Inspection on 25/11/08 for Ryland View

This inspection was carried out on 25th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ryland View 27/08/09

Ryland View 28/05/09

Ryland View 25/06/07

Ryland View 11/09/06

Ryland View 10/01/06

Ryland View 20/04/05

Ryland View 18/01/05

Ryland View 18/01/05

Ryland View 18/01/05

Ryland View 18/01/05

Ryland View 12/01/05

Ryland View 21/04/04

Ryland View 21/04/04

Ryland View 20/04/04

Ryland View 20/04/04

Ryland View 19/04/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Ryland View Arnhem Way Great Bridge West Midlands DY4 7HR     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jean Edwards     Date: 2 8 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 52 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 52 Information about the care home Name of care home: Address: Ryland View Arnhem Way Great Bridge West Midlands DY4 7HR 01215201577 01215570859 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : BUPA Care Homes (CFHCare) Ltd care home 140 Number of places (if applicable): Under 65 Over 65 60 44 0 0 dementia old age, not falling within any other category physical disability terminally ill Additional conditions: 0 0 26 10 One service user identified in the variation application of 29.11.04 may be accommodated on Manby Unit who is 56 years and over. This will remain until such time that the identified service users placement is terminated and whilst the home is able to meet her needs. That 14 elderly (OP) service users and 10 service users with a terminal illness (TI) be accommodated on Bloomfield Unit. That 26 physically disabled (PD) service users 18 years and over will be accommodated on Palethorpe Unit That 30 service users who are elderly and do not fall within any other category (OP) who are 58 years and over will be accommodated on Haines Unit. That 30 service users with dementia (DE)(E) 58 years and over will be accommodated on Heronville Unit That 30 service users with demetia (DE)(E) who are 58 years and over will be Care Homes for Older People Page 4 of 52 accommodated on Manby Unit. That the variation granted on the 5 September 2005 for one male service user with learning disabilities who is over 65 years and will be accommodated on Palethorpe House, will only be for the lifetime of that identified service user and whilst the home is able to meet his needs. The variation granted on the 31 May 2006 for one male service user who is 54 years will only be for the lifetime of that identified service user and whilst the home is able to meet his needs. There will be two registered nurses on duty at all times between 09.00 to 21.00 hours on Bloomfield Unit Date of last inspection Brief description of the care home Ryland View is a large nursing home owned by BUPA, with ample car parking in the grounds. It is located near to Tipton and is accessible by car and public transport. Each unit has its own garden area. Care can be provided for up to 140 people in five separate, purpose built and spacious bungalows, called Bloomfield, Haines, Manby, Palethorpe and Heronville. Bloomfield can have up to 24 people, who are 58 years old and above, 10 of whom may require palliative nursing care. Haines can have up to 30 frail older people needing nursing care. Manby and Heronville can each have up to 30 older people who have dementia. All bedrooms are single occupancy and there are 4 en suite bedrooms on Bloomfield. There are toilet and bathroom facilities near to bedrooms on other units. Each unit has a large communal lounge, dining room and small quiet lounge. Bloomfield and Palethorpe have an additional lounge. Bloomfield has a large meeting room also used for teaching sessions. Each unit has a small kitchenette, which can be used to make drinks and snacks. There are aids and adaptations such as grab rails, assisted baths and hoists available on each unit. The administration offices, central laundry and kitchen are situated in a separate block. Care Homes for Older People Page 5 of 52 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection took place on 26 June 2007. We, the Commission for Social Care Inspection (CSCI), undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. A lead inspector and an additional CSCI inspector spent a total of three weekdays at the home, accompanied for part of the inspection by a CSCI pharmacy inspector, who spent two days at the home. We monitored the compliance with all Key National Minimum Standards at this visit. The range of inspection methods to obtain evidence and make judgements included, discussions with the registered manager, unit managers, and staff on duty during the visit, discussions with residents, observations of residents without verbal communications and examination of a number of records. Care Homes for Older People Page 6 of 52 We also spoke to people visiting the home. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the CSCI. We were also assisted by a person with experiences of using care services for older people and we have included their findings as part of this report. We sent resident surveys, relatives surveys, health care professional and staff surveys to the home to be distributed and requested they be returned to the CSCI office in Birmingham. The collated results form part of this report. We toured the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents bedrooms, with their permission, where possible. The home had published the range of fees for the service. The weekly fees ranged between 470 pounds to 1130 pounds, dependant on the assessed individual needs of each person, and the type of room occupied. Items that are not covered by the fee included toiletries, hairdressing, chiropody and newspapers. People are advised to contact the home for up to date information about the fees charged. What the care home does well: The home was generally pleasant and we were told there was a refurbishment programme due to take place. People generally told us they were pleased with the home and happy there. There was good access throughout the building and a range of aids and adaptations available for dependent people. We saw that everyone, with the exception of people admitted to Bloomfield unit, had an assessment of their needs before agreement was reached for them to come and live at the home. This gave people reassurance the home could meet their needs. We were accompanied at this inspection by a person who had experience of using care services who was given the remit to look at the quality of life experienced by people living at the home. This person reported, I spoke to two visitors, a man and a woman, who had come to visit the womans father. They said that they were very satisfied with the service on offer. The woman said that her father was well looked after and could ask for anything. They were full of praise for the staff and the daughter said that she had the peace of mind knowing that her father was in good hands. The person accompanying us reported, The premises are spacious, well maintained and located in pleasant surroundings. A strong point of the home is the efforts that are made with structured activities for residents to keep them stimulated. Joint activity between residents, relatives and staff is encouraged. Staff are motivated and there is good rapport between them. All in all, the visit to this home was a positive experience. The persons report also stated, I was told that BUPA have always valued training and that it is being stepped up. Similarly activities are valued, as it is known that they help to prolong life. Staff comments were, Carers work as a team. The manager is very good and listens to us. The persons report included the following postives, I spoke to a resident who was waiting to get her hair done, something she always looked forward to. She could not remember how long she had been living there. It turned out that she had been living there for three months. She said, time flies when you are having fun. While I was chatting to her two members of staff ran into the lounge when a resident accidentally turned up the volume of the TV. This indicated that staff was attentive and responsive. Relatives and people living at the home told us staff were caring, kind and helpful. Comments included, staff are brilliant, has the best care, and no complaints. Each of the units at Ryland View had its own activity therapist who worked with people to help keep them engaged in their environment and hobbies and other interests. We saw very attractive Christmas decorations and ornaments made from salt flour and then hand painted. We saw photos of some group outings to Blackpool and the safari park displayed on Palethorpe unit. We also noted that a group of residents went to Merry Hill for their Christmas shopping on the first day of this inspection visit. Care Homes for Older People Page 8 of 52 People generally told us that they liked the meals provided by the home. We noted that there was plenty of choice available, especially on Haines unit. Though some comments we received indicated that soft diets, pureed diets were bland and repetitive. We saw and heard some friendly banter between the members of staff and residents during the visit. This inspection was conducted with full co operation of the registered manager staff team and people living at the home. What has improved since the last inspection? What they could do better: The registered persons must make sure that care records are monitored more closely, especially for people with complex needs. This is to make sure that all staff were aware and met their needs such as fluid intake, feeding, turning, and there are observations to prevent or minimise falls wherever possible. We also made the managers aware of a considerable number of areas of medication administration and recording, which must be improved. This is to provide assurances that each person living at the home receives their medicines as prescribed for their health, well being and safety. Although there were some improvements relating to activities and outings, these must Care Homes for Older People Page 9 of 52 be built on and individual activities planners put in place for all residents, relating to their preferred individual activities. Social contact must be improved for people being cared for in bed or in their bedroom. The records must be kept up to date and show refusals and any alternatives offered. During this inspection visit we identified a number of incidents where residents may have been put at risk, which had not been reported to other agencies. The registered persons must take immediate action to refer all incidents adversely affecting residents welfare and safety to the lead agency, Sandwell MBC and to the CSCI without delay. This is so that vulnerable people living at the home are protected from all risks of harm. We were told that there was a planned refurbishment due to take place over the next financial year, which was positive news. However a repairs, renewal and maintenance plan needs to be put in place and