Inspection on 20/06/08 for Old Wall Cottage

This inspection was carried out on 20th June 2008.

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

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

Old Wall Cottage 06/06/07

Old Wall Cottage 13/02/07

Old Wall Cottage 14/12/05

Old Wall Cottage 09/08/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Old Wall Cottage Old Reigate Road Betchworth Surrey RH3 7DR Lead Inspector Jane Jewell Unannounced Inspection 11:30 20th June 2008 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 Old Wall Cottage DS0000064426.V365463.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. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Wall Cottage Address Old Reigate Road Betchworth Surrey RH3 7DR 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) 01737 843029 01737 845223 oldwallcottage@ehguk.com European Healthcare Group plc Vacant Care Home 43 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (20), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (32), Old age, not falling within any other category (6) Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2007 Brief Description of the Service: Old Wall Cottage is a care home providing nursing care and accommodation for forty-three older persons some of whom have dementia or a past or present mental health condition. Since May 2005 the home has been owned by European Health Care Group Ltd, which own further registered homes across the country. The home is located in a rural setting in the village of Betchworth near to Dorking Town. The home is a converted domestic dwelling set in its own grounds with entry via electronic gates. The home is presented across two first with stairs and a stair left providing access to the first floor. The second floor is currently not in use for residents, due to unsuitable access arrangements. Communal space consists of two lounges and two dinning rooms. There is a secure garden at the rear of the property which is has some level access patio areas. Resident’s accommodation consists of twenty-four single and nine double rooms. The homes literature states that it “aims to provide excellent nursing care at all times, with overall objective being that service uses live in a clean, safe and comfortable environment. The fees for residential care are currently £449.17 to £751.00 per week, depending on the services and facilities provided. Extra such as: newspapers, hairdressing, chiropody, toiletries are additional costs. Old Wall Cottage DS0000064426.V365463.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 Zero star. This means the people who use the service experience Poor quality outcomes. The information contained in this report has been comprised from an unannounced inspection undertaken over seven and a half hours and information gathered about the home. Prior to the inspection the home was asked to complete an Annual Quality Assurance Assessment. This contained only limited information and was not completed to a standard necessary to inform the commission about the home. This was fed back to the person in charge on the day of the inspection. The inspection was facilitated by the deputy manager, who has been appointed by the provider to oversea the running of the home in the absence of a registered manager. Bernard Freeman (Responsible Individual) was also present for part of the inspection and involved in the feedback of the outcomes from this inspection. The inspection involved a tour of the premises, observation, examination of records and discussion with residents and staff. There were thirty residents living at the home at the home at the time of the inspection. The focus of the inspection was to look at the experiences of life at the home for people living there. Signs of residents well-being/ill-being (terminology used for observing behaviour for people with dementia) were observed. Relatives and a health care professional were also consulted with and their views and experiences are also included in this report. The home is currently undergoing significant changes in its environment and management and staffing arrangements with a major refurbishment and renovation of the home and the reorganization of the staffing structure, which has lead to some immanent staff redundancies. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection reports. The Inspector would like to thank the residents, staff and management for their assistance and hospitality during the visit. What the service does well: The home has worked hard to ensure that there is minimum disruption to resident’s lives during the refurbishment of the home. Generally relatives spoke positively about their experiences of the home. A sample of comments: “generally really happy with the home just the odd little Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 6 thing that there are problems with”; “Family very happy with the home”; “We are very happy, my Mother given lots of personal attention and treated as an individual”. A staff member said: “atmosphere is nice”. Signs of resident wellbeing included smiling, conversing with staff and walking around freely. The health needs of residents are met with evidence of good health care promotion and regular input from other health care professionals. A relative said that the home have always sought prompt GP intervention, another relative said: “they were 10 steps ahead of me in establishing what the health problem was”. Resident’s lives are enriched by the home providing various opportunities for occupation and activities. A relative commented included: “Activities try doing all sorts of things and I am aware that the activities lady does try to encourage my mum to join in”. Links with families is valued and supported by the home. Relative’s commented: “Can just pop in at any time, very accommodating always offered refreshments” and “feel very welcome every time I visit”. The chef is enthusiastic in providing meals that residents like, with alternatives meals easily arranged if needed. A resident described their meal as “Smashing”. Residents benefit from a staff team that were observed to be enthusiastic and hard working. Comments made about staff included: “incredible very caring and they know everyone so they give individual attention”; “weekend staff not so knowledgeable and accommodating”; “do