Inspection on 17/11/08 for St Clements Nursing Home

This inspection was carried out on 17th November 2008.

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

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

Other inspections for this house

St Clements Nursing Home 08/05/09

St Clements Nursing Home 29/04/08

St Clements Nursing Home 21/11/07

St Clements Nursing Home 02/05/07

St Clements Nursing Home 07/11/06

St Clements Nursing Home 24/05/06

St Clements Nursing Home 27/01/06

St Clements Nursing Home 09/08/05

St Clements Nursing Home 20/10/04

St Clements Nursing Home 23/04/04

St Clements Nursing Home 24/11/03

St Clements Nursing Home 19/08/03

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Maple Lodge

Heathlands

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Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOMES FOR OLDER PEOPLE St Clements Nursing Home 8 Stanley Road Nechells Birmingham West Midlands B7 5QS Lead Inspectors Sarah Bennett & Kerry Coulter Unannounced Inspection 09:00 17 and 18 November 2008 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000024892.V373208.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000024892.V373208.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Clements Nursing Home Address 8 Stanley Road Nechells Birmingham West Midlands B7 5QS 0121 327 3136 0121 328 1461 stclements@bmlhealthcare.co.uk 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) Noblefield Limited Manager post vacant Care Home 37 Category(ies) of Dementia (37), Old age, not falling within any registration, with number other category (37) of places DS0000024892.V373208.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 37 Old age, not falling within any other category (OP) 37 The maximum number of service users who can be accommodated is: 37 29th April 2008 2. Date of last inspection Brief Description of the Service: St Clements is a purpose built three-storey home situated in a residential area of Birmingham. The home provides nursing care and accommodation for up to 37 older people, some have dementia and some have general nursing needs. There are twenty-five single bedrooms and six double rooms, one of which is located on the lower ground floor. All have en-suite facilities consisting of a toilet and wash hand basin but these are not large enough for people with restricted mobility to access safely. Access to the home is gained by the lower ground floor and a passenger lift gives access to the ground and first floors. There are six covered parking spaces on the lower ground floor to the front of the property and unrestricted parking on the adjoining roads. There is a small garden with steep elevations that is accessed from the ground floor. Communal facilities consist of a large lounge on both the ground and first floor. There is also a dining room situated on the ground floor that is adjacent to the kitchen, which provides all the meals. The people living there can have their meals on either of the upper floors or in their own room. A laundry facility is situated on the lower ground floor, where washing of people’s personal clothing is undertaken. There are assisted bathing facilities on each floor. The home has pressure relieving equipment and a range of moving equipment to assist those persons who have restricted mobility. DS0000024892.V373208.R01.S.doc Version 5.2 Page 5 The statement of purpose stated that the fees for double en suite rooms start from £349.86 per week and for single en suite rooms from £380.46 per week. It stated that the fee structure is a guide only and all room prices quoted are negotiable. Fees do not include: hairdressing, dry cleaning, toiletries, chiropody, phone calls, medical supplies, physiotherapy, individual newspapers and aromatherapy. The annual quality assurance assessment for the home states that copies of our reports our available in the home for people to read. DS0000024892.V373208.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 stars. This means the people who use this service experience poor quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The fieldwork took place over two days. Two inspectors visited the home on both days. The home did not know that we were visiting on the first day of our visit. There were 35 people living at the home, one person was receiving care in hospital. This visit was the homes second key inspection this year, we also undertook a key inspection in April and a random inspection in July. Information was gathered from speaking to and observing people who lived at the home. Six people were “case tracked” and this involves discovering their experiences of living at the home by meeting or observing them, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. It is difficult to get peoples views about the home due to differing levels of dementia and peoples communication needs. However two people spoken with were able to give their views of the home and these have been included within the report. Staff files, training records and health and safety files were also reviewed. During the visit we spoke with the new manager and eight staff. Following our visit to the home we also spoke with four care professionals to seek their views on the home. Prior to the inspection the operations manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This tells us how well the home think they are performing and gives us some information about the home, staff and people who live there as well as improvements and plans for further improvements. Reports about accidents and incidents in the home were also reviewed in the planning of this visit. DS0000024892.V373208.R01.S.doc Version 5.2 Page 7 During our visit we found that the home had not met a previous requirement to promote and make proper provision for the health and welfare of people who live there. Code B of the Police and Criminal Evidence Act 1984 was invoked and copies of care plans and individuals health records were obtained for the Commission to consider in respect of what action should be taken. We are now considering further enforcement action to ensure that the home makes improvements to meet the needs of the people living there. We will also be talking to the providers formally to ask them how they plan to make this a better place to live. What the service does well: What has improved since the last inspection? Bedroom doors now close properly. This means that in the event of fire people will have more protection from smoke or flames. More one to one sessions and activities have been provided so that there is more to do for people who live at the home. A new manager has been appointed who has the skills and experience to run the home in a way that will benefit the people living there. DS0000024892.V373208.R01.S.doc Version 5.2 Page 8 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000024892.V373208.