the registered persons must continue with the improvements already identified, in a timely manner. Examples were the need for additional nursing profile beds and comfortable armchairs or recliner chairs for very frail and immobile residents, redecoration and renewal of equipment. A comment from a relative reflected the need for improvements, Heronville always seems to be overlooked, the rooms need redecorating, the main TV aerial needs to be replaced so that the residents can watch a clear picture and they needed more staff. The home was providing care, nursing and accommodation for a large number of residents in five separate houses. Each person had individual and often complex needs and aspirations, which required appropriate levels of clinical, care support and supervision. The organisation must seriously review and consider the number of staff on duty in each unit to meet the health, well being and safety needs of all residents accommodated. The person accompanying us reported the following, I did notice in Haynes that the beds had not been made in some rooms and also that the floor was untidy in one of the residents room. Considering what the resident of that room had said, I wondered if staff were stretched in the mornings. We noted that not all serious accidents involving residents had been reported in compliance with RIDDOR Regulations and though a regular accident analysis and evaluation was undertaken for staff accidents, there had been no analysis of accidents involving residents. A regular written accident analysis relating to residents must be put in place to highlight any trends or increased risks, which need to be evaluated and minimised. There were other significant areas of health and safety and fire safety at the home, which required prompt attention and improvement. These included assurances that remedial work to bedrails, fixed wiring and emergency lighting had been satisfactorily concluded, and that all staff, especially night staff had received up to date fire training and participated in fire drills. We made the management of the home aware that we would be reporting our concerns to other agencies such as the Local Authority Adult Protection Manager, the West Midland Fire Service Safety officer and the Health and Safety Executive. If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 10 of 52 following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 11 of 52 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 12 of 52 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Though there is published information about the home and the home has comprehensive assessment tools. People wishing to live at the home cannot always be assured their needs can be met. Evidence: We looked at copy of the homes statement of purpose and service user guides, which had been updated in August 2008. The documents contained comprehensive information and each unit had an individual service user guide. We were told that that each person living at the home had access to their own copies in the Welcome Pack in a drawer in the bedroom. The organisation had not included information about the range of fees in the service user guides but the Registered Manager added this information during the 3 day inspection visit. We recommended that information about the admission criteria for each unit should be included in the service user guides to give people comprehensive information about the service to help them make decisions Care Homes for Older People Page 13 of 52 Evidence: about the choice of home. From the information provided at the home we noted that the majority of residents were funded through Primary Care Trusts and Local Authorities. We looked at a sample of care records for people admitted to the home since the last key inspection. We were told that only the people funding their own care had contracts and terms and conditions. These included information about individual fees. The homes administrator told us that she was aware that there were BUPA contracts, terms and conditions but not everyone living at the home had been given contracts with up-to-date terms and conditions and information about their individual fees. It was agreed these would be issued for people admitted during November 2008, all new residents and for everyone else at their formal review. Contracts also needed to be updated and include individual fees, including reimbursement for free nursing care element, Registered Nurses Care Contribution, RNCC. There was evidence that everyone, except the people admitted to Bloomfield unit for palliative care, had a detailed assessment of their needs before they came to live at the home. We saw records that whenever possible the person or their representatives were involved in the assessment of needs, risks and planned care. The QUEST system encouraged staff and people receiving the service to take part in the assessment of their needs, though there were some inconsistencies with some of the information recorded, which we discussed with the respective unit managers and registered manager during the inspection visit. More care needed to be taken so that peoples needs were not misunderstood or left unmet. We asked the registered manager, appointed 12 months ago, for any evidence held at the home that a previous recommendation had been actioned. It had been recommended that greater numbers of staff on Palethorpe unit would benefit from further training in alcohol related dementia, mental health topics and learning disability. This was to give people living on the unit greater confidence in knowing that staff could recognise and understand their needs. The training plans did not contain evidence that this additional training had been provided and we were not provided with further evidence during the inspection visit. We were told that all unit managers had achieved competence as trainers in various topics, and the unit managers and four RGNs had achieved NVQ 4 and the Registered Managers Award. During discussions with individual unit managers, they acknowledged that they had no mechanisms or evidence to show that staffing levels were monitored or revised proactively in accordance with residents occupancy and dependency levels. This meant Care Homes for Older People Page 14 of 52 Evidence: that staffing levels may not be adjusted to meet residents changing and in some instances increasing needs and dependency levels. We received comments from surveys and discussions with relatives, staff and others that at times the home was short staffed and people did not always receive prompt attention. Care Homes for Older People Page 15 of 52 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are care plans and risk assessments, though these are not always adequate to identify each persons needs and provide staff with information and guidance. There are not always assurances that all individual needs will be met for each person. The arrangements for administration of medication do not always ensure people receive their medicines as prescribed by their doctor, which may pose risks to their health and well being at times. People are generally treated with respect and their privacy and dignity is maintained. Evidence: We looked at a range of residents care records in each of the 5 units. There were considerable variances in how well the healthcare screening tools, risk assessments and care planning were implemented, monitored and maintained. This meant that not all persons living at the home could feel assured that all their care needs were known about, understood and would be met. All units had a number of residents with complex Care Homes for Older People Page 16 of 52 Evidence: needs. Manby, Bloomfield and Palethorpe had a number of people needing to be nursed entirely in bed, and some of these people required end of life care. Some of these people were not being cared for on nursing profile beds, which would have minimised some of the discomfort when needing a change of position. The manager told us additional nursing profile beds could be ordered but acknowledged that there were insufficient of these beds for all residents being nursed in bed. We saw a resident on Manby unit, needing end of life care, nursed in bed with very limited movement, poor nutrition and a high Waterlow score with a support plan in place to maintain skin integrity. This person was not being nursed on a profile bed, and though there was with a pressure relieving mattress in place this person had developed on pressure ulcer on the right hip, which had deteriorated to grade 4. Following discussions with the unit manager and registered manager we established no Regulation 37 notifications had been made to the CSCI relating to any of the people currently at the home with significant pressure ulcers. We required that retrospective notifications be submitted and all future notifications be made without delay. There were some positive examples, such as some care plans gave staff detailed guidance about how to communicate for example face to face, speaking clearly, using simple words and closed questions. However the sample of plans we looked at, especially for the people with complex needs or towards the end of their lives, did not always consider all areas of the persons life such as health, specialist treatments, personal and social care needs. There were a number of areas where there were shortfalls. We noted that there were residents identified with poor nutrition and care plans, which instructed that the person should be weighed or screened using the Malnutrition Universal Screening Tool on a weekly or monthly basis but records were inaccurate or inconsistent. Although we saw that there were risk assessments in place for the reduction of pressure ulcer development, falls, nutrition and moving and handling, which were reviewed monthly, there was considerable variance in the scores for people identified at high risk. We noted that there were no turn charts in place for residents nursed in bed on Manby unit. The turn and fluid balance charts in place on other units such as Palethorpe and Heronville units were not readily available and were not appropriately completed, with instances showing insufficient fluid intake and often no record of output. Records were generally better at Bloomfield unit. The nurses in charge acknowledged our findings during the visit and we also discussed these areas needing improvement with the home manager during the three day visit. We saw a section of the QUEST documentation leading staff to consider whether the Care Homes for Older People Page 17 of 52 Evidence: person required a Mental Capacity Act, assessment. The entire sample we looked at were completed with the response, no. This did not appear to be accurate when considering the diagnosis and observations of some of the people. During discussions with the unit manager and later with the registered manager there seemed to be a lack of understanding of the actions required in compliance with the Mental Capacity Act and the involvement of