CARE HOMES FOR OLDER PEOPLE
Ridgeway House The Lawns Wootton Bassett Wiltshire SN4 7AN Lead Inspector
Roy Gregory Unannounced Inspection 9:20 21 February 2007
st 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 DS0000028401.V323671.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. DS0000028401.V323671.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Ridgeway House Address The Lawns Wootton Bassett Wiltshire SN4 7AN 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) 01793 852521 www.osjct.co.uk The Orders Of St John Care Trust Application pending for Miss Eleanor Walton Care Home 43 Category(ies) of Dementia - over 65 years of age (10), Learning registration, with number disability (1), Old age, not falling within any of places other category (33) DS0000028401.V323671.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Only the one named female service user under the category of LD, as requested in the application dated 24 November 2005. 16th November 2005 Date of last inspection Brief Description of the Service: Ridgeway House is a purpose-built residential home for 42 older people, some of whom may have dementia. Built in the 1970’s, the home was formerly owned and run by the local authority, but has for some years been provided by the Orders of St John Care Trust. It is one of a number of homes provided by them in Wiltshire and elsewhere. Accommodation is all in single rooms, located on two floors, with a passenger lift to the first floor. All bedrooms have wash hand basins, and one has en-suite facilities. Toilets and bathrooms are located conveniently. There are sitting rooms on each floor, whilst behind the home are secure gardens, including a landscaped patio area. The dining room overlooks the gardens. The home is located in a residential area a short walk from Wootten Bassett town centre, where shopping and social facilities are available. There are good bus links to neighbouring towns, whilst the home has its own car park in front of the main entrance. Weekly fee levels range between £395 (£370 for Wiltshire County Council block contract) and £460, according to assessed dependency. DS0000028401.V323671.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced visit for this inspection was made on Wednesday 21st February 2007 from 9:20 a.m. to 5:20 p.m., with a return visit on Friday 9th March between 9:50 a.m. and 4:20 p.m. The pharmacist inspector carried out a visit to assess medication practice on 28th February 2007. The manager, Miss Walton, was available during the inspection visits, whilst the inspector also spoke with two care leaders, the activities co-ordinator, the administrator, and members of the care and support staff teams. During the inspection there were conversations with a number of residents, in small groups including twice sharing lunch at table; individually around the home; and in private rooms, by invitation. The entire home was toured. It was possible to ask opinions of some visiting relatives. Prior to the inspection, pre-inspection information had been received from Miss Walton’s predecessor. Additionally, five survey forms have been received from residents. During the inspection, documentation looked at included records in respect of care planning and delivery, complaints, training and recruitment and fire precautions records. The pharmacist inspector examined medication storage and records in detail. A number of instances of care giving were observed. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visit to the service and taking into account the views and experiences of people using the service. What the service does well:
DS0000028401.V323671.R01.S.doc Version 5.2 Page 6 In conversations, residents spoke particularly of: making their own choices; very good catering; staff respect for their privacy; and a very clean environment. The inspector saw evidence of these features of everyday life in the home. Individual care plans were signed by residents and received regular review. Records showed the home made frequent referrals to resources such as chiropodists, the continence nurse and community psychiatric nursing service, and in turn obtained services from them for residents. Records also showed staff spent time chatting with residents, as was confirmed by a number of residents in person and by survey returns. At lunch times, there was respectful, individualised service. There was a daily choice of two cooked lunches, and two sweets, with the menu written up on a board. Salads could be made to order. One resident said he always had his lunch kept for him to fit with his return time from meeting a friend in town. All but one response from service users about meals were highly complimentary. Written comments included: “The chef is very good and a good variety of menus. We had an excellent Christmas lunch.” “We get plenty of food and really big portions. I usually enjoy them all.” “Mum says the food is very good and likes the fact there is always a choice.” It was evident during the inspection visits that friends and family members visited at any time. The visiting spouse of a resident was very complimentary of the home’s welcome and of provisions for privacy. There was very good provision for residents to maintain contact with their churches, where required, including regular services provided by different denominations within the home. Many residents said verbally and in questionnaires that they greatly enjoyed trips out, for example to local productions, and some spoke with enthusiasm about their participation in the home’s quiz team. Despite the environmental shortcomings (see below), housekeeping staff were maintaining very high standards of cleaning. There were no unpleasant odours or unclean surfaces, and several residents commented that this was always so. Every respondent to the questionnaire ticked that the home was “always” fresh and clean. The housekeeping staff had obtained NVQs (recognised qualifications) in cleaning and support services. Recently admitted residents recalled meaningful assessment visits. The manager and care leaders demonstrated a rigorous approach to assessment, including re-assessment of residents in hospital. This ensured that individuals’ needs could be met by the home without compromising the needs of the resident group as a whole. They were also efficient at securing additional resources from other agencies where this would enable someone to move into the home. What has improved since the last inspection?