well to keep the moral of the place going with all what is going on there and they are all under so much pressure and stress, what with redundancies” and “all very pleasant, plenty of interactions although my mother does not show signs of understanding staff still make the effort to communicate with her”. The systems for resident and relative consultation is good with their views being both sought and acted upon. A relative commented: “Management since the handover has all been very good, gone out of their way to keep us informed of the changes and they are generally receptive to feedback”. What has improved since the last inspection? The home has been required since February 2007 to improve aspects of the environment, and this is partly now being addressed through the major refurbishment of the home. The refurbishment is being undertaken in two phases with phase one having now been completed. This involved the redecoration of fourteen bedrooms, renovation of two bathrooms, new management officers and level access to parts of the building. Many new policies and proceedures have been developed, based on good practices in the care of people who have dementia. This includes the intorduction of As Required medication profiles, admission booklets and a bereavement booklet for relatives. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 7 A new activities co-ordiantor has recenlty been employed who has significantly increased the range of opportunities for occuapation and stimualtion. What they could do better: There are a number of serious concerns raised regarding some outcomes for residents noted at this key inspection, these are highlighted below. This has resulted in the provider being written to, in order to secure compliance, as they have failed to provide sufficient supervision, direction and monitoring of standards at the home, in the absence of a registered manager. A referral has also been made under safeguarding adult’s guidance to social services regarding the practices which did not promote residents dignity. The home is not being managed effectively in ensuring that residents are safe and their wellbeing is protected. The home has been without a registered manager for eighteen months with various management cover provided. This has lead to an inconsistent management approach, direction and monitoring of standards at the home. The registered provider must appoint an individual to manage the care home who has the qualifications, skills and experience required to be registered in respect of the service. The home is currently unable to meet the needs of residents who have complex dementia needs and also physical needs. This is due to the restrictions of the building, inadequate staffing levels and skills. Due to concerns regarding the fitness for purpose of parts of the building, including refurbished bedrooms, the provider has been required to undertake an assessment of the premises, by an occupational therapist or a person qualified to do so in relation to the suitability of the services and facilities and that when the refurbishment is completed the accommodation provides the adaptations, specialist equipment and facilities that meet the needs of residents and the services stated in the homes statement of purpose and aims and objectives. Staffing levels must be reviewed and action taken to ensure that there is always sufficient numbers of skilled staff on duty to meet the assessed needs of residents and meet the homes statement of purpose and aims and objectives for the home. Staff have been required to undergo the specialist training in dementia care and mental health needed to ensure that they are updated in good practices in working with people who have dementia and mental health needs. There is a good programme of formal supervision and appraisals for staff, however closure supervision of staff on a daily basis must be undertaken to ensure that the poor practices noted at this inspection are improved. This is in reference to some of the homes practices, which did not promote resident’s dignity, individuality and choice at meal times and in the routines of daily living. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 8 Care plans were not always accurate, or provided the appropriate guidance for staff to follow in order to meet residents assessed needs. Staff were not always aware of the recorded assessed needs of residents and therefore not all resident assessed needs were being met. Many new practices and procedures have recently been developed, which are designed to underpin good practices in the home, however these are not always being followed by staff. This is in particular referenced to care planning, admissions processes and medication practices, this must be addressed in order to protect vulnerable people from the risk of harm. In response to the draft inspection report the responsible individual and deputy manager completed an improvement plan which clearly stated the actions they are undertaking to address the shortfalls noted in this report and demonstrated their commitment towards addressing these shortfalls promptly. 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. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 4 and 5 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective and existing residents have information available to them about what services are provided and what to expect when living at the home in order to help them make informed decisions. This information needs to more accurately reflect the range of services and facilities being offered. There is a process in place to ensure that resident’s needs are assessed prior to them entering the home. The home is currently unable to meet the needs of residents who have complex dementia and also physical needs. EVIDENCE: Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 11 There is a range of information about the home and the services and facilities it provides. This is presented in a resident’s welcome pack, which are displayed at the home and available to resident’s families or other interested parties. Welcome packs contain a statement of purpose and service user guide, a relative described this pack as “very useful”. The deputy manager had previously identified that the service user guide needs to be in a format, which would aid residents