CARE HOMES FOR OLDER PEOPLE
Shouldham Hall Nursing Home Shouldham Norfolk PE33 0DF Lead Inspector
Kim Patience Announced Inspection 23rd February 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Shouldham Hall Nursing Home Address Shouldham Norfolk PE33 0DF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01366 347276 01366 347658 Shouldham Hall (Registration) Limited Natasha Obolewicz Care Home 48 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (34), Old age, not falling within any other of places category (14) Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To accommodate forty-eight (48) people in total, all of who are older people. Of these, thirty-four (34) Service Users will fall in the category of dementia and fourteen (14) Service Users will have needs associated with old age, not falling in any other category. One Service User under the age of 65 years who has dementia and is named in the Commission`s records may be accommodated. 3rd August 2005 2. Date of last inspection Brief Description of the Service: Shouldham Hall is a 48 bedded care home with nursing for the elderly, and elderly mentally frail. The home consists of two major elements, the original hall, and the new wing. There are 44 single rooms and 2 double rooms on the ground and first floor. The home receives its medical services from the local G.P. centre.There is an enclosed garden and large grounds, the car park is adjacent to the main entrance. There is work in place which will enhance the appearance of the gardens when completed. The home is situated at the edge of the village of Shouldham, which is 10 miles from Kings Lynn. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection and the third to be completed in the last 12 months due to concerns arising in respect of the quality of care offered to residents. The inspection team consisted of one Regulation Manager and three Regulation Inspectors. The registered manager and the operations manager were present throughout the inspection and helpful in facilitating the process. On this occasion, the inspection focussed mainly on the Dementia unit. Records relating to residents, staff and the running of the business were inspected. Staff and service users were spoken with and the inspectors observed staff and service users engaged in their daily routines. Comment cards were sent to service users and relatives, however, at the time of writing this report only three had been returned to the Commission. What the service does well: What has improved since the last inspection?
The management and staff have worked hard at meeting the requirements and recommendations made as a result of the last inspection. This does not mean that there is no further work to be done as this hard work now needs to be built on to create a service which is working above the minimum. Staff morale has improved. Staff interviewed liked the new shift pattern and had some sense of ownership of the work they did. Staff are receiving supervision and each had a supervision contract.
Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 6 There were lists of training inputs and accompanying lists of which staff had completed courses. Most of this training was in house and led by the manager or the training officer. This schedule has not been maintained following the departure of the training officer. A new training officer has been appointed and is due to start shortly. The recruitment of staff has improved and the home is now fully staffed and has its own bank of relief staff. This assists in the continuity of care. An activities organiser had been appointed and works five days a week. She had not had any specific training for this role, nor is she trained in dementia care. The premises are showing some signs of wear and tear, but there is an ongoing programme of replacement of chairs, dining room furniture and bed linen. The audit carried out by the company has been reviewed in line with comments made at the last inspection. The care plans have all been completed in line with the master care plan seen at the last inspection. This is work in progress. The menu choices for the day are displayed in each unit and people who are able, do make choices about their meal. The kitchen staff had just undertaken some nutrition training and had some ideas about how choices can be offered to those who found it more difficult to understand what was being offered. Residents were not hurried over their meal. What they could do better:
Care plans need to be developed in line with a person centred approach to care planning. Those in use in the home are not suitable for people with advanced care needs. Care plans must include social and emotional needs. There are insufficient risk assessments to cover all aspects of the service users daily lives. The plans focus on the physical rather than the holistic care. Care plans should be made accessible to staff and staff must be aware of the content of risk assessments. Records kept in service users rooms must be developed to provide meaningful information about how staff are to meet individuals care needs. Moving and handling practice must be improved through training on up to date techniques.
Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 7 Staff must be encouraged to communicate with residents and to be educated as to the importance of positive interaction with residents. Specialist equipment must be provided communication between residents and others. The home must promote the dignity of residents. The home must ensure that the medication arrangements are improved to protect the health and welfare of residents. The effectiveness of the key worker system must be monitored and improvements made where necessary. The home must ensure that they gather information about people’s life history, hobbies and interests so that meaningful activities can be provided. The home needs to find a way to monitor contact time with residents, so that they ensure that stimulation is offered to people at regular intervals. Staff should be encouraged to engage residents in the activities of daily living. The management need to ensure that the home is adequately heated at all times, this may encourage residents to venture out of the communal areas. Meals must be presented in an appealing, appetising manner and in a way that promotes dignity. The practice of getting residents to the dining room about an hour before the meal is served, must stop. People were seated at the table with no member of staff and no diversion. Residents continually asked why they were there. The practice of changing over who is assisting a resident to eat their meal should also stop (this happened midway through a meal). Nutritional needs assessments must be completed to identify those people who would benefit from finger foods. The home should make efforts to make the mealtime experience much calmer and pleasant for residents. Environment risk assessments must be completed and potential hazards identified and eliminated e.g. toiletries on sinks, cupboards with hot water tanks, unguarded stairs, laminate flooring.
Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 8 to promote effective The management must make improvements to the physical environment in the Dementia unit to make it more appropriate to the needs of people with dementia. The lighting in the corridors of the Dementia unit must be improved. Staffing levels need to be assessed and the home should complete a dependency assessment and staff according to the individual needs. The management of the home now need to develop the concept of teams, by delegation and firming up the roles of key workers. The home does not have any staff who are trained to NVQ 2 or above and this must be addressed along with other training needs. Training for staff in the Dementia unit, needs to be widened, so that staff are encouraged to look at the reasons for certain behaviours and try to deal with that rather than the outcomes. The Induction training for those in Dementia Unit needs to include the Skills for Care Dementia elements. The home needs to source appropriate training in dementia care and it is recommended that they approach the Alzheimer’s Society for videos and training packages. The manager of the home has recently completed her RMA award, but could benefit from some external training input about dementia care as she takes the lead in the training offered in house in this aspect of the service. The manager should also explore ways management tasks could be delegated. in which some of the The home urgently needs to carry out a quality assurance survey to explore ways in which the stakeholders feel the service could be developed and improved. Outcomes must be shared with stakeholders and the Commission. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 9 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 11 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 Standards not assessed on this occasion. EVIDENCE: Standards not assessed on this occasion. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, The home cannot fully demonstrate that resident’s needs are set out in an individual plan of care due to poor, disorganised records. The home is not able to show clearly that people’s health care needs are being met. The medication management system does not protect the health and welfare of residents. The home cannot fully demonstrate that people are treated with respect and their privacy and dignity is upheld. EVIDENCE: Since the last inspection in August, there appears to be little progress with improving records relating to service users. On this occasion, the inspector’s case-tracked four service users who reside in the Dementia care unit. The case tracking involved a full inspection of their records and discussions with staff and the service users concerned, where
Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 13 possible. Where it was not possible to communicate effectively with residents, observations were made. The inspectors found that care records were disorganised and it was difficult to find clear essential information. The records are kept in two parts, one part in the resident’s room and the other secured in the nurses office. Part one, is intended to provide staff with a summary of the care plan and other essential information from which to deliver care. The records here, were very limited and did not contain any other information than a moving and handling assessment, daily record reports and a continence assessment. There were no care plan summaries as such and no risk assessments. Care staff spoken with said they did not have access to the care plans and had not seen risk assessments. However, one member of staff said that the risk assessments had been discussed with her. It is important for care staff who are involved in the delivery of care to have access to all the relevant information relating to the individual. This was highlighted as a concern at the last inspection. See recommendations In part two of the records, basic information relating to the individuals was found and perhaps would suffice for individuals with low needs, however this home accommodates people with medium to high dependency and records need to be much more detailed. The care records were very clinical and task focussed with an emphasis on identifying and managing the ‘problem’ as opposed to taking a person-centred approach and looking at the individual, the causes and prevention of certain behaviours. For instance, one resident’s ‘perceived problem’ was that she becomes aggressive and agitated and that staff should assist to reduce the agitation and aggression to improve her life and reduce retaliation from other residents. However, the plan did not state why she may become aggressive, it did not identify any early warning signs or triggers and it did not state how staff should assist with the prevention of these behaviours perhaps by diversionary tactics i.e. linking with an activity she enjoys, reminiscence, or perhaps calming techniques. See requirements Care records contained very little information relating to social and emotional needs. There was in some cases, brief information on life history but for the most- part, this was not evident. Life history information for people with dementia is essential and forms the basis for person-centred care. Where previous interests and hobbies had been identified, there was no evidence that in practice staff were using the information available to provide meaningful activity and stimulation. For instance, one file stated that the resident had no interest in activities, yet another section stated that she enjoyed attending church and listening to music, there was no evidence to suggest that her interest in music was being facilitated within the home. See requirements Risk assessments were completed, however, not for all risks and some were duplicated, making it impossible to determine which was most relevant and up
Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 14 to date. For instance, one file contained four, falls risk assessments. Moving and handling risk assessments were in place, but little evidence of review. Inspectors observed some poor moving and handling techniques and staff not communicating with the service user before or during the moves. Risk assessments were seen for the use of bed-rails, but it was not clear in all cases looked at, that the bed-rails were being used appropriately and with the agreement of all parties involved. Bed-rails should not be used as a method of restricting a person’s movement. See requirements Some care plan reviews were completed over the last two months, however, in some cases there was no detailed record of the review. Therefore, it was not possible to ascertain whether the goals of each care plan had been followed up. See requirements There was evidence that the home were assessing people’s health care needs. Waterlow charts were in place and where scores indicated a high risk of poor skin integrity, pressure-relieving equipment was in place. This may indicate an improvement since the last inspection. The inspectors did not see nutritional needs assessments in all cases and where one was seen it was not consistent with other information seen in relation to the individuals nutritional needs. However, weight was being monitored and recorded. See requirements Not all health needs were identified in the care plans and in one case a resident with MRSA did not have a care plan about how it should be managed. See requirements The medication arrangements were inspected in brief in the Dementia care unit only. However, from this brief inspection, such was the level of concern about resident’s safety and welfare that a referral has been made to the Commissions Pharmacist inspector for urgent attention. The following concerns were found: • • • • • • Examination of the medication administration (MAR) charts showed that medicines were frequently out of stock, some for long periods. There were some gaps in charts where it was not possible to determine whether medicines were administered. Not all prescribed medicines were entered onto the charts and it was not possible to determine whether they were administered in accordance with the prescription. In at least two cases, there were no MAR charts, even-though medicines were found in the drugs trolley. When case tracking one service user, the records indicated that medicines were refused. No risk assessments were found and no MAR chart was in place. Medicines in the named tray were dated 04.05. Excessive stocks of medicines were found i.e. 4 boxes of Zopiclone, 1 pack was prescribed in 2004 - none entered on the MAR chart.
