Inspection on 17/09/08 for Nightingales

This inspection was carried out on 17th September 2008.

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

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

Other inspections for this house

Nightingales 27/09/07

Nightingales 31/07/06

Nightingales 20/02/06

Nightingales 04/08/05

Nightingales 06/01/05

Nightingales 20/05/04

Nightingales 28/01/04

Nightingales 30/09/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/03/2009.

CARE HOMES FOR OLDER PEOPLE Nightingales 34 Florence Road Wylde Green Sutton Coldfield West Midlands B73 5NG Lead Inspector Tina Smith Key Unannounced Inspection 09:15 17th and 18 September 2008 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 Nightingales DS0000017015.V371894.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. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nightingales Address 34 Florence Road Wylde Green Sutton Coldfield West Midlands B73 5NG 0121 350 0243 0121 350 1135 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.tuskhome.co.uk Tuskholme Limited Mrs Gayle Goodhead Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Nightingales DS0000017015.V371894.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 Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) 13 The maximum number of service users who can be accommodated is: 13 27th September 2007 Date of last inspection Brief Description of the Service: Nightingales is a family run home that provides personal care for thirteen older people. Located in a residential area, the home is near local shops and public transport to Birmingham to Sutton Coldfield. There are ten bedrooms in the Victorian house; three are double rooms. The top floor is used as an office and for staff. On the ground floor there are bedrooms, a large lounge, a laundry room, kitchen and a conservatory/dining area. There is a stair lift for accommodation on the first floor and some steps and there are stairs to the second floor. This means that people with limited mobility could not be accommodated on the second floor. Some of the rooms have ensuite facilities, and there are communal toilet and assisted bathing facilities on two floors. Up to 5 people from the community come to the home for day care, and food is prepared in the home for a local meal delivery service. Fees range from £371.50 to £422 per week. Extra charges apply to: hairdressing, chiropody, outside entertainment, newspapers, periodicals and some special diets. The fee information applied at the time of our visit and up to date information should be sought from the management. Fees are displayed in the Service User Guide on the notice board in the entrance hall. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience excellent adequate outcomes. Our inspections focus on the outcomes for people who live in the home and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, national minimum standards of practice, and on aspects of service provision that need further development. Before the fieldwork visit took place a range of information was gathered from the last inspection, surveys from people in the home, their relatives and staff, things the home and others told us about, and a questionnaire the home sent to us, called the Annual Quality Assurance Assessment or AQAA. This gave us some information about the home, staff and people who live there, improvements they have made and intend to make. Visits were made to the home by one inspector over two days, totalling 12 hours. The home did not know we were coming. On the second day further information was collected. Three people were ‘case-tracked’ to discover their experiences and outcomes of living there. This means we met or observed people and areas of the home that they use, looked at their records, medication, and equipment in detail. We checked what staff knew about them, their needs, and how care is provided. Five people who live at the home, one relative, one professional visitor and staff were spoken to. We looked around the building to make sure that it was warm, clean, comfortable and secure. We sampled a meal with people in the home. Records about running the home and managing staff were seen. There were two requirements from the last inspection. One has been met and information was collected for us to consider further action on an outstanding requirement. There was one immediate requirement after this visit to make sure people stayed safe and well. There are 3 requirements and 11 good practice recommendations made as a result of this inspection. We would like to thank people in the home, the management and staff for their cooperation and hospitality. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There is a Tuskhome webpage with information about their homes. A new care planning record, best practice tools, staff training and new aids have been introduced so that people’s conditions and needs can be assessed and managed effectively. The home is working towards the Gold Standard in end of life care, staff had training and the manager attends local NHS workshops. Improvements to the environment include redecoration, re-wiring, new radiators and use of best practice guidance on infection control. The home has also achieved a 4H award from the council for food safety. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 7 Management changed their umbrella body so that recruitment checks on staff can be quicker when new staff are needed. New systems are in place for managing people’s personal allowances, and recording incidents and accidents. Management achieved an internationally accredited quality framework, ISO 9001 from August 2006, which they have sustained. What they could do better: 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. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1-3, 5: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is information, access to advocacy and opportunity to try the home to decide if it is suitable. Needs are assessed by trained staff, but sufficient measures and equipment must be in place for admission so that needs are met and risks minimised. EVIDENCE: People and their relatives all told us they had enough information and ways to try the home before making an informed decision. People can visit for a day, or try the home’s day care over a longer period. Everyone has a 28-day trial so that they can decide if the home is suitable. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 10 Each person has a service user guide, statement of purpose, a price list and a contract with terms and conditions, in large print. Services and fees are explained, but some details need updating. The management structure has changed, as have CSCI contact details in the contract. The main service user guide referred to in the home’s information, including fire precautions and latest CSCI report, is on the notice board in the entrance hall. The information identifies which needs the home can and cannot meet. We recommend there is more detail about “mobility problems” that the home are unable to accept as many older people have impaired mobility. There are opportunities to visit the home, or to try day care over a longer period so that people can make an informed decision about whether the home is suitable. We were told that initial pre-admission assessments are archived, so we did not see them in people’s records. One person had an incomplete and insufficient assessment, but others were comprehensive. We saw that information is gathered from other professionals, the person and their family. Trained and experienced staff use this, and their own observations to assess risks and plan care. Plans are regularly reviewed and kept up to date. Contracts are signed by people or their financial representatives. One relative said, “The average age in the home is in the 90’s necessitating the involvement of friends, relatives… with all decisions relating to their care.” One person having end of life care was put in touch with an independent mental capacity advocate to help make a decision about remaining in the home or moving to a nursing home. Staff visited one case-tracked person in another care home that was unable to meet their needs, and the person then visited Nightingales. This was a planned admission, but there were insufficient measures/equipment in place to minimise a known risk of falls from the day of admission. At the time of our visit the home was full and had no vacancies. In addition to people living at Nightingales, two people were brought and collected for day care. One person told us that no alterations were received since their initial contract. We discussed this with the manager, who said that letters are written in March each year about new fees that apply from April. This is also in the contract we saw. Contracts state the room type rather than the room number, and clearly advise that people may find that their room may be changed and upgraded, and additional fees can apply. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7-10: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and care needs are monitored and reviewed when there are changes but managing falls risk and medication needs development. People need to be more involved in care planning and supported to maintain their independence. There is good access to specialist healthcare. EVIDENCE: Most people’s needs are known by their keyworkers and are being met once the home gets to know them. Health professionals visit the home, so people and staff benefit from specialist advice and healthcare support. People and relatives all told us there is good care at Nightingales and that staff are usually available when they need them. One person had been in the home for two weeks. Their needs and health changed rapidly, and we saw that their care and treatment also changed daily Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 12 as necessary. Some assessments are incomplete, for instance nutritional screening, although they have staff support to eat when they felt well enough, and a baseline body mass index is recorded. It was noted that they had stopped eating but a food and fluid diary was not introduced to carefully monitor this. Medication for an infection was queried with the pharmacist so the home knew what to expect, which is good practice. People longer in the home had their needs comprehensively assessed and regularly reviewed. Monitoring measures, aids and equipment are in place but we did not always see detailed care plan instructions about setting up, using and maintaining aids and equipment, for example washing slings, pressure mattress settings. One person scored a high risk of falls and night time confusion and anxiety but was insufficiently risk assessed, with measures not in place until three falls occurred at night. Their initial care plan only addressed day time mobility, not falls from bed. The home later misinterpreted the advice of a health specialist, and the measures we found in place that were not fully documented posed an entrapment risk to the person’s head and limbs, and lack of access to help if this occurred (see environment). An immediate requirement was made for their safety. A night time reassurance and continence plan could have been tried on admission to settle this person into the home. People need and want to be more involved in care planning. The Residents Questionnaire 2008 says that people feel that their independence has been taken away. We found, for instance that there is no one in the home selfadministering medication and did not see that this is routinely offered and assessed for safety. There is insufficient exercise, stimulation and activity for people to retain their mental and physical abilities. One person was happy with the home and their care, but had not been consulted on measures taken they were not fully happy about. They told us their family was consulted, but they did not know of the options under consideration, including chemical restraint. We did not see assessments about