independent advocates and multi disciplinary decisions for the persons best interests. We noted that the majority of residents or more generally their relatives and representatives, had signed the QUEST documentation containing plans of care to be provided, indicating their agreement. We saw evidence of referrals to other healthcare professions, for example a resident received support from the Speech and language therapists and the staff were given advice given regarding individual peoples poor diet and we noted that Thick and Easy was prescribed to assist some people who had difficulty swallowing fluids. There were some good examples of documentary evidence that people had been reviewed and discharged by the speech & language service, though the home was assured further referrals could be made if needed. We were told all residents had access to community services such as chiropody, dentistry and the optician. However when we asked for evidence that all residents had been offered regular dental screening, on 4 units we were told that residents could be seen by a dentist on request or as the need was identified but there was no regular screening. This was especially important for the screening of the oral soft tissue. We noted that there were generally no oral care plans in place, especially for people at risk of poor nutrition, dehydration or receiving end of life care. This was raised with the nurses in charge. An example was that we visited a person admitted for palliative care, nursed in bed, who was very tall and had obviously been well built prior to illness. This person looked reasonably comfortable but their mouth looked dry and sore. When asked if his mouth was sore and if he wanted anything, he said yes and asked for a drink and breakfast. This was arranged, though the unit manager stated he had been fed with porridge and tended to forget. There were records of food and fluid intake and output, which were more comprehensive than seen on other units. We raised the issue that there was no mouth tray or care plan for oral care. The unit manager had rectified these omissions by the end of the day, which was a postive response. We looked at the care of a people with type 2 diabetes, which was again variable across the units, some generally well managed, with information relating to diet, medication, and heath care monitoring. On other units the persons diabetic care plans were not sufficient and did not give staff guidance to manage the condition to maintain Care Homes for Older People Page 18 of 52 Evidence: or promote health and well being. We discussed the services offered by the diabetic nurse specialists in Sandwell with the unit managers and registered manager and recommended that she contacted the diabetic nurse specialist team to provide additional support, information, and appropriate specialist diabetic training for the trained nurses and care staff. There were some issues of concern such as the regular daily or weekly BM testing, regular urinalysis required as part of the care plan, was not always done consistently and there were no records of action taken to report results which were outside of the persons normal parameters. From the sample of care records looked at across the five units, with the exception of Palethorpe unit, there were generally no short term care plans found in the sections of the file indicated. One recently appointed unit manager confirmed she could not find any, despite the person having had several chest infections requiring antibiotics. The registered manager later on 27/11/08 told us that another nurse who had worked on Haines unit for a longer period had found some short term care plans for the person we had discussed. However, recent short term plans to be useful, should be on included as part of the persons care file for reference. During the tour of the home on the second day we noted a resident with severe facial bruising. We asked how this had occurred and the nurse in charge informed us that this person had fallen in the bedroom during the night. We saw the accident record dated 25/11/08, which indicated the person was not sent to hospital but the nurses waited for medical advice from the GP on routine visit, who did not send the person for further investigations of injuries at hospital. We looked at the residents bedroom and although we were told bedrails would have presented a greater risk of injury, we saw that bumpers for bedrails had been placed on the floor beside the bed. We discussed with the nurse in charge that this potentially created an increased risk of a trip or fall, should this person attempt to get out of bed unaided again. We were told that this had been put in place by the night nurse as a temporary measure. We noted that the risk assessment and falls assessment had not been updated. This was brought to the attention of the registered manager and unit manager. We requested that this be done and that referral be made to the falls team, or occupational therapist for advice. We were shown an updated risk assessment, which included more frequent checks during the night but had not included any indication that a referral would be made to the falls team or occupational therapist for an assessment and guidance to meet this persons needs and ensure her safety. We saw that staff treated residents with respect and protecting their privacy for the majority of time during the inspection. During discussions staff demonstrated a good understanding of how to protect residents privacy and dignity. Care Homes for Older People Page 19 of 52 Evidence: We noted that the care documentation included end of life care plans and relatives expectations but these were generally not completed on the sample of residents care records examined. The nurses told us that this was a sensitive area, which was often difficult to discuss, especially with relatives of very poorly residents. A notable exception to this was Bloomfield unit, with 10 palliative care beds, which had postive plans. Whilst we acknowledged the sensitivity of the subject, the lack of information may result in persons final wishes not being met and this may have important significance, especially for people with strong spiritual or cultural beliefs. We recommended that staff receive training to give them the skills and confidence to discuss and record final wishes for residents end of life plans. The home had a named nurse and key worker system, which should enable staff to establish special relationships and work on a one to one basis. We noted that staff were allocated in teams to work on identified parts of each unit but there were no named allocated workers to be responsible for the more intensive care and support for people with very complex needs. This meant that needs of people at risk of tissue damage, malnutrition or dehydration, or social isolation may not have all their needs met on very busy, heavy dependency units. We heard from some staff who told us that there are sometimes staff shortages but they try their best to meet each persons needs. We discussed with the unit managers and registered manager the options of some people being able to sit out a bed for short periods to relieve the pressure and provide some interest and stimulation. We were told that on some units, such as Manby that there were no suitable comfortable chairs, such as recliner chairs available and this was an issue for people needing specialised postural support. There were no care plans in place for social stimulation for any of the residents being cared for in bed. The unit manager and staff spoken to on Manby unit told us that due to the heavy dependency on this unit there was insufficient staff time available to spend quality time with residents. The pharmacist inspector visited the home on the 26th And 28th November 2008 as part of the key inspection and carried out an inspection of the medicines management systems being practiced within the home. The pharmacist inspector visited four out of the five home that made up Ryland View. We found similar problems with the management of medicines across all of the four units and as a consequence the medicines management systems within Ryland View were found to be poor and were placing the health and wellbeing of the people who use the service at risk. We found that the medication records were poor. We found that the quantities of Care Homes for Older People Page 20 of 52 Evidence: medication were not being recorded properly upon receipt. Any medication carried over from the previous month was not being taken into account with the new quantities. An audit of the receipt, administration and disposal of medication found that medication could not be accounted for. Comparison between the Medicines Administration Record (MAR) charts and the medicines present showed that staff on a number of occassions had signed the MAR charts to confirm that administration had taken place when in fact the medication had not been administered. We found that some medicines were not being administered because the nursing staff had either not found the products in the trolley or the products were out of stock. We also found that where variable doses had been prescribed the records did not show what quantity had been given. Also where medication had not been administered and a generic abbreviation had been used there was either no definition of the abbreviation or the same abbreviation had been used for two different scenerios. This therefore meant that the reason for the non-administration was not evident. It was therefore not possible for the home to demonstrate that they had been administering medication as prescribed by the doctor. An examination of the waste records showed that not all of the disposed medication was being recorded in the disposals register. We found that the care plans were poor for containing information about the administration of medicines. We found that changes made to the medication of some people who used the service was not being recorded in the care notes. We found little evidence of the doctors involvement in discontinuing some medicines. We found inadequate information in the care notes about the administration of when required medication. We found no detailed information about how and when rectal diazepam should be administered in the prevention of epileptic seizures. We found that some people who used the service were having their tablets placed into thickened liquid in order to aid in the swallowing of it. We found that the home had obtained permission off healthcare professionals for this action but there was no evidence that the person who this was happening to had been consulted or had consented to this action. We were concerned with the time period between the morning and lunchtime medication rounds. The morning medication rounds were not finishing until approximately 11:00am and with the lunchtime round starting at 1:30pm the administration process, as it stood, was not guaranteeing that there was an adequate gap between doses to ensure the safety