DS0000028401.V323671.R01.S.doc Version 5.2 Page 7 At the previous inspection in November 2005, a number of requirements had been made in relation to record keeping, because assessment, care planning and medications documentation were lacking in detail, thus posing risks to safe practice. On this occasion, good standards were noted in all these areas. In response to a requirement about staffing levels the provider Trust has increased the home’s staffing budget. It remains the case that staff are not often available to support activities outside the home, such as accompanying a walk into town, although it was seen that there is provision to accompany medical appointments and organised trips. Additional staffing at key times of the day was in place to ensure personal care needs were met, but one resident wished for two baths a week rather than one. Only one survey respondent considered staff to be “always” available when wanted. On taking up post as manager, Miss Walton identified a high number of recorded falls as a significant issue to address. One response was to survey how residents’ hydration needs were met, as there can be a correlation between falls and incidence of urinary infections. Consequently fresh cold drinks are made available in jugs around the home, with individual staff having responsibilities daily to oversee provision in different sitting rooms. The Trust has been giving emphasis to dementia training for staff in all positions: a two-day course for care staff and a half-day course for ancillary staff. What they could do better:
DS0000028401.V323671.R01.S.doc Version 5.2 Page 8 Assessments of the risk of individual residents sustaining pressure damage, and care planning to address such risk, are under-developed. At present, plans emphasise use of equipment as provided by community nurses, and checking skin for possible signs of damage. But once visible signs of damage are apparent, underlying damage can already be advanced. So there is a requirement that care planning documentation must contain an assessment of risk of pressure damage for each service user, accompanied by positive planning to reduce any identified risk. Fluid charts that are already put in place for some residents at risk of dehydration, would be more helpful to medical professionals and the home’s own staff if they were more specific in showing how much of any drink is consumed. Some medicine records were coded regularly as ‘asleep’; this can mean that the residents miss important doses of medication, for example antibiotics. There is a requirement that proper provision is made for residents to receive their full course of medication, with GP or pharmacist advice to be sought on timings of administration, if necessary. Safety of medicines practice must be improved by adherence to the Trust’s policy on double-checking written additions to the printed medication administration record. Identification of social and activity needs was lacking in care planning. Key workers and the activities co-ordinator need to share responsibility for this, to ensure social needs are seen as integrated with other needs, such as to promote mobility or to counter loneliness and anxiety. All toilets seen, and some bathrooms, were outdated, needing the addition of modern homely touches. In a setting where residents are dependant upon shared facilities, this is an important factor in quality of life. A recently admitted resident said the quality of toilets was their only real disappointment. Some fittings and deteriorated areas also posed a risk to control of infection in the home. This was a marked problem in the sluices, which were in a very poor condition. Furthermore, the downstairs sluice shared a room with the laundry, which is unacceptable, laundries being at high risk of contamination. The home had experienced outbreaks of gastric infection in 2006, and so it was surprising attention had not already been paid to the need to upgrade sluice facilities. This is now required, as is a system to ensure commode buckets are not in successive use by different individuals. Where residents or their families had requested the home to assist with safekeeping of personal monies, as many had, practice was sound and all transactions in and out of individual accounts were double-signed; but rarely was the resident one of the signatories. It would be an enhancement to feelings of self-worth and control for residents to be offered this role in management of personal money. The frequency of formal one-to-one supervision of staff had tailed off during the previous year. Staff members need to see that supervision is part and parcel of their job, and of most benefit to them if it is a transparent process
DS0000028401.V323671.R01.S.doc Version 5.2 Page 9 that consistently considers how delivery of care and associated training enhances quality of life for residents. There is a requirement to get supervision back on track as a consistent process that can be monitored by the manager. 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. DS0000028401.V323671.