people’s ability to make decisions, and there are people in the home with fluctuating capacity and limited communication. Staff need care plan instructions about how and when to offer choice, modes of communication, making and recording best interest decisions when necessary. The manager said staff had training and they are working towards the Gold Standards Framework and want to develop their service in this regard. Funeral and will arrangements are in most but not all records examined. We did not see care plans about pain management, emotional needs, religious and cultural wishes and preferences for last days. Nutritional preferences and special diet, catheter care and monitoring are in care plans. For one person, specialist health advice was sought when swallowing difficulties were suspected, but the Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 13 finding suggests the person has emotional needs to prepare for end of life. We saw good practice in making a person comfortable, affectionate re-assurrance and conversation, offering choices of things they liked, checking they had drinks/liquidised food that would not make them sick, and heel protectors. We found good outcomes for several people. For instance, someone with anorexia has food supplements, an enriched diet and is now gaining weight. Pressure sores healed, and fragile skin is now protected. We saw care provided that maintains people’s privacy and dignity. All staff administer medication. They are trained, supervised and competence is checked annually by observation. We only saw one staff certificate for accredited medication training, and were told that staff need to bring them in. Some staff told us they were last trained by the pharmacist, who may not be accredited to provide this training. This needs review. People are generally protected by the medication policies and procedures, but there is no policy for homely remedies or ‘as required’ medication; pain management would make the latter a priority area for development. There are regular internal and external medication audits (see management). A monitored dose system is used and there is timely ordering of new supplies. This ensures that prescribed medication is available. Medication receipt and disposal is checked and recorded. Medicines needs to be maintained according to manufacturer instructions to ensure it is stable and effective to treat people’s conditions. There are no daily records kept about room temperatures where medication is stored. The food fridge temperature is taken for food safety, where medication is also kept. There is an appropriate trolley chained to the wall, and controlled drugs cabinet. We found eye drops that needed refrigeration in the trolley, kept too warmly. The security of medication needs review so that people in the home and the public are fully protected. The key is accessible to anyone in or visiting the home because it is kept with other keys. There is a sign on a door requiring it to be closed. We pointed this out to staff who then did not know what to do with the key, so clearly it is rarely closed. Drugs for disposal are not locked in a specific drug cupboard. Staff did not note on the pre-printed medication administration record (MAR) from the pharmacy that a controlled drug was no longer prescribed or supplied and did not take this up with the pharmacist. This was confirmed during the inspection, as it looked as if the drugs were missing. There is an appropriate Controlled Drugs Register. The MAR does not have a list of signatures, making it hard for audits to identify someone responsible if an error occurs. There were 4 missing MAR codes, indicating people may not Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 14 have had or refused medication. Accurate recording is necessary so that people’s health can be effectively monitored. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12-15: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are flexible routines, respectful care and nutritious food. Dietary and religious needs are met, and families are kept informed about people’s health and wellbeing. More activities and outings are needed for people’s mental and physical stimulation and to match their lifestyle. EVIDENCE: We saw respect and dignity maintained by staff who use people’s preferred names, show affection and anticipate people’s needs, such as a blanket if they appear to be cold. People told us that they appreciate staff having a laugh with them. We also saw someone sensitively told about a family bereavement. A visiting professional told us that “the home is like a family”. There are flexible routines, and for instance people’s medication is adjusted to the time they rise each day. Two people spend a lot of time in bed, and we saw they are frequently visited by staff and health professionals, and records show that families are kept up to date about their condition. One record of a Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 16 person isolated in their room noted the type of music liked, but their radio was not used during our visit. A relative said, “Although the staff always inform me of any problem or situation that has arisen, it might be useful if we could be kept in touch with our relatives progress…This would be useful knowledge of improvement / deterioration of medical and mental health.” People and relatives gave us mixed views about activities. One person told us, ““This is an aspect that fails badly against what I was told before I became a resident. Activities that were supposed to take place have failed badly.” A relative told us, “In view of the age group… activities are more of a visual or listening type (travelling players & musicians and occasional trips out)”. Management acknowledged a gap plan to improve this so that people are physically and mentally stimulated and have more contact with the community. A Director stepped in temporarily to arrange activities, entertainment and outings as a relative could no longer do so. Another relative