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000024892.V373208.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have the information they need about the home so they know what they can expect from the service. The assessment process does not ensure that individuals can be confident that their needs can be met at the home prior to admission. This may mean that they have to move again to a home where their needs can be met. EVIDENCE: Each person had a copy of the statement of purpose in their bedroom so they know what the home provides and how to complain if they are unhappy with the service provided. The statement of purpose had been updated in October 2008. This ensured that it included up to date information so that propspective service users would have the information they need to make a choice as to whether or not to live there. It was produced using text only so may not be DS0000024892.V373208.R01.S.doc Version 5.2 Page 11 accessible to all the people living there. Consideration should be given to providing it in accessible formats. Records sampled included an admission procedure checklist. It did not include whether the person had been given a copy of the service users guide and complaints procedure and if staff had explained these to them. This should be included so it is clear that people have all the information they need about the home. Records sampled included an assessment on admission to the home which was not that detailed but included the information that staff would need to meet people’s basic needs. It was not always clear if an assessment was completed before a person was admitted to the home to ensure their needs could be met there. For example: Staff said that two people who live there are unable to speak English and none of the staff can communicate with them in their first language. This makes it difficult to meet their needs and has led to one person becoming frustrated because they are unable to communicate. Both of the people were admitted before the manager worked at the home. The manager said she is aware that the assessment process needed improving to ensure only people whose needs can be met are admitted to the home. The home does not provide intermediate care. Therefore standard 6 that relates to this was not assessed. DS0000024892.V373208.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10,11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Arrangements do not ensure that the health needs of the people living there are met which could impact on their safety and well being. EVIDENCE: We looked at care plans for the six people we case tracked. Care planning in this home has been poor for some time and does not show that people get the care they need when they need it , or in a way that they prefer. At this visit again these did not always show how individuals needs could be met or why care was being given. The manager told us that care is being given but that care plans need to be more person centred and staff need to write down what care they are actually giving to people. The manager said and reports of visits by the operations manager showed that care plan audits are done. One care plan audit was looked at. This showed that more detail was needed about what support the individual needed and that some information had not been completed so that staff would know how people preferred to be supported in their daily life. Records of nurses meetings showed that they had received training in care planning and were satisfied with this. However, care plans DS0000024892.V373208.R01.S.doc Version 5.2 Page 13 sampled did not show that they had been completed to sufficiently detail what support each person needed so that staff would be able to meet their needs. The requirement relating to care plans remains outstanding from the previous inspection. Health professionals spoken with said that they were concerned about the accuracy of care plans though they were improving. People’s night time plans stated that each person needed checking by night staff every two hours. For some people it was not clear why they needed checking this often during the night and this could result in their sleep being disturbed unneccessarily. An assessment of each persons needs was completed. However this did not always relate to their care plan. For example one person’s dependency care plan stated that they may need prompting with their eyesight but their assessment did not state why this was. One person had a care plan for nausea and vomiting which stated that they have a history of this but their assessements seen did not indicate this. This means that staff do not have accurate information about how to support the people living there. Care plans about continence and how people are to be moved had been updated to include more detail. They stated that if a person needed to wear a pad to manage their continence what type and size they wore. When people needed to be moved using a hoist the care plan stated what size sling was needed so that they could be moved safely. However on the day of the visit we say some poor manual handling practices that potentially place people at risk of harm. Care plans sampled did not consider how individual’s cultural or religious needs and preferences or communication