understanding. The inspection concluded that the home is currently not providing the services, facilities and meeting the aims and objectives as set out in the homes statement of purpose. For example in relation to standards of dementia care, providing person centred care and clear nursing profile systems. This was feedback to the responsible individual. Residents are provided with a written contract of terms and conditions of residency with the home. This can be used with residents and their representatives to make explicit the placement arrangements and clarify mutual expectations around rights and responsibilities. A signed copy of the contract is retained in resident’s files. There have not been any new admissions to the home since February 2008, due to the home gradually reducing the number of residents during the major refurbishment of the home. This decision was within the plan sent to the Commission as was required at the last inspection. The needs of a resident previously admitted had been assessed by the home and social services prior to them moving into the home. As part of the assessment process the deputy manager said that they spoke to health care professionals and others who know and understand the perspective resident. This was to help inform their assessment, this assessment then forms the basis of their initial care plan. The home has introduced and promotes “My home life” booklet, which is designed to create a smooth admission into the home. The main aim of which is to collate a range of information about what could be important to that individual during the admission process and highlight the actions to achieve this. This booklet is promoted as ensuring an individual admission experience, however of the booklets sampled, these contained in the most part the same information for each resident and did not provide clear guidance for staff to follow. The deputy manager agreed that the guidance provided for staff on their completion was not being followed or the contents being monitored by management to ensure that the aims of this booklet was being achieved as stated in the homes literature. The majority of residents are assessed as having high needs with at least fifteen residents who have complex dementia and also physical needs. Through observation of the daily practices, interactions between residents and staff, tour of the environment and examination of care plans it was concluded that the home is currently unable to meet the needs of residents who have Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 12 complex dementia needs and also physical needs. This is largely due to the restrictions of the building, staffing supervision, levels and skills, these issues are discussed throughout this report. A sample of comments made by relatives about their experiences of the home included: “generally really happy with the home just the odd little thing that there are problems with”; “Family very happy with the home”; “We are very happy my Mother given lots of personal attention and treated as an individual”. A staff member said: “atmosphere is nice”. Signs of resident well-being included smiling, conversing with staff and walking around freely. Residents representatives consulted with spoke of being provided with the opportunity to visit the home with their relative in advance to assess the quality, facilities and suitability of the home. All of the relatives consulted with said that they chose the home because of its location being near to them. One relative said: “Did impress me when I came to look around”. The deputy manager said that the first six weeks of occupancy is looked upon as a trial occupancy. Where social services are the placement authority it is usual practice that within this period a review be undertaken to determine whether the residents wishes to stay permanently or not. Intermediate care is not offered at the home therefore this standard is not assessed. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 13 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 and 11 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans were not always accurate, or provided the appropriate guidance for staff to follow in order to meet residents assessed needs. Staff were not always aware of the recorded assessed needs of residents and therefore not all resident assessed needs were being met. The health needs of residents are met with evidence of good health care promotion and regular input from other health care professionals, however some medication practices do not ensure that medication is being accurately administered or accounted for placing residents at potential risk. Not all of the homes practices preserve resident’s privacy and dignity. EVIDENCE: Five care plans were examined and these contained a wide range of information on the needs of residents, including, summary of needs, Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 14 challenging behaviour guidance and nutritional assessments. However care staff consulted with were not always familiar with the assessed needs of residents as recorded in their care plans. For example the nurse in charge said that care plans contained residents preferred times for going to bed yet a resident had been assisted into their bedclothes in the early afternoon, which was not their preferred routine. A staff member confirmed that this practice was part of their afternoon routine and necessary in order to have enough time to be able to assist all residents that needed help. The deputy manager spoke of having recently developed a system to involve resident’s key-workers in the development and review of care plans in order to help address this issue. There was evidence of the regular review of care plans, however significant changes in resident’s needs and preferences were not always identified through the review process, which resulted in care plans not containing all of the assessed needs of residents. Individual risk assessments are in place, which covered some of the risks faced and posed by residents, however not all areas of risk noted at the time of inspection were assessed, this with particular reference to high use of portable radiators in bedrooms. Where a potential risk had been identified the action necessary to manage or reduce the risk was not always recorded as guidance for