now manages fund-raising. There are celebrations such as birthdays, a golden wedding anniversary, and a strawberry tea. For outings we were told that the home hires a mini-bus with a lift for wheelchairs, and recruits relatives to help when possible. We saw that there is a daily activity programme for staff to follow, including games, exercise to music and discussions about current affairs and topics. But activities were not held during our visit. We were told that the previous week there was an entertainer one day, and a game was played at someone’s request on another day. Care plans note people’s interests and preferences, but there appears insufficient support and choice to fully maintain their lifestyle. There is an open visiting policy for families and friends. A Director holds religious services in the home and arrangements can be made for people to attend services of their choice. There is guidance on the CSCI website on improving equality and diversity assessment, such as sexual orientation, that would be of benefit to people using the service. Health checks are maintained, but support with their aids and oral hygiene, for instance, is not detailed in care plans. We saw a 4 week rotational menu, had a meal with people in the home and spoke to the cook. There is a healthy diet and people told us they always or usually like the food. Each meal has a choice, including a cooked breakfast, and people can eat where they want. We saw care staff preparing a cooked tea for someone on request, who wanted to eat in the lounge. Special diets are catered for, including diabetic meals, liquidised and pureed food, and staff assist people to maintain their independence, e.g. by cutting up meat. One person confined to their room was offered appropriate food, drink and help to eat outside of mealtimes, as well as respect for food refusal. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 17 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): NMS 16 – 18: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are policies and procedures to respond to complaints and concerns but staff need to show more compassion. Legal rights are mainly respected but consent for restraint and checks on staff need to be in place for people’s protection and so that people retain full control of their lives. EVIDENCE: There is an accessible complaints procedure and we confirmed there have been no formal complaints. The process and timescales are clear. CSCI contact details are up to date, however the Ombudsman listed does not currently apply and should be removed. Funding authorities, though, also have complaints procedures that most people can use. We discussed with the manager that minor concerns resolved quickly, such as missing clothing, should be logged so that any recurring problem can be recognised and changed. People told us they know how to get help with a complaint or concern. One person said, “some members of staff are excellent in dealing with problems, some not so good.” In response to a question about whether the home respond appropriately a relative said, “…situation has never arisen! But if it did I am confident ‘ Nightingales’ would respond appropriately. The home’s own resident’s questionnaire 2008 identifies that people do not always find Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 18 that staff are compassionate enough, and management plan to address this with staff. We found from our discussions with staff that they are familiar with abuse and the home’s adult protection and whistle-blowing procedures. We examined these and they are linked to the local council protocol and notifications to CSCI, which is good practice. We were told that the home monitors the wellbeing of one person who is benefiting from their care and protection. Staff attend induction and refresher training in this area. There are recruitment checks of staff but an outstanding requirement was not fully met in checking a long-standing staff member, to ensure that people are in safe hands at all times. Management had training about the Mental Capacity Act. Directors wrote to everyone about their right to make advanced decisions. People have access to advocates and the home in many respects consult people, appropriate representatives and professionals. We did not see recorded best interest decision- making, when people are assessed as unable to make decisions for themselves. One person with fluctuating mental capacity told us they had not been consulted about their care plan and arrangements in place, but knew their family was involved. They were not aware of the restraint options under consideration which could affect their health and wellbeing. Policies need updating so that people’s legal rights, health and safety are fully protected in light of new laws, best practice and codes of practice. Some policies need to be cross referenced to the home’s adult protection procedure. The home’s restraint policy does not include the various types, such as chemical restraint (sedation) and restrictions. We did not see recorded consent or best interest decisions about bed rails or restrictions on movement used in the home to prevent people coming to harm from identified risks. Restraint without informed consent or a best interests decision may be abusive and a crime. Staff need to understand the boundaries, and people’s rights to consent need to be protected by lawful procedures, care planning processes and care plans that guide staff practice. In contrast, we did see consent in records to share and seek information with doctors, and contracts were signed appropriately by people or their financial representatives. We also saw that day to day practice also includes giving people choices, so that they retain daily control of their lives. The home helped an incapacitated person without visitors to obtain a statutory advocate to help them with an accommodation decision. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 19 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): NMS 19-22, 25, 26: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean, hygienic and people usually have the equipment they need, comfortable and homely surroundings. Appropriate action was taken to risks identified, so that the health and safety of people is protected. EVIDENCE: The home is located in a residential area near to local shops and public transport, and there is an accessible and safe garden. It is not distinguishable as a care home. There is a refurbishment plan and the home is well maintained. People are consulted and their views are acted upon. For instance, we saw in residents meeting minutes that people wanted the lounge chairs cleaned. The manager told us this concerns people’s own furniture brought into the home, and cleaning is now completed. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 20 There is an up to date maintenance schedule and we sampled servicing by contractors, and internal checks. We pointed out a few risks that were immediately addressed for people’s safety. For instance, hot water temperature checks improved from the last inspection but we found one bedroom exceeding the Health and Safety Executive safe range to protect people from scalds. We confirmed that the home had been incorrectly advised by their legal advisors about this. Missing grouting was immediately repaired in a communal bathroom. The home’s infection control measures follow best practice guidance. We saw colour-coded mops, separation of clean and soiled laundry, sufficient paper towels, liquid soap, aprons and gloves. There have been no outbreaks of contagious infection. The home is clean, tidy and smells fresh. Provision for people with sensory impairments could be improved, e.g. hearing loops in communal areas. The kitchen was clean and food supplies are well managed. The home has a 4H award from the council for good food hygiene. There are large food stocks because the home also prepare delivered meals for the community. We checked and found good records maintained for fridge and freezer temperatures and probing food for people’s health and safety. Bedrooms are personalised with people’s own possessions and there is sufficient storage space. Screens in double rooms protect people’s privacy. We saw rooms with low divan beds, and were told the Primary Care Trust (PCT) provide profiling beds and specialist equipment for people’s mobility, to prevent falls and manage pressure sores. We checked bedrails and pressure mattresses from the PCT and found they are safely set up at pressure settings they are advised about. Heel protectors are also in use. The handy person and the PCT maintain equipment, such as wheelchairs, hoists, stand aid, and bedrails where assessed to be safe by the Trust. The home does not own any bed rails. The home needs documented assessments of risks associated with necessary aids, equipment and room arrangements at times to deliver safe care. We did not always see these in case-tracked records and found some significant concerns. We did not see pressure settings for mattresses, how often slings should be washed on care plans but we did see the size of incontinence aids, hoists and sling sizes, use of stand aids, etc. There are associated risks, such as head and limb entrapment and asphyxiation from the fitting and type of bedrail, and we saw similar risks posed to one person from an upended rubber-coated mattress held in place by a bedside cabinet. Their care plan did not detail this set-up. We were told that this is routinely used in the home as an alternative if bedrails are considered unsafe by the Primary Care Trust (PCT). Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 21 It is not explained in care records who was consulted and why the person does not have access to the home’s call system in their bedroom and cannot reach help when they need it. We were told the room was re-arranged by staff, but we found the measures in place to check on them to be insufficient in light of the entrapment risks posed to them. We were told they disturbed others by constantly using the call system at night. An immediate requirement was made to ensure people’s safety in the home. Care records need to document why equipment is removed if there is an identified need, the relevant risks, and a suitable alternative must be provided. Following the inspection the PCT confirmed to the manager that their advice had been misinterpreted and the mattress should be flat on the floor, and action was taken to make this safe. There are smaller ‘crash mats’ the home could consider that will also reduce risk of people tripping, and there are government safety alerts and best practice guidance to keep care homes up to date on health and safety. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 22 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): NMS 27 – 30: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs are met by consistent and experienced staff with qualifications beyond national minimum standards. Systems need further development regarding recruitment checks, night time arrangements, training and staff supervision for safe working practices. EVIDENCE: People said they feel safe and satisfied with how their needs are met, apart from falls. There is qualified, experienced and consistent staff. Rotas take into account the needs and routines of people using the service, so that there are staff at peak periods of the day when more are needed. The Manager and other staff tend to cover for staff leave and sickness, so that people have staff familiar with their needs. The home’s survey in 2008 reported professional views that there were experienced, knowledgeable and sufficient staff who provide care with respect for people’s dignity. The AQAA told us that there are staff trained to their role in first aid, so there should be a qualified first aider on each shift to help people in an emergency. During the night there is one staff member in the home, and there are arrangements for more support if emergencies arise. Staff told us that people Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 23 are left on the floor if they fall because two staff are needed to operate the hoist – so these arrangements are not fully used and a review with staff is needed. We sampled staff records and spoke to staff. New staff have an appropriate induction to safe working practices and the home’s procedures. Staff are clear on their roles and systems in the home, know people’s needs and preferences well. They feel supported by their management and their training. Staff meetings take place quarterly. We discussed our findings with the manager, that supervision records and plans for 2009 seen do not meet national minimum standards requiring at least six sessions per year to ensure that staff are fully supported and practice appropriately. Staff files could be clearer on whether mandatory and refresher training has been attended and actions taken about this as not all training certificates were evident. Most staff are trained in safe food handling, but the AQAA told us that only half are trained in infection control and we did not see plans to address this. Staff have annual appraisals of their competence, including medication administration. Most care staff have NVQ qualifications, and there is access to training and qualifications beyond the national minimum standards. Senior carers undertake NVQ Level 3, and three staff are completing nursing qualifications, so currently there are highly trained staff in the home. There is a staff development plan so that staff understands people’s conditions and best practice guidance - including person-centred care, dementia awareness, nutritional screening, equality and diversity. This was partly formed in response to the Residents Questionnaire 2008 discussed earlier in this report. Recruitment checks improved since the last inspection for new staff to ensure they are safe to work with vulnerable people. However the manager confirmed there is no staff file for a long-standing staff member we saw assisting people with a hoist in the home, and recruitment checks have never been done. We are told they attend training, but there are no certificates, supervision or appraisal records. The manager confirmed they had misinterpreted statutory regulations. Immediate steps were taken to remedy this that included safeguarding people at the home. However an outstanding CSCI requirement was not met and we are considering further action. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 24 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): NMS 31-33, 25-38: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Nightingales has an accountable and experienced manager. People in the main benefit from the way in which the home is led and managed, and their financial interests are safeguarded. EVIDENCE: The home has a competent and experienced manager/Director who is well supported by other Directors in this family business. There is a strategic business plan. The manager keeps up to date on new law and best practice guidance, such as malnutrition and infection control and has used these to provide new tools and measures in the home. People and staff told us that Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 25 the manager is supportive and approachable, relatives have confidence in management, and we found that the home is run transparently. The AQAA was completed on time and gave us required information. Barriers to development of the service are recognised but the AQAA did not tell us how all of the barriers are being addressed, such as shortage of staff time to attend training and complete documentation. A Director said that financial and management capacity constraints reduced activities and outings available to people. This is improving by a Director playing a role. We saw that the manager undertakes shifts when necessary, and at the time of the inspection she also cooks at weekends - a second cook is being recruited. Action was taken following the last inspection to address requirements, and use was made of recommendations to develop the service and staff in order to improve outcomes for people. We discussed with the manager that they and other Directors have relied upon some erroneous professional advice or misinterpreted, and need to review their familiarity with management responsibilities that legally apply to care homes. The manager accepted accountability. The home keeps us informed, but we found through case-tracking that CSCI are not always notified of hospital admissions, pressure sores and falls. There was one incident in the home’s log book that could not be accounted for and the manager said that staff initially were confused by a new recording system. Individual needs and risks are reviewed after such events, but management also need to periodically audit all incidents, accidents and complaints to note any learning and any patterns about the running of the home and make any possible changes to prevent them arising. We note that new CSCI guidance about notifications was recently checked by a Director. Quality assurance and quality audits are shared by the manager and a Director. The manager audits care plan evaluations completed by Senior Carers, and the medication system regularly. There are periodic external audits of medication, although we found cause to query erroneous advice given to the home with the professional involved during the inspection. There are now missing medication procedures that should be formed. We asked for quality monitoring reports about people’s experience of the service, and health and safety checks. We were told that quality audit is undertaken by a Director as part of an ISO 9001 external quality award, which is good practice. We recommend CSCI guidance on Care Home Regulation 26 responsibilities is consulted as we were shown an annual ISO 9001 audit in progress but were not provided with monthly unannounced spot check reports that should be on the premises for the manager to progress. We sampled maintenance and other records and contractor certificates and found these to be up to date so that the home is safe and well maintained. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 26 Action was taken during and just after the inspection to address environmental risks found. The registered provider needs to keep up to date on safety alerts, law and best practice in health and safety, such as water temperatures, aids and equipment. There is an up to date fire risk assessment, fire drills and the home have complied with other regulators. Most policies and procedures are up to date and protect people and staff. Others we sampled will need review in light of new laws and codes of practice so that people’s rights and independence are respected and promoted. People are consulted about the running of the home and standards of care, as are visiting professionals and staff. There are resident and staff meetings, and questionnaires. Results are published with accessible charts. People benefit from a developing person-centred approach and the Charter of Rights of the home. Management listen and have a plan to improve how people are supported to retain their independence and diversity, community links, and ensure staff practice is compassionate and lawful. Staff have feedback on their performance, including people’s views, but there is insufficient supervision. There are improvements needed to human resources discussed under ‘Staffing’. The manager is improving disciplinary processes so they reach timely conclusions. A proactive approach could also be considered to plan for the home’s current and future workforce. Overall we found that people’s records are updated, secured and confidentiality is maintained. We sampled the home’s records of people’s personal allowances and found these to be well maintained and correct, with receipts. People are helped to purchase personal items and services they prefer. Appropriately signed contracts show us that people and their representatives are involved at admission. People can have confidence that their financial interests are safeguarded. Nightingales has many strengths, committed manager and Directors and the service continues to develop. We have confidence that the manager will address the findings of this inspection and continue to improve outcomes for people using their service. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 1 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 2 2 X 3 1 X X 2 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 3 2 Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 13(2) Requirement Medication policies and work practices must be reviewed and amended regarding the security, storage, administration and accuracy of recording to ensure that residents receive stable medication as prescribed, in a safe manner. New workers must have a PoVA and CRB check before they begin working in the home in order to safeguard residents (Not Met 01/10/07 and 18/09/08, further action under consideration) The registered person must ensure that unnecessary risks to people’s health or safety are identified and eliminated, in respect of equipment and arrangements preventing harm from falls, and systems to access help when needed at night. (This was received as an immediate requirement) Timescale for action 31/01/09 2. OP18 19 18/09/08 3. OP22 13(4) 19/09/08 Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP7 Good Practice Recommendations Comprehensive pre-admission assessments should be carried out so that the home can confirm whether and when people’s needs can be met. Care plans should be agreed with people and provide staff with detailed instruction, including safe use of aids, equipment or other arrangements to meet needs, promote independence and minimise risks. If care plans cannot be agreed by people due to assessed mental incapacity, best interest care decisions and their process should be recorded, in accordance with the Mental Capacity Act Code of Practice. Management should review and ensure that all staff who administer medication have accredited training. It is recommended that all occasional use medicines have supporting protocols to administer them as the doctor intended, endorsed by a clinician. Sufficient activity should be available to meet people’s needs and interests for physical and mental stimulation, as well as promoting their self esteem and community links. Mental capacity laws, regulations and Codes of Practice should be used to review policies and procedures and staff understanding so that people’s legal rights are protected, particularly regarding consent, restraint and restrictions. There should be an up to date record on the premises for each member of staff, in accordance with Schedule (4), Care Home Regulations 2001. Audits of incidents, accidents and complaints should take place periodically to identify any possible patterns and changes needed in systems, practice and the environment to prevent harm. The registered person should ensure that the employment policies and procedures adopted by the company meet national minimum standards and are put into practice. Staff records should evidence recruitment, mandatory induction and training, supervision, appraisal of competence and discipline so that people’s needs can be safely met. It is recommended that existing on-call arrangements are DS0000017015.V371894.R01.S.doc Version 5.2 Page 30 3. 4. 5. 6. OP9 OP9 OP12 OP17 7. 8. OP30 OP33 9. OP36 10. OP36 Nightingales 11. OP38 reviewed with staff in the event a second worker is needed at night so that people’s health, safety and welfare is fully met. The registered manager should ensure that CSCI are notified of matters affecting health, safety and welfare in the home in accordance with current guidance. Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 31 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 Nightingales DS0000017015.V371894.R01.S.doc Version 5.2 Page 32 - 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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