of the residents, particularly with the administration of Paracetamol containing products. We found that with all the issues identified during the inspection that the nursing staff were not fully competent to handle and administer medication safely and correctly. Care Homes for Older People Page 21 of 52 Evidence: The Manager said that a number of training days had been organised in December 2008 and January 2009 to refresh the nursing staffs understanding of safe handling of medicines. The Manager also said that none of the nursing staff had undergone an assessment of competancy to administer medication safely for over 12 months. In light of some of the issues identified during the inspection the home was asked to review their training to ensure that the training needs of the nursing staff are addressed. The competency assessment programme also needs to be introduced with some urgency to ensure the safety of the people who use the service. We found that each unit had its own medication storage room. We found that a couple of the rooms were too hot for storing medication and the home was asked to monitor the temperatures of these rooms closely and take action if they remain above 25 degrees centigrade. We also found that a couple of the fridges which were used to store medication that required cold storage conditions were not maintaining the correct temperature. Care Homes for Older People Page 22 of 52 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are some social opportunities for some people living at the home. People are encouraged and supported to maintain important relationships and friendships. There are choices of nutritional meals throughout the day and night. Some people may not consistently receive appropriate levels of support to maintain good levels of nutrition and hydration, which may pose risks to maintenance of their health and well being. Evidence: We noted that though there were some records of each persons preferred routines these were not always achieved. The homes staffing levels and routines were generally not sufficiently flexible to meet individual needs, most aspects being task focussed and staff had to do the best they could in the limited time available. This was demonstrated with the protracted breakfasts and medication rounds on Manby and Haines units. We also discussed our concerns with the unit manager on Bloomfield unit when we witnessed a person unable to mobilise independently sat in the corner of the bedroom without any access to the nurse call system. When we visited this person in his bedroom he was complaining of abdominal pain and wanted to use the WC. The unit manager activated the nurse call but because the staff were busy with other people, she attended to the persons needs herself. The concern was that this person Care Homes for Older People Page 23 of 52 Evidence: had been in discomfort for an indeterminate length of time and it was uncertain how long he would have had to wait for a member of staff to check on him in his bedroom. This was because staff were extremely busy attending to other peoples needs. During our tour of the premises we also noted a number of people with late stage dementia in left in their bedrooms, which meant that additional staffing resources would be needed to monitor and meet these peoples needs. On a positive note we observed that people generally looked well groomed, with appropriate clothing for the time of year, and with some female residents wearing jewellery of their choice. There were activities co-ordinators for each unit, though the person allocated to Manby unit was off sick during this inspection. We talked to the activities co-ordinator allocated to Bloomfield unit, and we were told that though there was a high turnover of residents on this unit due to the palliative care beds. It was positive that the other frail older people who were not terminally ill were enjoying making things for Christmas. We were shown the very attractive salt flour, hand painted decorations in the activities room. We were also told that there were entertainments such as singers with songs from the 1950s and 1960s and there would be a carol service nearer to Christmas. The person accompanying us reported, I was asked to look at activities, food, cleanliness, decor, privacy, and how service users got on with staff, and at the quality of life on the whole. When visiting Haines Unit, The activities co-ordinator invited me to sit in on a bingo session. There were about 20 people present and those who could participate were enjoying the bingo. I could see that it was not just a formality. I talked to a service user who had been living there for seven years. He said that he liked it there but got fed up sometimes. When asked why he felt this way he said Oh things happen. I could not probe any further as the carer present kept interceding. He said that the food was ok although another resident I spoke to later was quite satisfied with the food and the choices on the menu. I also had a look at the menu and I found that there was a good choice on offer. When asked what he would improve, he said that he felt that staff were overstretched in the mornings. However when I spoke to a carer about this, she said that they could cope and it was not an issue. When I was in his room I noticed that the bed had not been made and the carpet needed hoovering. The person visited Bloomfield unit and reported, When I walked in there were three residents watching TV and the place was spacious, clean and fresh. A carer told me that Bloomfield provides mainly palliative care so things can change very quickly. I spoke to the activities coordinator and she told me that residents are mostly nursed in bed but even the poorly ones like activities. They are more active in the morning so Care Homes for Older People Page 24 of 52 Evidence: most activities take place between breakfast and lunch. The afternoons are quieter. Regarding spiritual needs, there is communion once a month. A vicar also goes from room to room so there is opportunity for everyone to participate if they wish to do so. The person visited Palethorpe unit for younger adults, and reported, I noticed an activities schedule on the notice board as soon as I entered. Activities included music, hairdresser, cooking, mosaic designs, arts and crafts, and card craft. I observed the activities coordinator in the special activity room working with 2 carers and about 6 residents making greeting cards. There was a happy and jovial atmosphere. The residents had been on two trips, to Blackpool and to the West Midlands Safari Park, and photographs of the trips were on display. The manager said she thought that the strong point of the unit was that residents are engaged all the time, I think everyone is looked after and no one is left out. The manager was proud that the units Inglebrook Garden had won an award and provided an opportunity for staff, service users and their relatives to work together. On Manby unit we noted that there were no care plans in place for social stimulation for any of the residents being cared for in bed. The unit manager and staff spoken to told us that due to the heavy dependency on this unit there was insufficient staff time available to spend quality time with residents. There were no records of any daily living activities or social stimulation. The activity records were variable throughout the five units but were generally insufficient to demonstrate people were offered social stimulation appropriate to their individual needs, especially for people with dementia or sensory impairments. We noted that there were generally more activities offered on Palethorpe unit, for younger people with chronic illnesses. The home had a variation to the registration to provide care for a younger adult with learning disabilities and we looked at how this persons needs were being met. This persons care records relating to lifestyle, included a map of life, which was well completed with important contacts. However not all information about routines and rituals, had been fully completed. The lifestyle plan, gave staff guidance about times of rising, 9 a.m. to 10 a.m., bath or bed bath on alternate days, likes to choose own clothes. Likes talking books, particularly comedy. The unit manager told us this person was not interested in get together meetings held on the unit, and had refused twice to attend. We were told that this person used to attend a local authority day centre but there were a problem with wheelchair access, and was no longer able to access this service. At the previous inspection we noted that there should be a staffing element of one-to-one for six hours each day, but as also highlighted at the previous key inspection, there was no mechanism in place to demonstrate that this arrangement was actually in place. Additionally we received comments during the inspection from members of staff that there were staffing Care Homes for Older People Page 25 of 52 Evidence: shortages on this unit on occasions. We saw that generally there were 2 trained nurses and 6 carers in the mornings, 2 trained nurses and 4 carers on the late shift, and 1 trained nurse and 3 carers nights for 26 younger adults with very diverse needs, including people at the end stages of their lives. We saw lots of visitors during the three day inspection, whilst a number of people told us that they felt generally felt welcomed, there were a variety of views. Some people told us staff were very busy and it also depended on the staff on duty at the time as to the level of attention and information available. We noted that it was very positive that the breakfast and main meal menus were displayed on large boards. We were also told that mid morning and mid afternoon there were snacks of fruit and or cakes. Teatime was at approximately 5:30pm and there was a choice of sandwiches or hot snacks. Suppertime was from 8 p.m. when milky drinks were offered. We noted the new positive improvement of the introduction of the night bite menu. These were meals and snacks available throughout the night, which could be pre ordered for people who did not sleep well or were wakeful through the night. We were told there were people on the units caring for people with dementia who made particular use of this new initiative. We noted on Manby, Heronville and Haines units there were significant numbers of people requiring liquidised diets and pureed diets and high numbers of people required to be fed, assisted or supervised to eat. We noted that some adapted crockery and cutlery was provided, which was positive to aid independence. However our observations were that staff did not have sufficient time to spend with each person requiring assistance with feeding or to be fed. We asked staff if any consideration had been given to staggering mealtimes, we were told this had not been considered as an option but if necessary nurses gave additional assistance. The majority of mealtimes observed were hectic and disorganised, with large numbers of people