to use on outings and invest in activity equipment. The manager told us that there were plans to continue to meet regularly with this group to make sure the home continued to use this valuable resource to the maximum benefit of the residents at living at the home. We were shown the refurbishment at Primrose house, which had made it a more stimulating environment for people with dementia. A “pub” had been created within the house, complete with bar and piano, which residents could visit with their friends and families for a drink and to socialise. We saw lots of visitors during the two-day inspection, whilst they generally felt welcomed, there were a variety of views. Some people told us staff were very busy and it also depended on the staff on duty at the time as to the level of attention and information available. Windmill House was the notable exception, where people consistently spoke warmly about the friendliness and helpfulness of staff. Though there were also comments about this House also being short of staff at times. The AQAA included the improvements the home had made over the last 12 months, such as, The introduction of the BUPA Menu Master helps us to ensure the menu meets the nutritional needs of the residents. We have started the BUPA Night Bite system to ensure that food is available 24 hours a day. We noted that it was very positive that the breakfast and main meal menu was displayed on a large board. We were also told that mid-morning and midafternoon there were snacks of fruit and or cakes. Teatime was at approximately 5:30pm and there was a choice of sandwiches or hot snacks. Suppertime was from 8 p.m. when milky drinks were offered. We noted the new positive improvement night bite menu, these were meals and snacks available throughout the night, which could be pre-ordered for residents who Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 24 do not sleep well. There were two residents at Windmill House who made particular use of this new initiative. We saw that lunch on one day was a choice between steak and kidney pie with vegetables or chicken curry. We were told that where needed meals were fortified with extra cream and oils. We noted on Windmill House there were 5 liquidised diets and 9 puréed diets needed for residents and a large number of residents required to be fed, assisted or supervised to eat. We noted that adapted crockery and cutlery was provided, which was positive to aid independence. However our observations were that staff did not have sufficient time to give to each person requiring assistance with feeding or to be fed. We asked staff if any consideration had been given to staggering mealtimes, we were told this had not been considered as an option but if necessary nurses staggered their meal breaks to give additional assistance. The majority of mealtimes observed were hectic and disorganised, with large numbers of residents needing individual support to be fed, or assistance, support or encouragement to eat. Windmill have thirteen people who need assistance with eating and drinking, one care staff serves the food, another gives it out to the service users, the remaining three care staff disperse to feed service users, the trained nurse does help. Dining tables are laid and some units also had table clothes but generally the dining area is unattractive and mealtimes are not made “special”. The person with personal experience of care services accompanying us reported Lunch time was drawing near and having not being offered a lunch choice or a cup of tea I went down the corridor along to the kitchenette area just off the lounge to observe lunchtime routines and see if I could get a drink and a sandwich. She also reported that a resident commented, felt the food was ok but was usually lukewarm by the time it reached his room. She also reported her experiences about Darby House, two carers at the food trolley and observed meat pie and vegetables and mashed potato being served, all with gravy regardless. There seemed very little interaction with the residents sitting at the tables and it was very quiet. The portions looked generous but the other member of staff present was delivering each meal and then went on to feed a lady sitting in her chair. I did not like the way the plate was waved about in front of this lady, the plate resting on the carers hand whilst food was forked into her mouth. I think a small table set out in front of someone is much more stimulating and appealing. Two other members of the care staff also fed two other residents in the same way in the other area of the lounge. I didn’t think it looked very dignified. We have recommended that the home consider offering several small nourishing meals each day, at more frequent intervals than the usual mealtimes, which may also relieve the pressure on staff trying to feed residents with very poor appetites. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 25 We looked at food stocks in kitchen and noted that there were adequate supplies of branded goods such as good quality white and wholemeal bread. We were told that food was purchased through consolidated orders and there were regular deliveries of fresh vegetables, meat and groceries, they just have to ring it through. We saw evidence of fresh vegetables and fruit available, including broccoli, spouts, grapes and melons. We also saw a sample of platters of fruit sent around houses on the afternoons to encourage healthy eating. During discussions the catering staff were knowledgeable about special diets, such as, gluten free, low cholesterol, although at present there were only diabetic diets required. The catering staff told us they were providing 10 liquidised and 25 – 30 pureed meals at each mealtime. These were prepared so that each food was pureed separately and sent as separate portions to the houses. There were dishes available for separate portions to be pt on one plate. The staff were also knowledgeable about adding nutritional value to meals. The assistant cook was very enthusiastic about her role and about the quality of the service they provided in respect of food, meals, which was very positive. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 26 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. Complaints are listened to and action is taken to look into them, and there are effective systems to record investigations and outcomes. Arrangements for protecting residents are satisfactory. Policies, procedures, guidance and staff training have been well implemented in order to provide residents with good safeguards from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes AQAA stated what we do well, we have a clearly defined company complaints policy with 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 policies for dealing with allegations of abuse or neglect. Staff cannot only raise concern within the home they have access to senior staff outside the home. There are well documented procedures for reporting under POVA should the need arise. The AQAA included information about improvements in the last 12 months, stating, BUPA Care Homes has appointed a Director of Quality and Compliance and has developed a national Quality and Compliance team of experts. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 27 The home had a detailed complaints procedure, prominently displayed in each house and in the administration block. People spoken to told us that if they had any concerns they would discuss them with the Unit Manager or the Home Manager. We noted from the homes AQAA that there had been 6 complaints, 4 resolved within 28 days, and 3 were upheld from April 2007 – April 2008. We looked at the complaints log and noted that there were 5 complaints recorded since 2 May 2008. Two related to the PCTs provision of physiotherapy for Saltwells House, another related to medication involving the GP, PCT and Pharmacy provider and other was anonymous. Two remaining complaints were investigated and resolved. The home had also received 43 written compliments since January 2008. During the past 12 months, prior to May 2008, the home made 4 safeguarding referrals to the Local Authority, the lead agency and there have been 3 safeguarding investigations, as a result the home referred 2 members of staff to the POVA register, which was put in place to safeguard vulnerable people. There have been no further referrals to the POVA lists since the new home manager was appointed in May 2008. The home manager had made a further two safeguarding referrals relating to people who were admitted to the home from hospital with serious pressure ulcers. We were told of the homes plans to improve in the next 12 months. There were plans to introduce Personal Best Training to ensure staff continued to develop with a personal service to residents, relatives and visitors. The home manager also planned to make sure all new staff were made aware of the complaints and safeguarding procedures as part of their induction. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 28 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, 24,26 Quality in this outcome area is adequate. The positive changes to the décor and furnishings are continuing and incremental improvements contribute to create a pleasant environment for residents to live in. The grounds are maintained to provide a safe and interesting outdoor environment for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We toured each of the four houses and noted that they are generally pleasantly decorated, clean and kept tidy. All houses had same layout with lounge, dining area, kitchenette, office, 30 single rooms and sluice, bathrooms and storage areas and a separate staff team. All house had a mix of showers, assisted baths and some raised WCs and some standard but all with grab rails. Some were larger than others although all were a fair size. The lounges were roughly divided into three with conservatory off one and division archways from one section to another. This encouraged smaller sitting areas rather than the traditional chairs around the wall model in one large room. All houses could Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 29 only be entered via a doorbell or keypad and all had hand gel dispensers for visitors by the entrance to the house, encouraging good hand hygiene. We asked the acting manager whether the ‘home has an ongoing refurbishment programme’ as stated in the AQAA. We were told there was no documented programme, just that the site is to have a complete refurbishment next year. Primrose house was decorated to provide sensory stimulation to people with dementia, with paintings of shop fronts, canals and trees. A “pub” with bar and piano had also been created in this house. We saw some residents living at Primrose and Windmill houses walking freely about. During the tour we noted that the nurse did not knock the bedroom door before entering and the person in the room could be observed in a state of undress. We stressed to the nurse the importance of maintaining and promoting peoples rights to privacy and dignity at all times. We noted that people were encouraged bring in personal possessions from their own home and many bedrooms were decorated with photographs, pictures and smaller items of furniture. The person accompanying us at this inspection reported the following impression about the environment at Darby house, There were tables set with cutlery in the top right hand corner in readiness for lunch but they were squashed in a dark corner and the layout and atmosphere was very dull with no linen. I have to say the area around these tables did seem restricted and as the residents were invited or brought to the table it was clear that a couple of ladies in Docherty type chairs (very highly padded with a high back and built in footrest) would not be able to join the others at the dining table even if they wanted to as there wasn’t enough room and they certainly weren’t asked. Decoratively Darby needs some TLC but I understand that the home is due for a phased refurbishment shortly. The home had a variety of aids and adaptations such as grab rails assisted baths and a shower available for dependent residents. There were a small number of nursing profile, height adjustable beds, however there were insufficient for the high number of very frail and dependent residents. The manager told us that she had ordered nine additional nursing profile beds. We were