DS0000015681.V273062.R01.S.doc Version 5.0 Page 15 Shouldham Hall Nursing Home • • • • • There was no visible audit of medicines and the inspectors were unable to establish an audit trail. Medicines were not booked in correctly. It was not possible to audit medicines due to the poor records in respect of receipt and return of medicines. There did not appear to be a clear organized procedure for re-ordering prescriptions. Hence the reason for many out of stocks, and excessive stocks in the case of others. There was a box of medicines relating to various service users, it was not clear what they were doing there. It was observed that the morning meds round was ongoing at 11.15, which raises concerns about the timeliness of morning and lunch meds. The pharmacy inspection will be conducted within 7 days of this inspection and the outcome will be produced in a separate report, available on request. See requirements. It was not possible to ascertain resident’s views as to whether they felt they were treated with respect and if their privacy was upheld. However, observations were made of service users and staff around the home. It is clear that the home lacks a person-centred approach and this is demonstrated further, by the practice of staff on occasions. Staff did not appear to communicate with residents before carrying out tasks for them. For instance, when residents had finished their lunch they were removed from the table without any explanation of where they were going. In the lounge, tabards were being placed around resident’s necks in preparation for lunch without first communicating why. Issues were also identified in respect of promoting peoples dignity and selfrespect. One service user was seen unshaven, with two pyjama tops and two pairs of trousers on the entire inspection, another lady was seen with matted hair. It is acknowledged that staff experience some difficulty with peoples behaviour, however, it is about creating the right environment in which to deliver effective person-centred care. Some of these difficulties could be overcome by discovering why residents respond to some aspect of care in the way that they do. Perhaps the way that it is delivered is not consistent with their past experience. See requirements. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 16 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 15 The home has made some progress in respect of standard 12. However, the home cannot yet demonstrate that the outcome has been achieved. The home cannot demonstrate that people are offered choice and control in their lives. The meals served appeared to be wholesome and appetising. However, improvements need to be made to the dining area and a person-centred approach should be adopted in all aspects of care. EVIDENCE: An activities coordinator has been employed at the home and works Monday to Friday 10 – 4 pm. On the day of the inspection, the activities coordinator was not interviewed and not observed in activity with residents. However, one inspector was told that activities take place in the morning and afternoons throughout the week and a programme of activities is displayed. The care plans pertaining to people in the Dementia unit did not contain information about peoples social and emotional needs nor did they contain historical information that would help to provide person-centred activity to people with dementia. (See standard 7) When observing residents in the Dementia unit, there was a lack of stimulation for people indicated by the fact
Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 17 that most were asleep during the inspection. The management need to take a person-centred approach in this area; it is essential to gather information about individuals past life and start to draw from that, to provide activity that is meaningful and of interest to the individual. For instance, one resident was seen clearing out a drawer, the member of staff said ‘she often does that’ and ushered her away. Here is an opportunity to provide this resident with something she enjoys doing, she could perhaps assist with the folding and putting away of clean laundry. Catering staff said that residents were not allowed in the kitchen even though they would enjoy helping with cooking and clearing up. See requirements. In one residents file, an activity plan was seen, but there was no evidence that this had been provided. The care plans inspected contained little information about people’s preferences in terms of daily living. Again, it is acknowledged that it may be difficult for some people with dementia to express their preferences and as mentioned earlier, this is where life history would be very useful. Staff need to be skilful in ensuring that choices are given and that decisions made in respect of daily living are consistent with those people would have made prior to the onset of dementia. During the inspection, very little choice was given to residents and staff must be trained and supported to understand how they can offer meaningful choice. For instance, people were moved from one room to another with little or no communication about where they were going. This standard will be explored in more detail at the next inspection. See requirements. The records in respect of peoples daily dietary intake were not inspected, however it was said that records are maintained. It was observed that residents were being brought into the dining area as early as 11 o’clock when the meal is served at 12.15 – 12.30pm. Residents were confused about why they were seated in the dining area and asked why they were there. One lady was sitting in the dining room for a total of two hours. When staff were questioned as to why residents were brought in so early, they stated that they ‘had always done it this way’. Consideration must be given to peoples needs in this respect and this practice must stop. See requirements. Overall, the food served looked and smelt appetising. On the day of inspection, there appeared to be a choice of food, which was quiche or ham with baked beans and chips. Dessert was tinned fruit and ice cream, but no alternatives were seen. Water was served with the meal at lunch, but no other hot drinks, such as tea, were provided. One resident, in the Dementia unit who required a liquidised meal, was served with a bowl of orange food with a soup-like appearance. Liquidised food in the other unit was served in its individual elements. Food should always be served in a way that is appetising, appealing and in a manner that promotes dignity.
Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 18 Portions should be liquidised separately and presented as such. See requirements. In addition, one resident was seen to wander during lunch and found it difficult to settle. In this case, the offer of finger foods may have been appropriate and consideration must be given to people’s individual needs in this respect. Nutritional needs assessments were not seen in the records inspected and these must be completed in all cases so that the above issues can be identified and resolved. See requirements. A number of residents require assistance with eating their meals. Staff were observed with this task and seen to be patient and gentle, allowing the individual to take their time to eat. However, in one case, the carer assisting with the meal swapped with another halfway through and this is not good practice. The resident is likely to become confused, disorientated and possibly agitated by the change and this practice must stop. See requirements. Other residents were given as much time as they needed to eat their meal and were left to eat in their own time. This is good practice. The dining room itself requires some refurbishment and this is planned for the coming year. It was observed to be very noisy and people were seated inappropriately, with others that they did not necessarily get on with. This caused some disruption, confusion and anxiety. Consideration should be given to making the lunchtime experience calmer and more relaxed. See recommendations. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 19 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. EVIDENCE: Standards not assessed on this occasion. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 20 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 It cannot be said that the environment is safe or appropriately designed to meet the needs of people with dementia. EVIDENCE: A tour of the Dementia unit was completed. There are 34 rooms in the unit, separated into four different wings, Clematis, Rose, House and Stable. Each wing was marked with its name. There is a large main lounge area split into two sections, one providing a quieter area and the other, a walk through to reach the various rooms. This lounge was quite busy with staff and service users moving around and perhaps not ideal for people who are confused or agitated, as being seated in this area could compound the issues for them. The lounge was fairly bright with natural light, reasonably decorated and furnished. However, it lacked any meaningful stimulus and the home could consider making one of the communal areas into a reminiscence room, which might create a more domestic feel. There were no games or other items that would aid to distract or stimulate conversation. On the day of inspection, music was playing at a level that would not promote effective communication. The
Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 21 type of music did not obviously have any meaning to residents. For instance, residents were not engaged in song and did not appear to enjoy the music played. Around the home, there did not appear to be clear signposting, cues or prompts, which you would expect to see in a unit caring for people with dementia. It is essential to provide ways of assisting people to orientate and with memory and recall. Some efforts had been made to colour code accommodation wings to aid recognition. For instance, in one wing, the bedroom doors were painted a dark purple and doors to the communal facilities were painted in a dark yellow. This would help people to distinguish between bedrooms and WC’s. However, the colours used were very dark and did not create an attractive mood-enhancing environment. The bedroom doors were all the same colour and if a person centred approach were adopted the door colour could be more meaningful to the individual, for instance, their favourite colour or the colour of their door at home. The lighting in the corridors was poor due to the use of low wattage bulbs, research shows that the lighting is equally as important as the use of colour and the home should consider improvements here. On the day of inspection, the home was noticeably cold, particularly in the bedrooms and corridors. This, together with the use of cooler colours does not necessarily encourage people to venture out of the communal areas, which were warmer. This was raised during the inspection and the timer was adjusted so the heating would be on during the day. The communal facilities need to well sign-posted, again with a picture that would aid recognition. Each bedroom door had a laminate sign showing the residents name and a picture that the individual would associate with. This is good practice. See requirements. During the tour, numerous potential hazards could be seen. For instance, one room contained a cupboard with a hot water tank within. There was a sign saying the door must be locked, yet it was not, and the residents bed was pushed up against it, however, could easily be moved. Other examples are toiletries on sinks, the unguarded stairs in Stable wing and the laminate flooring that is slippery when wet. The management must complete a thorough risk assessment of the premises and identify the potential risks for all residents, but in particular those with dementia. See requirements. The management have an ongoing plan for maintenance and renewal. Some improvements have already been made, such as replacement of flooring, furniture in some communal areas and renewal of bed linen. On the day of inspection, the home was clean, tidy and odour free. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 22 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 Staffing at the home has improved and service users can expect to receive some consistency and continuity of care. The provision of in-house training has improved, however, further training needs to be provided, in particular to promote a greater understanding of caring for people with dementia. The home does not have any staff trained to NVQ level 2 or above and this must be addressed. EVIDENCE: Since the last inspection, the home has recruited more staff resulting in a reduction in the use of agency staff. This provides residents with consistency and continuity of care. In addition, they have appointed a bank of staff to support with holidays and sickness. A new shift system has also been introduced and staff spoke about this as a positive change. The home has acted on advice from the Commission and introduced a designated team of workers for the Dementia unit. This will improve the quality of care provided in the unit and encourage staff to build greater knowledge of the people they are working with. A key worker system is also in place, however this needs some development to ensure that key workers have sufficient knowledge of their role.
Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 23 The adequacy of staff was assessed by inspection of the staff rota and through discussion with the manager. However, it was not possible on this occasion to ascertain the views of residents in this respect and more attention will be given to this at the next inspection. Most of the staff work 12-hour shifts, working 8am – 8pm. The waking night shift runs from 8pm – 9am. The manager is aiming to provide 2 trained nurses with 7/8 care assistants during the waking day and 3 trained nurses with three care assistants during the night. One resident requires one-to-one care and this has been provided consistently. In addition to the above, an activities coordinator is employed Monday to Friday 10 – 4pm. From the information given, the staffing levels would appear to be adequate, however, a relative made a comment that more staff were needed in the home. This suggests that the home needs to conduct a thorough assessment of people’s dependency levels and staff the home according to needs. See recommendations. Since the last inspection, when concerns were raised about staff training, there has been significant progress in this respect. Unfortunately, the newly appointed training officer has now left, which has led to some issues with keeping training records up to date. However, a new training officer has been appointed and will be commencing in the near future. New staff are now offered a more structured induction programme, but this needs to be improved for those working in the Dementia unit. The induction programme should include modules specific to caring for people with dementia. Existing staff have been provided with mandatory training such as moving and handling and health and safety in addition to other training such as challenging behaviour and in-house lectures on dementia care. Much of the training has been delivered in-house by the manager and has included the use of training videos. The training in dementia care needs to be improved and it is recommended that the management source a better external training package to enable this to happen. See recommendations. Staff do not demonstrate an in-depth understanding of people with dementia type illness and were often observed managing behaviours rather than understanding the cause of some behaviours and identifying triggers. However, if staff had access to care plans, which were person-centred, with information about the individual’s life history, they would form a greater understanding of the individual and their needs (see standard 7). Discussions with staff showed that an increase in training has been beneficial and that knowledge is growing, leading to an improved standard of care. Staff do wish to improve their practice and have a genuine desire to provide a good service, but the management need to invest in good training materials, use a combination of in-house and external training and support staff to apply new learning to practice. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 24 The home does not have any staff trained to NVQ2 or above and this needs to be addressed as a matter of priority. NVQ training will provide a solid foundation on which to build and add value to the team as a whole. See requirements. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 25 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 The home is managed by a person who is fit to do so, however the manager would benefit from further training in specific areas. The home cannot demonstrate that they are acting in the best interests of the service users due to a lack of a recognisable quality assurance process. EVIDENCE: The manager has recently completed the Registered Managers Award, but would benefit from some external training in Dementia care so that she is better equipped to deliver and evaluate in-house training. See recommendations. The manager also needs to look at how some of the responsibilities can be delegated to encourage greater ownership within the teams, add value to individual roles and provide more effective management of staff. For instance, staff supervision could be delegated to the person with responsibility for each
Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 26 unit. However, training in supervision techniques would need to be provided, in order that this is done effectively. Within the team, there is a lot of skill and expertise and the manager should use this to its full potential. For instance, the RMN assigned to the Dementia unit could use his knowledge and expertise to train staff who work in the unit. The home does not have a recognised quality assurance system in place and this must be addressed as a matter of priority. The home must implement consultation processes with all stakeholders and must include a quality assurance questionnaire. The questionnaire should seek individual’s views on aspects of the service that are relevant to them with an overall aim of identifying areas for development and improvement. The results of the questionnaires must be analysed and the home must publish the results along with any action in response