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000028401.V323671.R01.S.doc Version 5.2 Page 11 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 does not apply). Quality in this outcome area is good. Admissions to the home are preceded by full assessments of need, in which the prospective resident is fully involved. Where an assessment is that admission or re-admission should be refused, this is based on recognition of the health and welfare needs of the individual and of the existing resident group in the home. This judgement has been made using available evidence including a visit to this service. DS0000028401.V323671.R01.S.doc Version 5.2 Page 12 EVIDENCE: The manager was undertaking all assessments of people referred for potential permanent admission, whilst care leaders assessed short-stay referrals. The examples of assessment sampled were of high quality, showing how, when and where information was obtained, and making good use of the documentation. The assessments were clearly used to devise initial care plans, so that identified needs, agreed by service users or their representatives, were met. Also seen were examples of applications for admission that had been refused. Miss Walton demonstrated consistency in highlighting where the home would not be an appropriate placement, because assessed needs would put too great a strain on staff resources or the needs of the resident group as a whole. In one instance, re-admission of a resident who had been hospitalised had been twice refused, to ensure the person received further physiotherapy input in hospital. This meant that when they were discharged to Ridgeway House, they could be supported by one carer, and not two, as would have been the case before completion of medical tasks in hospital. Their return to the home was supported by an agreement between the home, care manager and community nursing service about additional provision to minimise the risk of pressure area damage. During the inspection, a care leader returned from assessing a resident in hospital, deemed fit for discharge. Miss Walton backed the care leader’s judgement that re-admission should be refused until observed feeding and mobility difficulties had been further addressed in hospital. Thus it was evident that the home admits people whose needs can be met, and advocates strongly for people to have needs met in a more appropriate setting, when that is the case. Five recently admitted residents said in person and by questionnaire that they recalled assessment visits and being provided with information about the home, which they considered good. DS0000028401.V323671.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. Quality in this outcome area is adequate. Individual care plans receive regular review and direct care across a spectrum of need. There is prompt awareness of and response to health needs, including excellent liaison with health professionals. Assessments of risk of pressure damage, and care planning to address such risk, are under-developed. Systems are in place for the safe handling of medicines, however they are not always followed consistently and this can lead to some residents not receiving a full course of medication. The approach to the care task is based on respect for diversity and privacy. This judgement has been made using available evidence including a visit to this service. DS0000028401.V323671.R01.S.doc Version 5.2 Page 14 EVIDENCE: Care plans sampled showed attention to detail and change. They received monthly review, and inserts to both short-term plans, and long-term assessments, showed these were working documents. However, where elements of a plan are consistently reviewed simply as still applicable, it would be helpful to show occasional evaluation of how the plan works in practice and contributes to quality of life, perhaps by the key worker. Where plans indicated a need to keep food or fluid charts, these were in place. Care plans were signed by residents. A resident regarded staff as knowing his needs well. There was good cross-referencing between care records and attention by doctors and other medical professionals. For example, the “multi disciplinary record” for one person showed all contact with the district nurse regarding arrangements to care for pressure areas and skin tears. All changes to medication were recorded in “doctors notes”. These supplementary records showed the home made frequent referrals to resources such as chiropodists, the continence nurse and community psychiatric nursing service, and in turn obtained services from them for residents. A simple example was of referral of a hearing problem, leading to a prescription for eardrops and a later appointment with a practice nurse for syringing. The resident concerned was taken to the latter appointment by a member of the care staff, as a delegated duty. Daily care notes by staff showed alertness not only to physical symptoms, including monitoring of pain and associated support to medication, but also to psychological wellbeing. In response to a particular incident, staff had been provided with additional training input by a mental health professional. Care plan changes had been agreed with the resident and their family supporters. In another instance, too, a meeting with a resident and family member had resulted in an agreed plan of action, including measures to promote the resident’s sense of dignity and privacy. These measures were seen in place and working. There were continuing attempts to secure greater involvement by community psychiatric services for this person. Daily records showed staff sensitivity to when the resident was distressed, and time spent chatting to counter negative feelings. On taking up post as manager, Miss Walton identified a high number of recorded falls as a significant issue to address. One response was to survey how residents’ hydration needs were met. An outcome of this was to ensure fresh cold drinks are made available in jugs around the home, as well as the routine hot drinks rounds, with individual staff having responsibilities daily to oversee provision in different sitting rooms. Experience had shown that staff had to be more active in encouraging use of the drinks provided. An aim was to reduce the incidence of urinary infections, which cause discomfort and disorientation.