told that providing furniture and equipment was problematic for Saltwells House where beds were block purchased by the PCT but new equipment was not funded. During this inspection we noted that there were very frail people placed in unsuitable beds and high backed chairs, which were uncomfortable for them and not well suited to their needs. We also noted there were excessive gaps on two residents bedrails. The nurse charge told us extensions were not in place to remedy gaps, though they were on order they had not been delivered. We noted that the large main kitchen was well organised and well equipped. We looked at a sample of the records in the kitchen. We were told that the Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 30 menu sheets were sent to kitchen from each house so that the catering staff have a good idea as to how much they should supply. The menu sheets were also kept as a record of what choices residents made. There were very comprehensive records in respect of food safety, which were well maintained. We noted the home had complaint forms relating to deliveries, and the records demonstrated that these have been used to complain about quality of delivered goods, whenever necessary. The home had a large Laundry situated in main building, which was well equipped. We were told that the home takes responsibility for labelling residents clothing, and that there was very few problems with the clothing going missing. We saw that there were different trolleys for transferring used or soiled linen and red bags disolvo sacks for any infected linen. The laundry assistants returned clean laundry to the houses in four large blue trolleys. However we noted that two trolleys were cracked, one quite badly at bottom. This compromised good hygiene and safety standards. We raised this issue with the home manager who told us that she was hoping to get new ones with a new contract from supply of cleaning materials. We saw that there was 1 full time member of staff and number of other part time staff; sufficient to run laundry between 7am and 3pm. Laundry staff told us that they had received infection control training in July 2008. We also noted that there were laundry handling procedures available in laundry. The laundry staff told us that the ventilation in the laundry was not adequate, as the extractor fan did not work properly. There were two floor standing fans but we were told did not help much with ventilation from laundry side where it was excessively hot with all washers running. The home had generally satisfactory infection control procedures in place to safeguard people from the risk of cross infection. We noted that in all houses there was liquid soap, paper towels available in all bathrooms, WCs and kitchens, with notices giving people guidance for effective hand washing techniques. We noted the following areas, which needed to be improved, though this was not an exhaustive list: Saltwells House - WC/shower 32 – shower head was touching the floor and there were 4 tiles missing from wall Wheelchairs were reasonably clean but records of cleaning (should be done daily scoring to printed record) were inconsistently completed. Saltwells Kitchen - Fridge temperatures showed that fridge running at well above acceptable temperatures for week (between 1c - 13c degrees. Temperature on thermometer in fridge was 13c). Cracked shelf in fridge needs replacing. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 31 Microwave had some chips to paintwork and would benefit from replacement. Bathroom 32 – floor level shower, showerhead reaches floor, clip broken. Extractor fan not working- talcum powder on floor, some staining on floor around shower area. Malodour in corridor around bedrooms 24/23 – seemed to be emanating from 23 WC 23 extractor fan was not working. One of the TVs in the lounge was working off portable aerial with very poor reception. The oxygen facemasks were stated to be changed weekly but this was not recorded. Treatment room – suction machine, told not currently in use but tube not stored separately Windmill House Bathroom 32 - floor level shower there was a gap between the joint in flooring in shower and main bathroom and rough surface where adhesive had been. Extractor fan - switched off on the ceiling - when switched on not working. The Pool chair was showing some signs of carrions and rust, with discolouration around frame. Suction Machine, though told not currently in use, the tube was not stored separately and there was black detritus within the tube. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 32 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): Quality in this outcome area is adequate. The home has well trained staff, though residents cannot always be assured there are at all times sufficient numbers of staff to meet their needs. Recruitment and selection procedures are robust and safeguard residents. The organisation demonstrates a strong commitment to staff training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA submitted by the previous manager stated, We maintain the correct numbers of staff agreed with the inspectorate and taking account of the individual needs of the residents. We perform appropriate CRB, POVA and NMC PIN checks for staff. There is a training matrix specific to the home that identifies the training requirements of the staff. We were unable to verify the accuracy of all of the positive practices claimed in the homes AQAA. The staffing levels in place to meet all residents needs were questionable as highlighted though the previous sections of this report. There were approximately 117 residents accommodated, with a variety of dependency levels, complex and diverse needs over the two-day inspection. We saw and heard about people waiting for attention, especially pain relieving medication, assistance with feeding and to be taken to the toilet. The dependencies fluctuate considerably at each house; most markedly at Saltwells house and we were not shown dependency tools, which linked to staffing levels to allow the home to respond in times of increased need. We were told that the Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 33 dependency was very heavy at Saltwells house