staff to follow in order to promote residents safety. The home has been required to ensure that comprehensive written personal risk assessments are completed as part of the care planning process, which records the actions to manage or reduce identified risks. The home maintains a daily record for each resident on events and occurrences in the lives of residents. A significant example was noted whereby this record did not record the events in a resident’s life, which the nurse in charge said lead to the administration of additional medication in order to help ease the residents anxiety, and help manage their challenging behaviour. Therefore there was no evidence to confirm that the decision made by the nurse to administer additional medication was based on the prescribed instructions from the GP. Records of medical intervention showed that the home works closely with other health care professionals including GP’s, chiropodists, opticians and dentists to ensure residents receive a good range of health care intervention. A relative said that the home have always sought prompt GP intervention, another relative said: “they were 10 steps ahead of me in establishing what the health problem was”. The nurse in charge on the day of the inspection had undergone training in tissue viability and spoke knowledgeable about good practices in preventative care. They reported that there are very few incidents of tissue breakdown. None of the residents accommodated are assessed as safe to administer their own medication. Medication was stored appropriately and generally well Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 15 organised. The deputy manager spoke of undertaking a large review of all PRN (“as directed”) medication which resulted in individual “as required” profiles being developed. These gave clear guidance for when these medicines had been prescribed for the particular individual. Of the sample medication charts seen a significant example was noted whereby the individuals profile was not being followed, resulting in medicines not being administered in accordance with the GP instructions. The deputy manager agreed to ensure that this was reviewed as a matter of urgency by the GP. Poor practices were noted in the way in which a medication record had been updated which lead to confusing administration instructions and did not accurately record the history of the dosages given. A good standard of laundering clothes resulted in residents dressed appropriately, in accordance with preserving their dignity, prevailing weather and individual style. Staff consulted with showed an understanding of good practices in preserving resident’s rights to privacy and dignity and were able to give examples of how they promoted this in their everyday practices. However good practices were hindered by the constraints the building imposed, for example hair being dried in corridors as no mirrors in bedrooms or private area, no appropriate locks on bedroom doors and ill-fitting curtains. Further practices observed which did not promote residents dignity, included the naming of some items of clothing with visible marker pen and sticky tape, some chairs were named with previous residents name. The size and layout of some bedrooms does not always enable personal care to be undertaken in a dignified manor by being able to freely access the room, use moving and handling equipment. It was reported that there are eight shared bedrooms with a number provided with commodes. Although privacy curtains are provided in shared rooms, the use of commodes in shared bedrooms can not always promote a residents dignity. Staff and management spoke sensitively about the care and support provided to residents and their families when residents receive end of life care. The home have produced a very good guidance booklet for relatives on practical matters following the death of their relative. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 16 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 and 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s lives are enriched by the home providing various opportunities for occupation and activities. Links with families is valued and supported by the home. Not all of the homes practices promoted resident’s dignity, individuality and choice, with much poor practice observed during a mealtime and in the routines of daily living. EVIDENCE: There is a range of well-organised activities available. At the time of inspection a group of residents were observed actively participating in a music session. A newly appointed activities co-ordinator spoke knowledgeable about a range of activities they undertake to suite the needs and interest of residents. This included; horticultural therapy, music, one to one sessions and cooking. Relatives commended: “Activities try doing all sorts of things and I am aware that the activities lady does try to encourage my mum to join in” and “I have Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 17 never known of any outings taking place”. Discussion with staff highlighted that occassional outings have occurred, which has included a shopping trip for a resident and a visit to a local flower festival for a small group of residents. Staff said that they have use of an estate car, which can be used to take mobile residents out to appointments and outings. A relative spoke of how the home had organised for their relative to receive communion and how important this had been to their relative. Relatives commented upon how welcomed they are made to feel during their stay, this included being offered beverages or meals and staff being friendly and approachable. A sample of relative’s comments included: “Can just pop in at any time, very accommodating always offered refreshments” and “feel very welcome every time I visit”. For a few people living at the home, being able to exercising their choice was difficult due to their level of dementia. A staff member was seen to use their acquired knowledge of a person to help provide an appropriate range of choices over beverages. However it was not always clear that residents had been given choices in their daily routine. For example a group of residents remaining in lounge or reclining chairs for a significant part of the day and not being provided with the choice of sitting at dinning room