DS0000028401.V323671.R01.S.doc Version 5.2 Page 15 Some residents were highlighted in care plans as needing encouragement to drink, or to eat. One person had shown good weight gain, then steady maintenance of weight, since admission, as had been remarked favourably by their doctor. Where fluid charts were in use, they showed consistency of drinks offered and taken, but they would be more helpful to medical professionals and the home’s own staff if they were more specific in showing how much of any drink is consumed. For some residents there were plans in place to promote tissue viability, with stated aims of minimising risks of pressure sores developing. However, the emphasis was on use of equipment as provided by community nurses, and checking skin for possible signs of damage. There was no tool in use by which risks of pressure damage, for example as a result of existing skin condition, nutrition or degree of mobility, could be identified and planned for. Once visible signs of damage are apparent, underlying damage can already be advanced. A plan to minimise risks should consider whether supports to nutrition or activity, for example, are indicated. It was evident from observed practice, and records, that staff have the knowledge and skills to develop this important area of preventive practice. For example, a carer invited a resident for a walk along a corridor, as an opportunity for talking and seeing other residents, but also explaining to the resident that they would benefit from relieving pressure on their back from prolonged sitting. The inspector is aware that the Provider trust intends introducing a pressure area risk assessment tool. Arrangements for handling of medications in the home were inspected separately by the specialist pharmacist inspector, who reports as follows: All medication is stored securely. The room is too small for the amount of medicines that are required and a new room is being prepared which will enable staff to work in there more easily. Medication administration records are completed with signatures or codes for missed doses. Some records are coded regularly as ‘asleep’; this can mean that the residents miss important doses of medication, for example antibiotics. Written additions to the printed medication administration record were not all signed or checked by a second member of staff. Records of medicines received and returned for disposal are kept. Some medicines were seen to be over-stocked. All staff received training in the safe handling of medicines and their competency to administer is regularly checked and recorded. A medication policy is in place and staff have access to information about drugs. Some residents retain the responsibility for administering their own medicines. The home conducts a thorough risk assessment, which is reviewed frequently; care staff could discuss interventions they had made to help a resident whose circumstances had changed. DS0000028401.V323671.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 – 15. Quality in this outcome area is good. Activities provision is being developed within the home but is not linked to assessment of residents’ needs. Within daily life, residents are able to exercise many choices. Community and family contacts are facilitated. Meals are of very good quality. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing budget for the home provides for 20 hours per week specifically for an activities co-ordinator. At the time of inspection the person in this post was able to provide 12½ hours, which was to rise to 15 hours in April 2007. The activities co-ordinator aimed to provide a service particularly to those residents who had few family or other social contacts outside the home, with much of her input being on a one-to-one or small group basis. During the inspection, for example, about an hour of her time was spent with one resident deciding the locations for nest boxes in the garden, and putting them up together. Many staff, including the co-ordinator, spoke of low motivation amongst residents for organised group activities. This was echoed by some residents,
DS0000028401.V323671.R01.S.doc Version 5.2 Page 17 who could find life in the home boring, but they related this to the loss of involvement in familiar domestic routines rather than an absence of specific interests or activities. Such an outlook highlights the importance of taking a broad view of “occupation” rather than “activity”, something of which the coordinator was aware. Miss Walton had directed her to canvass all residents on activities and life skills they would like to develop. An important next step is to ensure care plans include identification of social and activity needs, as this was lacking in care planning. Key workers and the activities co-ordinator need to share responsibility for this, to ensure social needs are seen as integrated with other needs, such as to promote mobility or to counter loneliness and anxiety. A resident said: “there are enough things to do, but not necessarily what I want to do”. Another said “you tend to lose interests at this age”. Contact with family and friends, the ability to go out, and relaxing with one’s own TV or