to comments made. It is important that stakeholders see the benefit of contributing to these processes and that the home actively seeks to provide a quality of service that is consistent with people’s needs and expectations. The results of the quality assurance review must be produced in a report and made available to stakeholders and the Commission. See requirements. At the last inspection, a requirement was made in respect of reintroducing staff supervision. This requirement has been met and staff have received one-toone supervision, conducted either by the manager or her deputy. As recommended earlier, supervision needs to be further developed by delegation, so that staff are clear who will be responsible for their supervision in the future. In addition, supervision contracts have been introduced and staff team meetings are held every two months. Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 27 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 2 28 2 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X 3 X X Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 28 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 16 (m)(n) Requirement The registered providers must make ensure that adequate information relating to resident’s social care needs is contained within the service user plan. The registered provider must ensure that risk assessments are completed and are meaningful to the individual. The registered provider must ensure that a review of the apparent blanket use of bedrails is conducted to ensure that they are not used as a method of restraint. The registered provider must ensure that service user plans are kept under regular review. This includes the review of care plans and risk assessments. The registered provider must ensure that proper provision for care is made and treatment and supervision of service users. This relates to the need for nutritional screening and assistance with eating meals. The registered provider must ensure the home has
DS0000015681.V273062.R01.S.doc Timescale for action 30/05/06 2 OP8 13 (4)(b) 30/04/06 3 OP8 13(7) 30/04/06 4 OP7 15(2)(b) 30/05/06 5 OP8 12(1)(b) 30/04/06 6 OP9 13(2) 30/03/06 Shouldham Hall Nursing Home Version 5.0 Page 29 7 OP10 12(4)(a) 8 OP10 12(5)(b) 9 OP12 16(m)(n) 10 OP14 12(2)(3) 11 OP15 16(2)(i) 12 OP19 23(2)(a) 13 OP19 13(4)(abc ) arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered provider must ensure that the home is conducted in a manner that promotes the privacy and dignity of the service users. The registered person must encourage staff to maintain good personal and professional relationships with service users. This relates to engaging in conversation with residents, acknowledging their presence and effective communication. The registered person must consult with residents or their representatives in order to establish their interests, hobbies and preferred activities. This information must be recorded in the care plan. The registered person must ensure that choice is promoted and residents are encouraged to make their own decisions where possible. The registered provider must ensure that liquidised food is presented in a manner that is attractive and appealing and that staff assisting with eating do so in a consistent manner. This also relates to the need to stop the practice of taking residents to the dining area one hour before the meal is ready. The registered person must ensure that the physical design of the home meets the needs of its users. This relates to the improvements needed in the EMI unit. The registered person must ensure that risks to service users
DS0000015681.V273062.R01.S.doc 30/03/06 30/03/06 30/04/06 30/03/06 30/03/06 30/05/06 30/03/06
Page 30 Shouldham Hall Nursing Home Version 5.0 14 15 OP28 OP33 18(1)(c)(i ) 24(1)(2)( 3) are identified and eliminated. This relates to the need for a premises risk assessment. The registered person must 30/09/06 ensure that 50 of care staff are trained to NVQ level 2. The registered person must 30/05/06 ensure that a quality assurance system is introduced and a report on the quality of the service is made available to stakeholders and the Commission. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP15 OP27 OP30 Good Practice Recommendations It is recommended that a major review of the care plans take place, to ensure that the structure and content are of a high quality. It is recommended that the home aims to make mealtimes calmer and more relaxed for residents. It is recommended that the home conducts a review of staffing levels to ensure that the assessed needs of residents are met. It is recommended that a training programme for all staff be drawn up to ensure that the home has staff who are trained in the area of care/work required. This relates to the need to introduce more effective training in dementia care. It is recommended that the manager undertakes external training in dementia care to ensure that she can deliver in house training more effectively. 5. OP31 Shouldham Hall Nursing Home DS0000015681.V273062.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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