needs are to be met. This does not show that people are considered as individuals and can be cared for in a way that centres on the person and their preferences. Records sampled included a pre-printed risk assessment form where staff had recorded if something was a risk to the person or not. It included falling, leaving the building, constipation, abusive behaviour, choking, unstable blood sugars, chest infection, urine infection, wandering, having a fit, loss of memory, incontinence, pressure areas, entrapment in bed rail, self neglect, communication and compliance with medication. It was unclear what had been considered when assessing if there was any risk to the individual. Where risks had been identified a risk assessment had been put in place. Some people had been assessed as needing bedrails when they are in bed to keep them safe. A risk of this is entrapment. Records sampled showed that the part of the assessment about gaps present had not been completed. The assessments did not state that to reduce this risk bumpers needed to be fitted to the bedrails. However, in bedrooms seen bumpers had been fitted. One person who had bedrails fitted with bumpers did not have a risk assessment as to what action should be taken to reduce any risks of entrapment. DS0000024892.V373208.R01.S.doc Version 5.2 Page 14 Records sampled showed that people had attended check ups with the dentist, optician and where needed the chiropodist. Records showed that people had been weighed regularly. This is good as losing or gaining a significant amount of weight can be an indicator of an underlying health need. One health professional who works with the home said that there is a low incidence of pressure sores in the home and one person who was admitted there with a pressure sore had improved since living there. The manager said that nobody living there had a pressure sore. This indicates that the home are good at managing the skin care of people. The health professional also said that the home are very prepared to call in other professionals and had recently involved a diabetic nurse. Records showed and staff said that the diabetic nurse had suggested new blood sugar monitoring charts, which they had implemented that week and would be delivering training to them on managing people’s diabetes to ensure their well being. One person had a care plan for high blood pressure that stated that their blood pressure was to be checked twice a month and recorded on their chart. Their chart stated that the GP had requested that their blood pressure was to be checked weekly for four weeks. Their chart did not show that this had been done as required which could have put their health and well being at risk. One person had recently been assessed by the Speech and Language Therapist who had prescribed thickeners to be used in all their drinks to reduce their risk of choking. Some staff spoken with did not all know that the person needed thickeners or at what consistency. This could put the person at risk of choking and impact on their health and well being. Another person had been identified as being at risk of choking. Their plan stated their food needed to be cut into small pieces. Their main meal was liquidised. Staff gave them their pudding which was sponge and custard but the sponge had not been cut up which could put them at risk of choking. One person’s records included a care plan for epilepsy. It did not state what type of epilepsy the person has or how often they have a seizure. This is so staff would know if there were any changes in the person’s seizure pattern which could indicate that they are unwell or their medication is not effective in controlling their epilepsy. Staff spoken with said that the person does not often have fits and they were not aware of what type of epilepsy they had. A medication audit was completed by the operations manager about a week before our visit. This identified a number of issues and action needed. Sampling of the medication at our visit showed that improvements had been made since then. The medication was looked at on the second day for the people who were casetracked. Boots supply the medication in blister packs using the monitored DS0000024892.V373208.R01.S.doc Version 5.2 Page 15 dosage system so that people’s medication is separate for each dose and it is indicated when each dose should be given. This makes it easier for staff to know what and when to give and helps to reduce medication errors. The qualified nurses give medication to individuals. At the front of each persons Medication Administration Record (MAR) there is a photograph of the individual so that unfamiliar staff would know who to give the medication to. Some medication cannot be kept in blister packs as this affects how effective it is. Boxes of these medications were looked at for the people sampled. These cross-referenced with the MAR indicating that medication had been given as prescribed. Staff said that they need a bigger medication trolley for upstairs as there are several blister packs and there was not enough room to store them. The trolley was very full and this could result in difficulty in finding people’s medication so they do not get it when they need it. One person’s records showed that they administer their own medication. An assessment for administering medication to the person without their knowledge for example disguised in their food had been used to assess how able the person was to administer their medication. This is not appropriate to assess this risk as it does not cover the areas needed. This could put the person at risk of not having the medication they need. The person was prescribed an inhaler and their records showed that their GP recently checked their inhaler technique and were happy for them to administer it. There was nothing in their records to state what they used the inhaler for or how often it was to be used. Staff spoken with did not know why the person needed the inhaler. The manager spoke to the person and identified that they had a medical condition. This was not stated in their