radio were highly valued, and residents considered they retained a large measure of choice over how they used their time. The co-ordinator set out a weekly plan as a basis from which care staff could provide some stimulation in her absence. This included such things as facilitating choice of music or TV film in a sitting room, or encouraging take up of card games. She was also involved in planning outings, which many residents said verbally and in questionnaires that they greatly enjoyed. The survey questionnaires returned to the inspector made no negative comments about activities. One added “our activities lady is very good and goes out of her way to get tickets for plays & we get transport to go there. I love live theatre.” Some outings were to other homes run by the Provider trust, to take part in quizzes or dances, and such events were also hosted at Ridgeway House. Some residents spoke with enthusiasm about their participation in the quiz team. Funding for trips was said to be difficult, although there was a reluctance to ask residents for contributions. A newsletter helped to disseminate information and feedback about activities around the home, and there was also a large collection of photographs in the entrance foyer to give residents and visitors a picture of the variety of events that have been enabled. The shortfall in use of allocated activities hours was to be used for introducing a twice-weekly shopping trolley around the home. Residents consistently said all staff took time to stop and chat, but staff availability to support walks out of the home was extremely limited. Some more able residents were accustomed to regularly going into town. One said he always had his lunch kept for him to fit with his return time from meeting a friend in town. Another often bought a light lunch from a local supermarket to eat in the dining room, if the cooked choices did not appeal to him. It was evident during the inspection visits that friends and family members visited at any time. The visiting spouse of a resident was very complimentary of the home’s welcome and provisions for privacy. The inspector saw
DS0000028401.V323671.R01.S.doc Version 5.2 Page 18 considerate provision made for grieving relatives. There is a pay telephone in an accessible but private place. A computer had just been provided by the Trust for residents’ use, with the intention of facilitating family contact as well as internet use. Tuition will be essential, and larger, better designed equipment may be indicated, but this is an innovative step. There was very good provision for residents to maintain contact with their churches, where required, including regular services provided by different denominations within the home. Meals could be supplied to individual rooms, but were mostly taken in the dining room, which was attractive and well furnished. At lunch times, there was respectful, individualised service. Tables were laid with cloths, cruet and water jugs. Second helpings were offered. There was a daily choice of two cooked lunches, and two sweets, with the menu written up on a board. Salads could be made to order. Breakfasts and high teas included cooked options. All but one response from service users about meals were highly complimentary. An issue for the other resident was that they would prefer a main meal in the evening. Health and safety considerations do not allow for re-heating of meals and alternative options had not been identified, although the matter had been recognised in the person’s care plan. Comments from questionnaires about meals were: “The chef is very good and a good variety of menus. We had an excellent Christmas lunch.” “We get plenty of food and really big portions. I usually enjoy them all.” “Mum says the food is very good and likes the fact there is always a choice.” DS0000028401.V323671.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 & 18. Quality in this outcome area is excellent. There is good provision for receipt of and response to complaints, which are addressed competently. Staff and management understand and exercise responsibilities in respect of keeping residents safe. This judgement has been made using available evidence including a visit to this service. DS0000028401.V323671.R01.S.doc Version 5.2 Page 20 EVIDENCE: The Provider trust has a clear complaints procedure that is made available through literature provided to all residents, and on notice boards in the home. This details the approach and specific steps to be taken to address complaints in a consistent fashion. Miss Walton had received and answered two complaints since being in post, both from relatives of residents. The records of complaint investigation were thorough, reflected in turn in reply letters to the complainants. One of them had in response written an appreciative letter. Residents spoken to, and answering questionnaires, generally knew there was a formal complaints procedure, but felt confident in simply taking any concern or dissatisfaction direct to their key carer, or the manager. One wrote: “our new manager is very good with any problems we have”. Miss Walton has experience in co-operative working with local inter-agency safeguarding procedures, from her previous post. There was evidence of staff at all levels in the home having received training in the past year in adult abuse awareness, and there was a system in place to ensure this is repeated two-yearly. There had been an allegation concerning the behaviour of a member of staff towards a resident. Miss Walton had been asked to investigate this matter. There was a full record of interviews with relevant people, and of references to care records concerning the resident involved. One outcome was an amendment to the care plan, by which the resident now received all care from staff working in pairs. No grounds for disciplinary action had been established. DS0000028401.V323671.