needing individual support to be fed, or assistance, support or encouragement to eat. Manby Unit had fifteen people who needed feeding and others needed assistance with eating and drinking and at most times there were just 6 care staff, though we noted that the trained nurses helped out. In some units dining tables were attractively laid and some units also had table clothes but generally the dining areas were not arranged for social interaction and mealtimes were not made special. We have recommended that the home consider offering several small nourishing meals each day, at more frequent intervals than the usual mealtimes, which may also relieve the pressure on staff trying to feed residents with very poor appetites. Care Homes for Older People Page 26 of 52 Evidence: We looked at food stocks in kitchen and noted that there were adequate supplies of branded goods such as good quality white and wholemeal bread. We were told that food was purchased through consolidated orders and there were regular deliveries of fresh vegetables, meat and groceries. We saw evidence of fresh vegetables and fruit available. During discussions with catering staff they told us supplies of fruit were sent around to the units on request for staff to prepare and distribute. We discussed the impact on very limited staff time. We were told that the activities organisers frequently came to the main kitchen to make smoothies for people to encourage healthy eating. The catering staff were knowledgeable about special diets, for people with diabetes, and high cholesterol. The staff were also knowledgeable about adding nutritional value to meals. The acting assistant cook was very enthusiastic about her role and about the quality of the service they provided in respect of food, meals, which was very positive. We discussed comments from residents received through the inspection with the registered manager. An example was one person who told us that they did not always have their preferred option and cited a Sunday roast meal of beef being substituted for lamb without explanation, and another time of the beef was tough and being told it had been boiled. There was another example of someone telling staff that the sponge and custard pudding was cold and it being removed without comment and no other option offered. We spoke to a person who had been at the home for some time and who was not aware of any residents meetings where ideas and issues could be aired. We have strongly recommended that regular quality monitoring processes be introduced. Some comments about food were good, and some people on Haines unit have two cooked meals each day if they wished and there was evidence of many different options available, sometimes as many as 15 or 16 different choices for meals each day. Care Homes for Older People Page 27 of 52 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot have confidence their concerns or complaints will be listened to or investigated and the management practices do not protect residents from harm or abuse. Evidence: The complaints procedure was displayed on the main notice boards in the reception areas of the home and was also included within the Welcome Pack and within the service user guide. This helped people to understand who to approach if they are unhappy or wish to express concerns. However we noted from examination of the complaints log, that responses to complaints appeared defensive and not in a style, which would encourage people to raise concerns. On a positive note we saw many cards of thanks and compliments from relatives, displayed on the notice boards in the reception areas of each unit, complimenting the staff and care at the home. We looked at the care of a person living on Manby unit who had been refusing to eat, drink or take medication. The registered manager had discussed this persons situation with us prior to this key inspection and because the person had dementia and medical Care Homes for Older People Page 28 of 52 Evidence: conditions including diabetes we had recommended discussion with the health care professionals and a safeguarding referral to the lead agency Sandwell MBC. The registered manager told us that this persons social worker informed them that Sandwell safeguarding manager had not felt this persons refusal to eat, drink, take medication required investigation under the safeguarding remit. However a referral had been made to specialist dementia team. We noted that though the staff had left finger foods for the resident to eat in the bedroom, she had not eaten or taken any fluids during the first day of the inspection visit. We observed that she was resting on top of the bed, very lethargic and not responsive when spoken to. We contacted the social worker, who stated that he had visited the home on a previous occasion with the intention of admitting this person under Section 2 of the Mental Health Act, but eventually she had agreed to a voluntary in-patient hospital admission for 28 days. The social worker expressed concern about the lack of contact or involvement of either the relative or anyone from the home during this persons 28 day stay in hospital. He also stated that the home had not attended planned multidisciplinary meetings whilst person was in hospital for 28 days. This was also referred to in the consultant psychiatrists letter. The social worker stated he though it would have been particularly important that the deputy manager, RMN trained, attended. He stated that the home had sent junior members of staff to one meeting, which was not considered helpful or appropriate. We discussed these comments with the registered manager and unit manager who felt these comments were unfair, and stated that a registered nurse, accompanied by the activities co-ordinator had attended a meeting. The unit manager had been unable to attend another meeting because she was unavailable. The registered manager stated she was unaware that the meeting was planned and therefore no one was sent as a substitute. The registered manager stated that the person lost a further 4 kg in the 28 days in hospital, and therefore the home did not feel that her care had been managed any better as an in-patient in hospital. The home had a letter on file from the residents relative commending staff and stating it was not their responsibility if the person died, it was her choice to stop eating and drinking. We discussed the issues that this raised in view of the fact that no assessment had been made of this persons mental capacity, and ability to make decisions understanding the risks that they posed. There appeared to be conflict between the GP and consultant psychiatrist about undertaking an assessment for mental capacity, which needed to be resolved. We have raised this with the social worker as an issue requiring resolution. We have requested that the CSCI be kept informed. We were very concerned that there were incidents at the home, which were not being recognised and reported under the procedures in place to safeguard vulnerable adults. We noted situations recorded in regulation 37 notifications held at the home, which we Care Homes for Older People Page 29 of 52 Evidence: were unable to verfify had been received at the CSCI Birmingham office. An incident occurred on Haines unit in April 2008, where a resident reported hearing a member of night staff shouting at another resident, the homes investigation notes indicated that this involved POVA, meaning Protection of Vulnerable Adults. The home conducted an internal investigation. The registered manager confirmed that they did not use advocates when interviewing resident who raised the concern. There was no evidence at the home to show that a safeguarding referral had been made to the lead agency, Sandwell MBC, The homes internal investigation did not uphold allegation. The member of night staff concerned left the homes employ. Another incident occurred on Heronville unit on 24 May 2008, when a resident found another resident sleeping in his bedroom. The records indicated both fought, one person fell to the floor, the other person then stamped on his face, head, left shoulder, injuries sustained included bruised, painful left wrist, small cut on his nose. The injured resident was sent to Sandwell General Hospital, where a fractured left wrist was suspected but unconfirmed. It was recorded that the person needed to go back for further checks. We discussed this incident with the registered manager and asked whether it had been reported under the safeguarding procedures. She could not find any evidence to show that it had been reported but stated she had been on holiday abroad in the spring. A third more recent incident occurred on 26 October 2008 on Heronville unit. Whilst looking at the care of a person recently admitted to the home from Bushy Fields Hospital in Dudley, we noted a record, which described a situation where staff found a female resident in an empty bedroom with the lights off and the male resident standing in front of her with his trousers undone and halfway down his buttocks. We were assured that the female resident did not seem distressed, her clothing was intact and she was escorted away by staff. We saw evidence that the behaviour had been reported to the doctor who had prescribed Promazine twice daily and PRN for one month. Staff told us that there had been no further instances towards other female residents but some members of staff told us that this person had shown inappropriate advances towards female staff, which could be easily discouraged. The registered manager and staff on the unit acknowledged that the home had not made a safeguarding referral regarding this incident. There were no additional supervision or monitoring arrangements in place on this unit, where we observed staff were very overstretched. We required that retrospective safeguarding referrals be made of all identified incidents and any other unreported incidents or issues to Sandwell MBC. We informed the registered manager we would be discussing our concerns relating to safeguarding Care Homes for Older People Page 30 of 52 Evidence: with the Sandwell Safeguarding Manager and Locality Manager. We subsequently received a retrospective Regulation 37 notification from the registered manager, which gave some information, which was inconsistent with information given at the time of inspection from staff at Heronville unit. It was a matter of further concern that at the time of writing this report Sandwell MBC reported that that no retrospective safeguarding referrals had been received in relation to the issues identified during this key inspection. The home had appropriate policies and robust recruitment and selection procedures to ensure that people who were not suitable to work with vulnerable people were not employed. However there was insufficient evidence that all staff had received training to safeguard vulnerable people living at the home. Care Homes for Older People Page 31 of 52 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The changes needed