tables to eat their meals. The deputy manager spoke of the individual mental capacity assessments that had recently been undertaken for each resident in order to help promote residents rights to make decisions. The meal time was observed, this is a particularly busy period with all staff observed assisting residents to eat, this included the maintenance and domestic staff. Neither of whom had received training in assisting a resident to eat and what action should be taken should the resident refuse food, become unwell or choke. A resident described their meal as “Smashing”. The meal served at inspection was presented well including pureed meals, however a staff member was observed not following good practices in the serving of pureed meals in order for it to remain appetising. The chef spoke of a large number of pureed meals they provided. It was not always clear why particular residents had been provided with pureed meals. The deputy manager agreed to review the provision of pureed meals to ensure that this was part of an assessed need. Much positive feedback was received regarding the chefs flexibility in providing alternative meals, a relative commented: “she was not able to eat so the chef made her some smoothies”. The chef spoke of developing the menus based on residents preferences and was in the process of developing a list of likes and dislikes. The chef was enthusiastic in ensuring that residents were given good quality meals that were appropriate for people who have dementia. They reported that they have not yet undertaken any specialist training in dementia. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 18 Good practices were observed in a resident being provided with a bowl of food in order for them to continue being able to walk around and eat, as they did not wish to remain seated. Staff were in the main observed providing gently support when assisting residents to eat, however they were clearly very busy and often struggled to ensure residents were given individual support. Staff members were observed helping several residents simultaneously which led to a lack of consistency in the support being provided to a resident and placed them at great risk of choking. There are two dinning rooms, one is a small dinning area pleasantly decorated and set and a further larger dinning room. However, the majority of residents were observed eating their meal from either lap tables or from reclining chairs. Concern was noted regarding this practice, as this did not promote good posture when eating or orientation/prompting of meal times namely by sitting at a table. The TV also remained on over the lunchtime, which was clearly distracting for one resident. No explanation could be provided as to why residents were not given the choice to sit at dinning room tables to eat their meals. Examples were noted whereby lap tables remained in place for the duration of the inspection. This practice prevented the resident from being able to move from the chair freely and could be considered as a form of restraint. This practice should be reviewed and an appropriate risk management strategy put into place if residents are at risk of falls if these were to be removed after each meal and drink. Staff stated there was no specialist eating equipment, such as adapted cutlery, available to help maintain residents independence. Two residents were observed to find it difficult to us standard cutlery. The kitchen is due to be relocated as part of the refurbishment of the home, the chef reported that the recommendations made by Environmental Health on their last visit have been addressed. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 19 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 and 18 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is an effective complaints system with evidence that relatives feel that their views are listened to and acted upon. Not all of the homes practices offered adequate protection to residents from the risk of abuse. EVIDENCE: There is an accessible complaints procedure for residents, their representatives, and staff to follow should they be unhappy with any aspect of the service. Relatives consulted with said that they felt able to share any concerns they had with staff. Two relatives spoke of raising minor issues with the home and felt that these had been addressed or were in the process of being addressed. There has been one complaint received by the commission in the last twelve months, which was forwarded onto the home for investigation. The commission was satisfied that the complaint had been managed effectively by the home. Staff consulted with showed some understanding of their roles and responsibilities under safeguarding adult’s guidelines and said that they had undertaken protection of vulnerable adults (POVA) training. As a result of the number of shortfalls in practices noted at this inspection relating to the Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 20 residents dignity not being preserved this information was forwarded onto social services under safeguarding adult’s guidelines. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 24 25 and 26 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean environment, however the premises are currently not fit for purpose and do not enable the home to meet the aims and objectives of the service as stated in the homes statement of purpose and homes registration. EVIDENCE: The premises consist of a converted domestic dwelling, which has been gradually extended by the previous owners. A relative said about the environment: “fine its not beautiful but is realistic”. The home is presented across two floors with three bedrooms located on the first floor, these have now been decommissioned due to their difficult access arrangements and are instead planned as office space. The home has been required since February 2007 to improve aspects of the environment and this is being addressed Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 22 through a major refurbishment of the home. Phase one of this programme has been completed. This has involved the redecoration of a fourteen bedroom wing, creation of a wet room and providing level access to parts of the building. Concern was noted by the inspector as to the suitability of some the redecorated rooms, as due to