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, 24 & 26. Quality in this outcome area is adequate. There are good standards of hygiene around the home, but these are severely compromised by dated and inadequate sluice facilities, where infection control measures cannot be maintained to recognised standards. Many bedrooms are in need of redecoration, whilst toilets are dated and devoid of homely touches. Communal areas provide a variety of pleasant environments, although the gardens are not fully accessible to all. This judgement has been made using available evidence including a visit to this service. DS0000028401.V323671.R01.S.doc Version 5.2 Page 22 EVIDENCE: There was evidence of some recent improvements to the fabric of the home, such as new carpets in some locations, and it was said that most windows were to be replaced in the very near future. But overall the environment did not present well. Individual bedrooms have wooden built-in wardrobes and vanity units, which have an old-fashioned makeshift appearance. Replacement of the vanity units in some rooms was underway. A residents’ survey in 2006 showed most residents were satisfied with personal accommodation, as was the case with those spoken to by the inspector, but there were comments about decoration, carpets and curtains. A rolling programme of redecoration of rooms was slowly underway. Many residents had personalised their rooms effectively. The hairdressing room was very old-fashioned, with unsuitable furniture for the resident group. The hairdresser said she had recently submitted ideas for improvement. All toilets seen, and some bathrooms, were outdated, needing the addition of modern homely touches. In a setting where residents are dependant upon shared facilities, this is an important factor in quality of life. A recently admitted resident said the quality of toilets was their only real disappointment, but stressed they were always clean. A group of toilets near the dining room entrance had rusted frames, worn seats and stained basins. This area was to be refitted imminently, but had been allowed to reach an unacceptable state. It was noted that there had been significant outbreaks of diarrhoea and sickness in 2006 (January and again in March). The laundry, despite efficient working practices on the part of the designated member of staff, was very crowded, and the downstairs sluice facility was incorporated in the middle of the room. A bin store on the opposite side of the corridor could perhaps be converted to a sluice, but only by resolution of a number of issues. Storage of this nature was anyway in short supply. The upstairs sluice presented still more compromises of expected standards of infection control. It had advanced rusting of brackets, a peeling ceiling and cracked floor tiles. Commode buckets were not numbered, and so their use was shared, posing another possible route for cross infection. Whilst major work will be necessary to address these shortcomings, there should be a regular audit of areas, such as under sinks and around toilets, to identify possible hygiene risks and earmark them for action, such as repainting or replacement of fittings. The home has the benefit of a handyman who has received training in infection control. DS0000028401.V323671.R01.S.doc Version 5.2 Page 23 Despite the environmental shortcomings, housekeeping staff were in fact maintaining very high standards of cleaning. There were no unpleasant odours or unclean surfaces, and several residents commented that this was always so. Every respondent to the questionnaire ticked that the home was “always” fresh and clean. There was a good variety of communal areas, including a quiet sitting room upstairs that had no television but did have a sink, kettle, crockery, fridge and water dispenser. A number of residents were seen to enjoy use of this room, alone, to meet friends from within the home, and as a resource for entertaining visitors. One resident spoke of the ability to make a cup of tea there at 4:00 a.m. A nearby room, with TV and good furnishings, was a resource for smokers; one resident was not a smoker, but liked this room as somewhere to sit quietly. Many residents commented on their appreciation of the secure garden to the rear, saying they spent a lot of time outside when good weather permits. One area is attractively landscaped. However, this area is distanced from the home by a wide uneven paved area, which poses trip hazards to people with visual impairment or impeded walking ability. Thus safer walkways need to be made to ensure full enjoyment of the grounds by all residents. DS0000028401.V323671.