and there were people in other houses requiring end of life care and close others needing monitoring. The staffing rotas both in terms of numbers and stability did not demonstrate the managers regularly monitored residents dependencies and occupancy levels and reviewed / revised staffing levels, with appropriate adjustments made. We were told that the home was experiencing difficulties retaining and recruiting experienced staff, especially trained nurses. The homes AQAA included the information that 29 staff had left the homes employ in the 12month period up to April 2008. Some staff told us they struggled to meet peoples needs and staff morale was low. The recently recruited manager told us that she wanted to move Primrose House forward, and was trying to recruit a new unit manager, without success. She stated she had received only two applications, one from an internal applicant and one from an external applicant. We were told that Primrose House was staffed with the trained nurse on a shift-by-shift basis with the unit manager from Windmill House providing management overview. We recommended that consideration should be given to a system, that in addition to the named nurse and key worker, named staff be allocated on a daily basis to provide care for the most dependent residents requiring frequent attention, for example fluids, feeding, turning, close monitoring. The person accompanying us reported, I have to say that whilst I witnessed some functional interactions between staff and residents in Darby, I didn’t witness any of the normal banter and teasing or kindly gestures I have seen so often in other homes neither did I find that Darby held the warm homely atmosphere one so often experiences and whilst I don’t expect a banner waving “welcome” when I arrived, with the exception of the unit manager not one member of staff enquired whether I needed any assistance or chatted with me. I would not be very happy if I were a relative having a look around. I found Darby to have quite a dour and depressing atmosphere. I spoke with 8 residents who were able to express an opinion all of whom were in their own rooms and I did not hear anything to confirm that they were involved in a positive way in the way they spent their day or offered opportunities to make choices. …. I was greeted and spoken to by three staff as soon as I walked in to Windmill. I was also offered lunch and a cup of tea. We looked at a sample of staff personnel records, which demonstrated that recruitment was conducted in a rigorous and safe manner, which safeguards residents. All staff files examined had appropriate checks such as Protection of Vulnerable Adults checks; Criminal records disclosures, satisfactory written references and validation of qualifications, including the trained nurses PIN. We noted all new staff had been given an appropriate induction period and there was a demonstrated commitment to staff training and development. We Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 34 noted that there were 48 of the 63 permanent care staff with an NVQ level 2 care award or above. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 35 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 38 Quality in this outcome area is Good. New management arrangements, demonstrate that the home is well managed and has effective leadership, giving assurance that the health and safety of people who live at the home will be safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This home had a new Home Manager from April 2007 having been without a permanent manager since November 2006. This person was a registered nurse, with considerable experience at managerial levels within the NHS, private hospitals and has been a home manager at another BUPA home for more than three years. However she was promoted within the organisation and another new Home Manager was appointed in May 2008. Heather Hunter, the new Home Manager has an RMN background, she has had extensive nursing Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 36 experience, and she had previously been a registered manager and regional manager in another national organisation. We saw evidence that she had training and experience with dementia care mapping. The Manager told us that her application to be the registered Manager of this home with the Commission for Social Care Inspection (CSCI) would be sent to CSCI as soon as she could arrange an appointment for the CRB checks in the Birmingham office. We were told the Manager had the support of an Area Manager and within the home a new deputy manager was appointed in August 2008. Three of the four houses had a Unit Manager, as previously identified there was a vacancy for a Unit manager at Primrose house, providing care for up to 30 people with late stages of dementia. We were told that the home had a quality plan, which reviewed all areas of the home at least annually. The home manager conducted monthly audits of the incidence of pressure sores and care plans and quarterly audits of accidents and complaints. She had introduced new improved medication audits. Unit manager meetings and staff meetings were held and annual resident surveys are undertaken, though relatives and stakeholder surveys were still to be introduced. We noted the following information recorded from Unit Managers meeting dated 12/08/08 – Medication audits two trained staff as mistakes on admission are still happening. Care plan audits are complete but action plans are still outstanding for several audits done in July 2008. This demonstrated that the home was striving to improve and with the new manager and deputy manager in place quality monitoring will achieve improved care for residents living at the home. We noted that there were secure facilities for the temporary safe keeping of residents’ personal money and valuables. Written records were available for all transactions with two signatures. Regular external audits of residents personal money in temporary safekeeping were undertaken. Residents were able to control their own finances if they preferred and were capable. We undertook a random assessment of a sample of health and safety and service maintenance records examined demonstrated that they