their sizes and layout restricted easy access around the room in order to provide personal care in a dignified and safe manner. There were several indications that this wing had not been thoroughly assessed either by management or an occupational therapist before being recommissioned and occupied by residents to ensure its fitness for purpose. This is with particular reference to the size and layout of bedrooms, call bell accessibility, décor and furniture. The deputy manager said that they were aware of work being undertaken to add appropriate orientation prompts along the corridor to make it look less clinical. Phase two of the refurbishment programme was reported to be starting immanently, this involves amongst other things, the decommissioning of four bedrooms and relocation of the laundry and kitchen. There was lots of information located around the home about what building works were planed to be being undertaken. All relatives consulted with said that they were kept regularly informed of developments and had been invited to meetings to discuss any concerns that they had. All felt that the building works to date had not caused any undue stress to their relatives. A staff member said in response to the impact on residents of the building works said “lot going on at the moment it can be very stressful for some”. A staff member also said “A lot of building works and a lot of the long term staff are struggling with this, no one knows quite what is happening if it comes off it will be smashing”. There was evidence that resident’s bedrooms had been personalised and all were observed to be clean. An example was noted whereby the curtains in a bedroom did not easily cover all of the window which looked out into the car park. Standards of bedding was variable with some observed to be very poor. Sheepskins liners used in reclining chairs to help in the prevention of tissue breakdown were observed to be threadbare in parts. The size of one of the bedrooms did not facilitate for any additional furniture other than a bed and commode. It has been required since February 2007 that bedrooms are provide with adequate furniture, bedding, and other furnishings including curtains and floor coverings and equipment suitable to meet the needs of service users. Therefore it was assessed that this remains outstanding and must be addressed as a matter of priority. The deputy manager said that some new bedding had been ordered and some had been delivered. None of the bedroom doors had suitable locks fitted which enabled residents to lock their doors when it is not being occupied or from the inside to afford privacy but which enable emergency access from the outside. There were currently no plans within the refurbishment phase to undertake this work. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 23 Communal space is spacious and consists of two lounges and two dinning rooms. Access to the garden is via some steps from one of the lounges and level access through the other lounge. The garden is secure with patio areas that have numerous seating arrangements. There is a steep bank raising from the patio area which meant that residents would not be able to access the garden unsupervised. A small section of the patio area is used by the activities coordinator for horticultural therapy. During the refurbishment of the home much of the patio areas are used to store old furniture ready for disposal. The deputy manager said that this would be removed in the near future. Level access has been provided to some parts of the building and phase two of the refurbishment is planned to address this further, access to some ground floor bedrooms will remain through small corridors and steps. Good systems are in place for the control of infection and all staff consulted with said that they had undertaken training in infection control. Staff were observed to be working in ways that helped to minimise the risk of infection, by wearing disposal protective clothing when required. Phase one saw the removal of sluicing facilities; this will be rebuilt as part of the second refurbishment phase. In the mean time the deputy manager agreed to monitor practices to ensure that they minimised risks of infection during the handling of commodes without being able to use a sluicing facility. Much equipment was evident around the home to support residents mobility and independence, this included raised toilet seats, walking aids, hoists, ramps, grab rails, pressure relieving mattresses and some height adjustable beds and hoists. Lack of storage space on the ground floor meant that hoists were stored in bathrooms and toilets, which were being used by residents presenting a potential hazard. Information sent to the Commission does not show any plan to address storage arrangements. Fitted throughout the home are call points, which enable assistance to be summoned when pressed. These consist of boxes, which are portable or can be stored on the wall. It was questioned as to the suitability of the call bell system as once attached to the wall these were not always accessible from the main living area (the bed). The inspector was informed that the boxes would be removed from the wall and placed next to residents in bed, however it was noted that this had not occurred for a resident who was bed bound. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from a staff team that were observed to be enthusiastic and hard working, however there must be sufficient staff on duty to meet the assessed needs of residents in a safe and dignified manner. Staff are not being adequately monitored and supervised by an experienced manager, nurse or senior care worker who has the experience and competencies to ensure care plans, good practice guidance and the homes policies and procedures are followed and translated into good practices that protects vulnerable people from the risk of harm. Robust recruitment practices ensures that staff are suitable vetted. EVIDENCE: A sample of comments made about staff included : “Staffing incredible very caring and they know everyone so they give individual attention”; “weekend staff not so knowledgeable and accommodating”; “do well to keep the moral of the place going with all what is going on there and they are all under so much pressure and stress what with redundancies”; “very friendly you