to the decor and furnishings would contribute to create a pleasant environment for people to live in. The grounds are maintained to provide a safe and interesting outdoor environment for residents. Evidence: We toured of the entire premises, comprising the five units, which accommodated residents, the main kitchen, laundry and administration block accompanied by the deputy manager. We expressed our concerns about the lack of evidence that the home was being proactively maintained to satisfactory standards with an ongoing repairs, maintenance and renewal program. In the main, all of the units required some minor repairs to linen cupboards with broken locks where the home stored items other than linen. The unsecured cupboards could pose health and safety risks to people living in the home. There were broken paper towel dispensers on Haines and Palethorpe Units. An assisted bathroom Manby unit had no liquid soap in dispenser. The replacement of these items was required to ensure that all staff working at the home could maintain good infection control practices. We found a high number of assisted bathrooms and shower rooms being used as inappropriate storage for items of equipment. The deputy manager told us that these particular rooms were not in use apart from two bathing facilities on Care Homes for Older People Page 32 of 52 Evidence: Palethorpe and Bloomfield units where there were items of furniture and mattresses. We were told that these items which, caused a lack of room for people needing any physical assisting and posed risks to staff assisting people in taking baths and /or showers, would be removed. We noted that some toilets were out of use because one toilet was blocked and others because the flooring was being replaced. We were concerned to see evidence of a mug left on the side of the washbasin in one bathroom on Manby unit, where staff had been drinking a hot drink. These actions compromise health and safety and good infection control. The deputy manager removed the mug. The decor in many corridors looked tired and faded, particularly on Bloomfield and Manby Units. Additionally carpets needed replacing, as they were very worn in corridors on both Manby and Haines units. These issues were acknowledged by the deputy manager. We found quite a large area bare plaster in evidence on Bloomfield, which was where a door had originally been. We discussed the bland environment with the registered manager and unit managers, particularly related to units where people with dementia were accommodated. We noted there was no differentiation of corridors and the doors in some of the units lacked any individuality in relation to peoples personality. Oreientation is particularly important for people experiencing dementia. Managers acknowledged that more thought needed to be given to environments to provide more orientation and stimulation for people with dementia and sensory disabilities. We found bedrails, which were loose in some bedrooms and required tightening and in some cases bolts and brackets were worn. There were also bedrails with excessive gaps or bumpers, which were not close fitting. We were assured that the deputy manager would action these to be remedied immediately and we witnessed that they were noted in the maintenance records kept on each unit. However we were concerned that we had to repeatedly ask if the work had been carried out and it was not until day three of this visit that we had assurance the remedial work had been carried out. Some redecoration work had taken place on Heronville in the past year in the lounge and dining area of the unit, which had made it a more relaxing area for people to sit and have their meals. However we noted that not all dining tables were laid with cutlery and place mats at meal times. We found throughout the home that there was generally a satisfactory supply of gloves and aprons and liquid soap. These items were available to help to reduce the risk of cross infection to people living at the home. We visited the large laundry sited in a separate part of the home. There were Care Homes for Older People Page 33 of 52 Evidence: dedicated staff who undertook all laundry tasks, three on duty each day from 05:00 16:30. We noted the laundry was well equipped with three commercial washing machines and two dryers. There were supplies of gloves, aprons, paper towels, and liquid soap. There were separate hand washing facilities and evidence of infection control procedures displayed. The trucks for distributing the laundry had wheels on them but one member of staff stated that these needed replacing, and the deputy manager was aware of the issue. We saw evidence of cleaning schedules and the laundry looked clean and well organised. The home had a main kitchen, which provided all of the hot meals for people throughout the home. There were catering staff on duty every day. We were told that the catering manager had resigned and an assistant cook was away on sick leave. The catering staff should consist of a catering manager, assistant cook and kitchen assistant. We were told that interviews were taking place for the post of catering manager. There was evidence of a wide range of food available including some brand named items, white and brown bread, choices of cereals, a range of milk which included semi-skimmed and full fat and choice of snacks. All foods seen were appropriately labelled and food, fridge and freezer temperatures were recorded daily. The food store cupboard appeared to be well organised. The last Environmental Health Report contained serious areas of concern, with legal requirements for actions to be completed. The concerns were mainly around the cleanliness of the kitchen, and walls. The Environmental services Officer had re-inspected and acknowledged that the staff had undertaken a complete clean of all the kitchen walls. There were only a small number of areas to be completed. We noted that the staff working in the kitchen had undertaken training appropriate to their role. The person accompanying us who had experience of using care services also toured the home and reported their perceptions. The first thing that struck me was how peaceful and tranquil the place was, considering that it was only a hundred yards or so from the main road. The bungalows looked in good shape with rooms overlooking nicely kept gardens. Right by the front door I found BUPA information being displayed, as well as information on dementia. The reception itself was bright and tidy and the staff welcoming. Care Homes for Older People Page 34 of 52 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skill mix of staff do not always consistently meet the needs of people living at the home. Recruitment and selection procedures are robust and safeguard vulnerable people. Evidence: The homes AQAA cited the following as evidence of what they do well, BUPA Care Homes has comprehensive Human Resource policies and procedures to aid staff management and recruitment. We endeavour to maintain agreed staffing levels at all times. We perform appropriate CRB, POVA and NMC PIN checks on all staff. There is a training matrix specific to the home that identifies the training requirements of staff. We have a good level of staff retention. We have a unified style and format for staff files. We have an improved skill-mix. All mandatory training is up-to-date. Comprehensive Whistle blowing Policy. BUPA Care Homes has received IIP accreditation and it has been reviewed since 2003. The homes AQAA cited the following as evidence of improvements of the past 12 months, Staff training is now being rolled out in a more structured manner. Attendance at mandatory fire training has improved. Use of agency staff has been virtually eradicated. Implementation of a new BUPA-wide NVQ training programme, with 3 monthly intakes of new candidates. Care Homes for Older People Page 35 of 52 Evidence: We were unable to verify the accuracy of all of the positive practices claimed in the homes AQAA. The staffing levels in place to meet all residents needs were questionable as highlighted though the previous sections of this report. There were approximately 134 residents accommodated, with a variety of dependency levels, complex and diverse needs over the three day inspection. The homes AQAA recorded that there were 25 people who were bed fast, 73 People who have dementia, and 84 People who require help, and supervision or prompts to eat meals. During the three day inspection we saw and heard about people waiting for attention, especially medication, assistance with feeding and to be taken to the toilet. The dependencies fluctuate considerably at each house; most markedly at Bloomfield unit and we were not shown dependency tools, which linked to staffing levels to allow the home to respond in times of increased need. We were told that the dependency was very heavy at Manby unit and there were people in other houses requiring end of life care and others needing close monitoring. The staffing rotas both in terms of numbers and stability did not demonstrate the managers regularly monitored residents dependencies and occupancy levels and reviewed and revised staffing levels, making appropriate adjustments. The homes AQAA recorded that 385 nursing shifts and 2737 care shifts were covered by temporary or agency staff in the previous 3 months. These were potentially people who would not know the residents and their needs well. This confirmed information given to us that some units experienced high levels of staff sickness absence. We were told that the home was experiencing difficulties retaining and recruiting experienced staff, especially trained nurses. The homes AQAA included the information that 25 staff had left the homes employ in the 12-month period up to December 2008. Some staff told us they struggled to meet peoples needs. The unit managers on three units told us that at times there were insufficient staff to provide the quality of care they wished to provided. The other two unit mangers appeared not to recognise that at times the lack of consistent, experienced staff were adversley affecting positive outcomes for people in their care. We looked at the staff files for 6 members of staff. We did this to ensure that the home was continuing to recruit people in a way that safeguards the people living at the home. We found that all staff files had the appropriate recruitment checks in place. All Criminal Record Bureau Disclosures were stored at BUPA head office. We saw evidence that all new staff were given a personal best folder, which contained all of the induction standards. We were told that all new staff were supported on the units by senior carers or trained nurses. Care Homes for Older People Page 36 of 52 Evidence: At present only 30 out of 94 care staff have obtained an NVQ qualification. We were told that there were a further 10 care staff who were working towards this Award at present. The deputy manager had taken action to improve the systems for mandatory training at the home. We were told that