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 – 30. Quality in this outcome area is good. A good level of developmental training has been maintained amongst care staff, who provide consistent care to the satisfaction of residents and their families. Provision of staff is sufficient in number and mix of attributes. Recruitment practice is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Rotas provided for five care staff (including a care leader) on duty in the mornings, and four later in the day. Miss Walton said 27 residents needed help with washing and dressing, in response to which she had been able to provide an additional two hours cover at key times in the mornings and evenings from “floating hours”. As a result of staffing budget increases being introduced by the Provider trust in April 2007, it would now be possible to sustain that additional team member for the whole shift duration. A further benefit of new staffing arrangements was to be off-rota time for care leaders, to allow a better distinction between their administrative and direct care duties. Residents spoken to considered staff availability to be sufficient, in that they felt staff had time to chat whilst also being able to respond to emergencies, although there was a comment that “I can see they are pushed sometimes”. However, there was some expressed regret about lack of staff availability to assist walks outside the home, or to provide more than one bath per week. Staff themselves, through minuted staff meetings, were encouraged to identify
DS0000028401.V323671.R01.S.doc Version 5.2 Page 25 priorities, resident perceptions, and efficient ways of responding to residents’ needs. Miss Walton was endeavouring to ensure a mix of skills and experience was available to residents on each care staff shift. The Trust has been giving emphasis to dementia training for staff in all roles: a two-day course for care staff and a half-day course for ancillary staff. The Trust training department arranges a wide variety of courses on a continuous programme, for staff in all its homes. Courses booked for Ridgeway House staff in the period immediately following the inspection included dementia, mental health and tissue viability. A centralised training record-keeping system meant renewals of training could be tracked and offered to staff at the right time. There was evidence of further in-house training on pressure ulcer prevention and health and safety. Records supplied pre-inspection showed that all care leaders had achieved National Vocational Qualification (NVQ) in care to at least level 2, as had the majority of carers. Those not qualified in this way were either working towards the award, or had been nominated to do so in due course. The housekeeping staff had NVQs in cleaning and support services. Records of recruitment of staff since the previous inspection showed adherence to regulations, to ensure residents were not put at risk by unsuitable appointments. There were very full records of interviews, and Miss Walton had made a record of a telephone call made to amplify a “thin” written reference. DS0000028401.V323671.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 & 38. Quality in this outcome area is good. Residents and their supporters experience an open style of management, with provision for canvassing of views. Residents’ financial interests are safeguarded, where required, although residents themselves could be included more in signing for transactions. Supervision of staff is in need of planning to ensure continuity. Provision for health and safety is good. This judgement has been made using available evidence including a visit to this service. DS0000028401.V323671.R01.S.doc Version 5.2 Page 27 EVIDENCE: Although relatively new to the home, Miss Walton was already well known to many of the residents and had engaged with the various staff groupings through formal minuted meetings and plentiful informal contact. She has been a successful manager at another Trust home and holds the Registered Managers Award. Registration as manager of Ridgeway House is awaited. Monthly senior care team meetings had been instituted. The home received “monthly operational visits” from a Trust manager, which provided for audit of a variety of indicators of service provision. There had been a quality survey within the home, of which there was a summary of findings to assist management with forward planning. Miss Walton said she had deliberately delayed holding a residents’ meeting, whilst she had got to know the home and how it functioned. She intended to do so soon after the inspection, and periodically thereafter, as a means of encouraging residents to voice ideas or areas of dissatisfaction. The chef is required by the Trust to obtain direct feedback from residents about meals, and there was evidence of responding to wishes expressed. Complaints monitoring is another way in which managers build a picture of areas for improvement. One resident suggested there should be an easy channel through which