were generally satisfactory. It was positive that the handyman recorded sling checks for all houses. There were areas, which needed some improvement. Examples were the manager told us that contract to check the hoists was 12 monthly, this was also detailed in risk assessments. Checks in compliance with LOLER regulations should be undertaken 6 monthly and weighing chairs should also be included. We were told that the handyman carried out and recorded monthly bed rail checks, included measurement of gaps. However we noted that there were at Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 37 least two sets of bedrails with excessive gaps. The nurses in charge told us that the required extensions for bedrails were on order and were awaited. We expressed our concern that waiting for essential safety equipment placed residents at potential risk of harm. We also noted that the wheelchairs daily checks on brakes, footplates, lap straps etc. were not documented consistently. The water temperature checks were being undertaken monthly, last done 28/8/07, however the written risk assessment stated weekly checks were required. There were also a number of other health & safety and infection control risk assessments, which needed to be reviewed, for example relating to showerheads, suction equipment. We noted from the most recent EHO report, from the visit on the 12/5/08 the outcome was that the home was given 5 star rating. There were only three issues identified and all had been resolved. We saw that were good statutory training opportunities for fire safety training, moving and handling, infection control, the protection of vulnerable adults, first aid and health and safety. An example was that all six catering staff had certificates for food hygiene received in March 2008. We were told that the cook was assisting the staff with food hygiene training using distance learning books. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 38 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 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 2 X 2 X 2 STAFFING Standard No Score 27 2 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 2 2 Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 39 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 12(1) Requirement The registered persons must take action to ensure that residents with poor nutritional intake and / or weight loss are weighed or monitored using the MUST as frequently as required by their risk assessment and care plan. This will ensure that staff take required actions to promote residents health and well being. 2. OP8 12(1) The registered persons must 01/11/08 ensure that special care records such as food, fluid balance charts and turn charts are in place, with care provided appropriately recorded and monitored. This will ensure residents health and well being is maintained Timescale for action 01/11/08 3. OP9 13(2) Medicine records for the administration of medication must be accurate and document administration of medication or a DS0000004886.V372000.R01.S.doc 01/11/08 Netherton Green Nursing Home Version 5.2 Page 40 reason for not administering the medication in order to ensure that the people who use the service are safeguarded. 4. OP9 13(2) 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. The registered persons must ensure that the organisation responds swiftly to purchase orders for essential equipment such as extensions for bedrails to reduce excessive gaps. This is to safeguard residents from risks of harm. The registered persons take action to provide all residents with equipment that is suitable to meet their needs, such as nursing profile beds, comfortable chairs. This is to promote residents health and well being and minimise risks of harm The registered persons must put in place robust monitoring systems and take action to ensure high standards of infection control and that all equipment is appropriately maintained. This is to protect from residents are from risks of cross infection 01/11/08 5. OP38 13(4)© 01/11/08 6. OP38 13(4) 01/12/08 7. OP38 13(4) 01/11/08 Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 41 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. OP1 Refer to Standard 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 this home; and this should contain information about fees be easy to read and understand for people needing to use the service We strongly recommended that BM testing is consistently undertaken as directed by the care plan and a record of action taken to report results outside the persons normal parameters be maintained. It is recommended that the services offered by the diabetic nurse specialist service in Dudley be contacted to provide additional support, information, and appropriate specialist diabetic training for the trained nurses and care staff. The medicine policy should be reviewed and updated in order to ensure it is specific to the service, particularly with regard to the ‘step down’ arrangements to ensure that the health and welfare of residents taking medication are safeguarded. It is recommended that there is a documented protocol available which describes the care to be given to residents who could become agitated or aggressive. This must include details for the administration of medication prescribed ‘when required’ for behaviour management. It is recommended that the consideration be given to offering several small nourishing meals each day at more frequent intervals than the usual mealtimes, which may also relieve the pressure on staff trying to feed residents with very poor appetites. A review of the suitability of equipment including beds and footstools should be undertaken. DS0000004886.V372000.R01.S.doc Version 5.2 Page 42 2. OP8 3. OP8 4. OP9 5. OP9 6. OP15 7. OP22 Netherton Green Nursing Home 8. OP36 The registered person should ensure that staff are appropriately supervised on at least 6 occasions each year. Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 43 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Netherton Green Nursing Home DS0000004886.V372000.R01.S.doc Version 5.2 Page 44 - 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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