all staff were now attending regular training sessions ensuring that their knowledge and skills were being kept up to date. Unfortunately this was not supported by training records, which were not up to date. We spoke to the nurses about clinical practice and updates available for diabetes, tissue viability, Parkinsons, infection control and whether there were any link nurses with specialist areas provided or supported by the PCT. We were told that that there was good access to all mandatory training but little access or opportunities for keeping up to date with clinical practices. We discussed the comments with the registered manager who insisted that regular information about clinical training courses were circulated around the units for nurses to apply for. She did acknowledge that there was not a significant take up of these training courses. Care Homes for Older People Page 37 of 52 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home cannot be assured that the new management arrangements always provide effective leadership to ensure that their health, well being and safety of will be safeguarded. Evidence: This home had not had the stability of a consistent registered manager in post for some time. The current registered manager, Ms Kalmit Jagpal had been in post since September 2007. We noted that she had achieved the Registered Managers Award, RMA and she showed us an impressive portfolio, with numerous training certificates. She had RGN qualifications and many years of clinical experience. She used to be unit manager at Ryland View, and moved for career development opportunities to be the registered manager of a large single site 60 bedded home, where made significant improvements to achieve a quality rating good two star home. We were told the registered manager had the support of an Area Manager and an experienced deputy manager within the home. Care Homes for Older People Page 38 of 52 Evidence: We were told that the home had a quality plan, which reviewed all areas of the home at least annually. The home had a unit manager who conducted 3 monthly audits of the incidence of care plans and risk assessments. There were also medication audits. There were minutes to show that unit manager meetings and staff meetings were held. The registered manager told us that BUPA questionnaires were issued to residents and relatives in October 2008 but results were not returned or collated at the time of this inspection. There were no stakeholder questionnaires issued. We also saw reports of the Regulation 26 monitoring visits undertaken by the organisations representative, the area manager. We discussed our concerns that though some shortfalls had been identified at monitoring visits, these had not been rectified at the time of this inspection. The homes quality monitoring arrangements did not appear effective in supporting staff to improve consistent practices across the home and rectify ommisions affecting people being cared for. Additionally we were seriously concerned that the homes monitoring arrangements had not identified potentially serious variances and failings with the management, storage and administration of medication, as identified by the CSCI Pharmacist. We were told that any residents monies held in temporary safekeeping were held in a pooled bank account with individual records for each person. Any interest accrued was allocated pro rata. We noted that there were secure facilities for the temporary safe keeping of residents personal money and valuables. Written records were available for all transactions with two signatures. Regular external audits of residents personal money in temporary safekeeping were undertaken. People living at the home were able to control their own finances if they preferred and were capable, though we were told there was no one who had chosen to do so at the present time. We were told that staff could request money for resident with permission of clinical manager. We were also informed that sometimes carers purchased items for residents using their own money, which was then reimbursed. An example given was the purchase of vests. It was explained that the BUPA policy stated the home can only hold 150 pounds cash float, and 15 pounds petty cash at any time, even though there can be up to 140 residents accommodated. This practice should be reviewed to ensure residents funds are readily available to meet their needs. We were told that people living at the home could request larger amounts of cash, which have to be withdrawn and we were shown an example where someone wanted a larger amount to purchase Christmas gifts. The home had a corporate BUPA health and safety policy and procedure, the deputy manager as the named person. We spoke to him about our concerns that he did not appear to take the responsibilities of this role seriously. The health and safety, maintenance and service records were disorganised he was unable to find records or evidence required by 15:15 on day 3 of this inspection visit, despite notice the Care Homes for Older People Page 39 of 52 Evidence: previous day of records we would need to examine. We looked at a sample of mandatory staff training records, fire safety and maintenance service records, which were not entirely satisfactory. Examples were that though the fire alarms and emergency lights had been serviced on Haines unit there were 13 defective lights identified and there was no verbal or written indication that they had been rectified. We saw a 5 yearly fixed wiring certificate dated 14/2/01 and some time later another certificate dated 24/8/06 was found. This was recorded as unsatisfactory, some items were priority 1, urgent, but there were no records or verbal assurance from the management of the home that the remedial work had been carried out. There was a Legionella Risk Assessment, which required a range of frequent checks. However the only water temperatures we were shown were monthly checks on the hot water boilers, 60 degrees in the boiler and 50 degrees on the return circuit. There were also a number of other health & safety and infection control risk assessments, which needed to be reviewed, one for example relating to showerheads. We looked at the records for fire training, which were not up to date, and this was acknowledged by registered manager and deputy manager. We were told that the maintenance person conducted the fire drills, however the records did not show all staff had participated in a fire drill and there was no evidence of fire drills being provided for night staff. This meant that staff would be unfamiliar with evacuation procedures for vulnerable people especially at risk during night hours. The unit manager on Manby unit had told us that the work was underway to update the fire risk assessments and she told us that when identifying people at high risk in the event of fire and evacuation, the majority of the 30 people living on Manby unit were coded red, high risk, each requiring assistance of two staff. The Registered manager and deputy manager were informed that we would be making a report to the West Midland Fire Service about our concerns. We were told that the handyman carried out and recorded monthly bed rail checks, including measurement of gaps. However we noted that there were at least two sets of bedrails with excessive gaps. Additionally, whilst looking in detail at the care of a person being nursed in bed we noted that the bedrails were not fully fitted to the bed. We noted other issues relating to ill fitting, insecure bedrails during the tour of the premises. We asked for the deputy and maintenance person to check bedrails and resolve any deficiencies, this was not done until after further prompting on the third day of the inspection visit. We noted that there were some gaps in mandatory training, which need to be provided Care Homes for Older People Page 40 of 52 Evidence: for all staff commensurate with their role. We identified that there were at least 3 records of residents sustaining serious fractures at the home. It was acknowledged that these injuries had not been referred to the HSE. We discussed non referral of fractures to major bones in accordance with RIDDOR with the registered manager and deputy manager. The deputy manager claimed that whilst working at previous home, to have been told by someone at HSE, there was no need to report accident of fractures involving residents, and that only serious accidents involving staff were notifiable. We stressed that it was for the HSE to decide whether accidents to residents were notifiable and that all injuries to major bones including head injuries must be reported in accordance with RIDDOR and that retrospective notifications to HSE must be made without further delay. We made the deputy manager and registered manager we would be discussing this issue with the Health and Safety Executive. We looked at the accident records for the past 12 months. There were 83 recorded accidents relating to residents and 14 recorded accidents relating to staff or others in the last 12 months. The registered manager showed us evidence that she had undertaken regular documented analysis of accidents relating to staff but acknowledged that she had not undertaken any analysis of accidents relating to residents since her appointment the year before. Although she showed us evidence that she had analysed and evaluated accidents involving residents when she had previously worked at the home, recognising the importance of identifying and minimising risks to peoples health, well being and safety. There was insufficient evidence to show that all unexplained injuries, especially bruises and skin tears had been thoroughly investigated. There were also accident records relating to limbs entrapped in bedrails, where risk assessments had not been reviewed. This meant that people living at the home might not be adequately safeguarded from risks of harm. An example may be incorrect moving and handling techniques from staff who may be unfamiliar with each persons needs, risk assessments and care instructions. All accident records were file in lever arch file in the main office and there were no copies of the accident records kept on residents individual files. On the sample of residents care looked at none of the falls risk assessments highlighted accidents sustained or remedial actions, which meant that dealing with accidents in isolation posed risks that staff would not be aware of previous incidents and the risk of further harm to residents would not be managed or minimised. An example of concern was that whilst we were observing at lunchtime on Heronville we noted a resident with a badly bruised face. We asked staff how this had happened, and the nurse in charge told us this had occurred as a result of an accidental fall from Care Homes for Older People Page 41 of 52 Evidence: bed. The person was observed to be unsettled and agitated, continually shuffling to the edge of chair. A cantilever table had been placed in front of her chair and a nurse sat feeding