to make observations or express ideas at any time; a possible measure would be a tear-off slip in the newsletter, which could be handed to staff or to the office. The administrator demonstrated the systems in place for safe keeping of residents’ personal monies, where this is requested – as it was by a majority. All transactions in and out were double-signed, but rarely was the resident one of the signatories. It would be an enhancement to feelings of self-worth and control for residents to be offered this role in management of personal money. For those where this was unwanted or impractical, the care plan should show why, with an endorsement by the resident or their representative. Actual access to monies is not a problem, as there is always a key holder on duty. The administrator had little need to be directly involved with this, although she would settle bills, such as with the hairdresser. She maintained roughly monthly audits to ensure residents’ separate money containers tallied with individual accounts, and had never come across any discrepancy. Additionally, visiting Trust staff often carried out spot checks. Miss Walton said care leaders had acknowledged that one-to-one supervision sessions with staff had become irregular, as staff records showed. The last recorded supervision on one record was in June 2006. The notes showed an appropriate agenda had been covered, but they were in a sealed envelope. Given the records are kept in confidential staff files, there is no need for this extra confidentiality, and Miss Walton was intent on routine oversight of the content of staff supervision. Supervision is of most benefit to staff members if DS0000028401.V323671.R01.S.doc Version 5.2 Page 28 it is a transparent process that consistently considers how delivery of care and associated training enhances quality of life for residents. A care leader had recently been delegated to keep oversight of health and safety matters. Miss Walton had identified a lack of a fire evacuation plan, which was being rectified, with documented evidence of discussion with all night staff about this. Miss Walton was to ensure night staff all received fire marshal training, and she had commenced a requirement of hourly safety monitoring at night. Good systems were in place for monitoring of the effectiveness of fire precautions, whilst routine servicing of hoists, passenger lift and so on, was arranged centrally by the Trust. Accident records were of good quality, and could be linked to care records. DS0000028401.V323671.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 2 3 X X X 2 X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 DS0000028401.V323671.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? NO 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 12 (1)(a) 13 (4)(c) Requirement Care planning documentation must contain an assessment of risk of pressure damage for each service user, accompanied by positive planning to reduce any identified risk. The registered manager must ensure that the Home’s Medication Policy is adhered to by all staff when written additions to the medication administration record are made. The registered person must ensure that proper provision is made for residents to receive their full course of medication, the GP or pharmacist must be consulted as to the appropriate time to administer doses. For each service user there must be a care plan for meeting their needs and wishes in respect of activity and occupation. Adequate sluice facilities must be provided, in which it is possible to prevent infection, toxic conditions and the spread of infection. Action plan to be devised by date shown and
DS0000028401.V323671.R01.S.doc Timescale for action 30/04/07 2. OP9 13(2) 28/02/07 3. OP9 13(2) 28/02/07 4. OP12 16 (2)(m) 31/05/07 5. OP26 13(3) 30/06/07 Version 5.2 Page 31 6. OP26 13(3) 7. OP36 18 (2) notified to the Commission. There must be a system in place to ensure any service user using a commode is consistently provided with the same commode bucket. All staff must receive regular one-to-one supervision that is recorded; the process to be monitored by the registered manager. 30/04/07 30/04/07 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. 3. 4. 5. 6. 7. Refer to Standard OP7 OP8 OP12 OP19 OP20 OP26 OP35 Good Practice Recommendations Encourage key workers through supervision to evaluate elements of care plans periodically in terms of impact on service users’ quality of life. Fluid charts should show an indication of quantities of drinks taken. Consider introduction of a policy on asking service users to contribute to the costs of certain activities. Consider ways to provide for homeliness in bathrooms and toilets. Improve access to the gardens by provision of walkways with even surfaces. Commence a regular audit and making good of areas presenting high-risks in terms of infection control in bathrooms, toilets and sluices. Service users should be routinely invited to sign for transactions of their personal monies. DS0000028401.V323671.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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
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