can see that they are under a great deal of pressure with staff leaving” and “all Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 25 very pleasant, plenty of interactions although my mother does not show signs of understanding staff still make the effort to communicate with her”. Staff consulted with felt that there was not always sufficient staff on duty for them to be able to undertake their role in a timely manor. A relative commented: “staffing levels they could always do with more but staff do their best”. Many good examples were observed of positive interactions between residents and staff, with many signs of wellbeing noted, this included recognising staff, smiling, communicating via a writing board, relaxed body language and touching. Some poor examples were also noted which in the main related to insufficient staffing levels and skills as previously noted in standards 14 & 15. This is in relation to meal times and daily routines. It was therefore concluded that the number of care staff working in the home, was not sufficient to meet the assessed needs of the residents accommodated. It was discussed that staffing must be provided at a level that is determined by the physical and mental dependency of residents, the layout of the building and events and activities planned and not based on a ratio of staff to service users. This was fedback to the provider and it has been required that staffing levels be reviewed and action taken to ensure that there is always sufficient numbers of skilled staff on duty to meet the assessed needs of residents and meet the homes statement of purpose and aims and objectives for the home. The deputy manager reported that they are currently trying to create further opportunities for staff to undertaken National Vocational Qualifications, as currently very few staff member have achieved this training. Through the examination of training records and discussion with staff confirmed that staff have undertaken the mandatory training needed to work safely with residents, however had not undertaken specialist training in the care of people who have dementia or mental health. (which are the homes category of registration). This has now been required in order to ensure that staff are updated in good care practices in the care of people who have dementia and mental health and be able to meet the statement of purples and the aims and objectives of the home. Staff spoke of undertaking an induction when they first started at the home but were not aware of having completed a “skills for care” induction, which is the industry recommended minimum induction standards. This helps to ensure that new staff entering the industry have at least a minimum basic level of induction. The personal files of three staff were inspected and these showed that a robust recruitment process is followed which includes the use of an application form, interviews, Criminal Records Bureau (CRB) checks and written references prior to employment commencing. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 26 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 35 36 and 38 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is not being managed effectively in ensuring that residents are safe and their wellbeing is protected. The systems for resident and relative consultation is good with their views being both sought and acted upon, however the service does not have a cohesive approach to self monitoring itself to ensure that these systems are effective at identifying areas for service improvement. The health and safety of residents and staff is promoted and protected. EVIDENCE: Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 27 The home has been without a registered manager for eighteen months, the home was being managed by an unregistered manager up until their resignation in May 2008. This situation was of particular concern as during this time the person appointed by the registered provider to manage the service failed to make an application to the commission to become registered to manage the home and this was not rectified by the provider. The deputy manager has been appointed by the provider, a week before the inspection, to oversee the running of the home until another manager is appointed. Prior to this arrangement a manager from another one of the organisations service was appointed to temporarily oversee the running of the home, however this arrangement lasted for a few weeks. The deputy manager has been deputising for three years and had been instrumental in instigating many good new policies and guidance, however these were yet to be translated into good practices by staff. Many of the relatives were confused as to who was currently managing the service but once the management arrangements had been identified with them they spoke positively about the deputy manager a sample of comments made about the deputy manager included; “incredible helpful”; “absolutely lovely, very understanding”; “Very impressed with the new management aware of the plans for the huge improvements which are much needed”. The deputy manager had already highlighted some of the shortfalls in practices noted at this inspection and appeared enthusiastic in implementing the necessary changes to improve the quality of the services being provided. However as evidenced by the number of the concerns noted at this inspection there is a lack of management consistency and direction, which has lead to staff and practices not being effectively monitored. The required monthly-unannounced visit to the home (required by Regulation 26 of the Care Homes regulations) by the provider or their representative to monitor practices was inconsistent. This has been made a requirement and subsequent to the inspection the provider has been written to regarding the management arrangements for the service and the Commissions requirement to ensure compliance with the regulations. Residents are encouraged to retain control of their own finances for as long as they are able to do so and if unable then this responsibility is taken on by a relative or another responsible persons external to the home. The administrator reported that they do hold small amounts of money for a few residents, which are kept secure and records maintained of any expenditure. There is a good programme of formal supervision and appraisals for staff, however closure supervision of staff on a daily basis must be undertaken to ensure that the poor practices noted at this inspection are improved. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 28 The home has produced a comprehensive development plan, which highlights areas for service development and shortfalls. This did not however always accurately reflect the practices present at the home but nerveless provided some direction and guidance on the development of the home for management. There are several mechanisms in place for the home to obtain feedback from residents, relatives and other stakeholders involved in resident care on the quality of the services provided. Evidence was seen that changes to practices have been made based on this feedback. A relative commented: “Management since the handover has all been very good, gone out of their way to keep us informed of the changes and they are generally receptive to feedback” . However there was a lack of cohesion in the practices the home has developed to effective self audit itself to ensure that they could promptly identify areas for future service development, this was bore out by the number of shortfalls noted despite there being many systems in place to monitor the quality of the services. The deputy manager reported that systems were in place to support fire safety, which included: regular fire alarms and emergency lighting checks, staff training and maintenance of fire equipment and fire drills. The deputy manager reported that a fire risk assessment had been undertaken on the home by a member of the organisation, which recorded the actions necessary to ensure fire safety at the home. The deputy manager spoke of a recent visit by a fire safety officer to look at the fire safety arrangements during the refurbishment and that no recommendations were made. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 29 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 3 1 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 1 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 2 3 3 1 2 3 3 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 3 X 3 Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(4)(c) Requirement Timescale for action 30/07/08 2 OP7 15(1) 3 OP9 13(2) That written personal risk assessments are completed for all service users as part of their care plan, which are reviewed regularly and records the actions to manage or reduce any identified risks, to ensure that residents safety is promoted. 30/07/08 That care plans provide clear guidance for staff on all aspects of the health, personal and social care needs of service users and which make explicit the actions needed to meet these needs and which are reviewed regularly to reflect changes in the needs and preferences of service users. This is so that any changes in residents needs are promptly identified and the appropriate guidance provided for staff. That there are arrangements in 30/07/08 place for the adequate recording, handling, safekeeping, safe administration and disposal of medicines at the home so that service users receive medication in accordance with their prescribed instructions. This is to ensure that residents are DS0000064426.V365463.R01.S.doc Version 5.2 Old Wall Cottage Page 31 4 OP10 12(4)(a) 5 OP14 12(2) 6 OP22 16(2)(c) 7 OP24 23(1)(a) & 23(2)(a) safeguarded by the homes practices. That there are suitable arrangements to ensure that the care home is conducted in a manner which respect the privacy and dignity of service users. In that care staff have their care practices regularly monitored by an experienced, competent manager, nurse or senior care worker to ensure they provide care based on good practice guidance that is safe and respects and promotes the privacy and dignity of service users and that auditing systems are in place to regularly monitor standards of service delivery. That so far as practicable the home enables service users to make decisions with respect to the care they are to receive and their health and welfare, with particular reference to being able to have their preference observed for going to bed, rising and meal time arrangements. The registered persons must ensure that rooms occupied by service users have adequate furniture, bedding, and other furnishings including curtains and floor coverings and equipment suitable to meet the needs of service users. First made at inspection of February 2007 with timescales of 28/05/07 and 06/09/07. That the premises are suitable for the purpose of achieving the aims and objectives of the service as set out in the statement of purpose and the physical design and layout of the premises meets the needs of the people for whom the service is DS0000064426.V365463.R01.S.doc 30/07/08 30/07/08 30/07/08 30/11/08 Old Wall Cottage Version 5.2 Page 32 8 OP27 18(1)(a) 9 OP30 18(1)(c) 10 OP31 8 (1) (a)(b)(i) & 8(2)(a)(b) 11 OP31 26(2)(a) (b) (c) and (4)(a)(b) (c) intended. That at all times throughout the twenty four hours, staff are on duty and working in sufficient numbers and who are appropriately qualified, experienced and trained to ensure the health and welfare of service users and to meet the assessed care needs of service users That a training plan is put into place for staff to undertake specialist training in accordance with the needs of the service users accommodated, in order that they can provide the appropriate support to people with dementia and mental health needs. The registered provider must appoint an individual to manage the care home who has the qualifications, skills and experience required to be registered in respect of the service. That the Registered person shall appoint a person to visit the service unannounced at least once a month and compile a report of that visit in accordance with the regulations, so that they can demonstrate that they are aware that the service is being managed and carried on in accordance with the Care Homes regulations. 30/07/08 30/07/08 20/08/08 30/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 33 No. Refer to Standard Good Practice Recommendations Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Old Wall Cottage DS0000064426.V365463.R01.S.doc Version 5.2 Page 35 - 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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