two residents at the same time, also trying to make sure that the person stayed in her seat in the lounge / dining room. We visited the persons bedroom and noted that bedrail bumpers had been placed on the floor beside the bed. We highlighted to the nurse in charge that this potentially created an increased risk of a trip or fall, should this person attempted to get out of bed unaided again. We were told that this had been put in place by the night nurse as a temporary measure. When we looked at the care records we noted that the risk assessment, and falls assessment had not been updated. We requested that this be done and that referral be made to the falls team, or occupational therapist for advice. Later in the inspection we were shown an updated risk assessment, which included more frequent checks during the night but had not included any indication that a referral would be made to the falls team or occupational therapist for an assessment and guidance to meet this persons needs and ensure her safety. Care Homes for Older People Page 42 of 52 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 43 of 52 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 12 The registered persons must 02/03/2009 ensure that each persons has a care plan, which reflects all of their assessed needs, and for example includes the following, wound dressing regimes, special dietary nutritional regimes, specialist diabetic care regimes and the management of all risks. This is to ensure care for residents health and well being is properly maintained at all times. The registered persons must 02/03/2009 take action to ensure that the all aspects of health care assessments and risk assessments identify and provide guidance for all areas of risk and reflect all changes to each persons health and needs, including short term care needs. This is to ensure that people 2 7 13 Care Homes for Older People Page 44 of 52 living at the home are safeguarded from risks to their health and well being and safety at all times. 3 8 13 The registered persons must 02/03/2009 take action to ensure that residents with poor nutritional intake and, or weight loss are weighed or monitored using the MUST as frequently as required by their risk assessment and care plan. This is to ensure that staff take required actions to promote residents health and well being. The registered persons must 02/03/2009 ensure that special care records such as food, fluid balance charts and turn charts are in place, with care provided appropriately recorded and monitored. This is to ensure residents health and well being is maintained. Staff who administer 02/03/2009 medication must be competent and their practice must ensure that people who use the service receive their medication safely and correctly. This is to ensure residents health and well being is safeguarded. Medication must be stored within the temperature range recommended by the 02/03/2009 4 8 13 5 9 13 6 9 13 Care Homes for Older People Page 45 of 52 manufacturer to ensure that medication does not loose potency or become contaminated. This is to ensure residents health and well being is safeguarded. 7 9 13 The records of the receipt, 02/03/2009 administration and disposal of medicines for the people who use the service must be robust and accurate to demonstrate that all medication is administered as prescribed. This is to ensure residents health and well being is safeguarded. Appropriate information relating to medication must be kept, for example, in risk assessments and care plans to ensure that staff know how to use and monitor all medication including, when required medication, to ensure that all medication is administered safely, correctly and as intended by the prescriber to meet individual health needs. This is to ensure residents health and well being is safeguarded. 02/03/2009 8 9 13 9 18 13 There must be suitable and 27/02/2009 appropriate arrangements in place that includes staff training to prevent people living at the home being harmed or suffering abuse Care Homes for Older People Page 46 of 52 or being placed at risk of harm or abuse. This is to ensure that the health and welfare of people living in the service are safeguarded. 10 18 13 The registered persons must 06/02/2009 demonstrate that all complaints are fully investigated, with records of outcomes, actions and responses to complainants where they are known. This is to ensure that the health and welfare of people living in the service are safeguarded. 11 18 13 The registered persons must 06/02/2009 ensure that ALL allegations or suspicions of abuse are referred to the designated person in accordance at the Lead Agency in accordance with the multi-agency Safeguarding Procedure without delay. This is to ensure that the health and welfare of people living in the service are safeguarded. 12 27 12 The registered persons must 27/02/2009 take action to ensure staffing levels are reviewed in conjunction with occupancy and dependency levels to ensure that each persons needs are consistently being met throughout the day and night. Care Homes for Older People Page 47 of 52 This is so that each persons health, well being and safety can be assured. 13 33 24 The registered persons must 02/03/2009 implement effective quality monitoring systems, which demonstrate that positive quality outcomes are consistently achieved for all persons living at the home. This is so that the health, well being and safety of each person living at the home is assured. 14 37 13 The registered persons must 06/02/2009 ensure that all injuries to major bones including head injuries must be reported in accordance with RIDDOR and that retrospective notifications to HSE must be made without further delay. This is to safeguard the health, well being and safety of people living at the home. 15 37 37 The registered persons must 06/02/2009 ensure notifications are submitted to the Commission of Social care and Inspection of any incident that has affected the health, safety or wellbeing of the people at the care home, without delay. Some examples are incidents requiring safeguarding referrals and all significant pressure ulcers. Care Homes for Older People Page 48 of 52 This is to safeguard the health, well being and safety of people living at the home. 16 38 13 The registered persons must 06/02/2009 ensure that there is suitable fire protection in place, including servicing and maintenance of equipment and staff training and fire drills for all staff at intervals deemed appropriate by the West Midland Fire Service. This is to safeguard the health, well being and safety of people living at the home. 17 38 13 The registered persons take 06/02/2009 action to provide all residents with equipment that is suitable to meet their needs, such as nursing profile beds, comfortable chairs. This is to promote residents health and well being and minimise risks of harm. 18 38 13 The registered persons must 06/02/2009 implement management systems to ensure the safe use of bedrails, which includes correct fitting, rigorous risk assessments, diligently followed, documented checks and staff guidance and training relating to bedrails. This is to safeguard the health, well being and safety of people living at the home. Care Homes for Older People Page 49 of 52 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 Each person living at Ryland View should be given a statement of terms and conditions detailing their fees, including the RNCC element, the provider responsibilities and their rights and obligations whilst they are resident at the home. That all residents are offered access to dental services, with records of visits, advice, treatments or refusals to accept dental checks. It is recommended that the services offered by the diabetic nurse specialist service be contacted to provide additional support, information, and appropriate specialist diabetic training for the trained nurses and care staff. It is strongly recommended that where the care plan indicates regular blood glucose monitoring, urinalysis or other tests are required that recorded tests and results be clearly recorded with any remedial actions required. That manufacturers guidelines for use and maintenance of pressure relieving mattresses should be available on each persons risk assessment and care plan to ensure that they are maintained that the correct pressure for the persons individual care. That each persons last wishes in respect of death and dying should be explored and be recorded within their end of life care plan. That there should be a review of those residents care who spend all their time in bed with only very minimal stimulation, with evidence to demonstrate their needs for social interaction are being met. That there should be a record of peoples preferred leisure activities and their choice of daily life and routines such as getting up and going to bed, with evidence to demonstrate preferences are met. That each persons property inventory be fully completed on admission with clothing, furniture, valuables, hearing aids etc. and thereafter kept up to date signed and dated by staff, resident or representative. That action is taken to involve appropriate advocacy for decision making for residents lacking capacity, in relation to 2 8 3 8 4 8 5 8 6 11 7 12 8 12 9 14 10 14 Care Homes for Older People Page 50 of 52 The Mental Capacity Act 2005. 11 15 It is recommended that the consideration be given to offering several small nourishing meals each day at more frequent intervals than the usual mealtimes, which may also relieve the pressure on staff trying to feed residents with very poor appetites That the action is taken to undertake minor repairs to linen cupboards with broken locks where the home stored items other than linen, which could pose health and safety risks to people living in the home. That the organisation continues the maintenance, renewal and redecoration programme throughout the home, with clearly identified priorities and timescales to provide a pleasant and comfortable environment for people living there. That serious consideration be given to the internal environments of each unit to provide more orientation and stimulation, especially for people with dementia and sensory disabilities. That all assisted bathrooms and shower rooms being used as inappropriate storage for items of equipment are cleared of all extraneous items, which limit space for people needing any physical assisting and pose risks to staff assisting people in taking baths or showers. That there are working liquid soap in dispensers in all areas to ensure that all staff working at the home can maintain good infection control practices. It was strongly recommended that regular analysis and evaluation of accidents relating to residents be recommenced to highlight trends and identify actions to minimise risks to residents health, well being and safety. 12 19 13 19 14 19 15 22 16 26 17 38 Care Homes for Older People Page 51 of 52 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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