records and the manager said they would be writing a care plan so that staff knew how to support the individual. The room where the medication was stored was very warm so arrangements are not in place to store medicines in accordance with their product license. Where medication needed to be stored in a fridge, fridge temperatures were too high. Staff said that they use a fan and this was observed. Staff said they need an effective air conditioning machine. The manager said that one had been ordered. People were observed to generally look well groomed. Attention had been given to brushing people’s hair. Staff were observed supporting individuals with the care of their fingernails. On the first day we observed breakfast in the dining room. The nurse was observed taking a person’s blood sugar and then after administering their DS0000024892.V373208.R01.S.doc Version 5.2 Page 16 insulin whilst at the breakfast table. Later they repeated this for another person. One person had to pull up their top to have their insulin and the nurse pulled up the sleeve of the other person to administer theirs. This does not respect individuals privacy and dignity and lacks consideration for the other people who were eating their breakfast. When we asked staff what people were having for breakfast they referred to people as this lady or that lady rather than using people’s names. This does not show that they respect people as individual’s. Staff said that senior staff complete a list of toiletries that each person needs, based on their preferences. They said they do not bulk buy all the same type of toiletries so that people can have the toiletries they like and that suit their skin type. Records sampled did not include people’s preferences regarding their toiletries. We observed that staff were unable to understand what one person was saying to them. The person’s records did not include a care plan on how to communicate with them. It was stated on their preference sheet which was not easily available to staff so they had guidance on how to communicate with the individual. Some staff demonstrated an understanding of how to communicate with the person but others were unaware and said they did not always understand what the person said. This can lead to frustration and isolation for the person. There were no communication aids but the persons preference sheet suggested that these may be useful. There was an end of life supportive care pathway in place that staff had been taught how to use by the Primary Care Trust (PCT). The manager has asked for more training for nurses in this. Records sampled included an end of life care plan. However, these were the same for all the people whose records were sampled. This does not demonstrate that a person centred approach to people is taken and means peoples wishes are not met. DS0000024892.V373208.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Arrangements do not ensure that the people living there experience a meaningful lifestyle that meets their individual needs. EVIDENCE: At the last key inspection it was identified that arrangements for activities needed to improve so that they enhance and stimulate people’s lives. Some improvement has taken place in that the activities co-ordinator post has been increased to a full time post from a part time post. Individual activity plans have still to be developed for people that take into account their personal needs and preferences. However discussion with the activity co-ordinator showed she had a good understanding of the activities that people enjoy. For example she knew that one person enjoyed fishing and supported Aston Villa and so was trying to arrange trips out for this. She was aware that another person liked hand massages and listening to gospel music. The home has an activity plan in place, this shows that activities on offer include arts and crafts, bingo, board games, parachute activity, music and walks out. External entertainers also come into the home every alternate week DS0000024892.V373208.R01.S.doc Version 5.2 Page 18 to supply an exercise class. On the afternoon of our visit an arts and crafts session was underway whilst ‘old time’ music played in the background. Most people seemed to be enjoying this. One person told us ‘we get activities’ and they showed us a Christmas calendar that they had made in an art session. Photographs on the wall of the home showed that people’s birthdays are celebrated and that parties are organised for days such as Halloween. Records are kept of activities undertaken by people. These did not show that people are offered activities to do every day. For one person who spends all of their time in bed their record was blank and it was not clear if anything was offered to them. Staff said that 1:1 time is sometimes spent with people who spend their time in bed. This included talking to the person or giving hand massages. Care plans did not include how staff are to support the individual to meet their leisure needs. Some did include information about what things the person liked or disliked doing on a ‘preference’ sheet. However, this was at the back of the person’s file and not easily available so that staff could quickly see what activities the person preferred to do. Some staff spoken with knew what people liked to do. Discussion with the manager and activity co-ordinator indicate they are enthusiastic about improving the activities on offer. Both said they recognised that individual activity plans were needed to make sure people do the things they enjoy. Fundraising is underway to provide a greenhouse. The manager told us that she is organising pets as therapy to come into the home and the home will also be getting a rabbit. Next year it is intended to provide a sensory garden. Staff said and it was observed that some people have regular contact and visits from their family and friends. Care plans did not reflect that people had contact with family and friends or how often this was. This is needed so that all staff know how to support individuals with maintaining these relationships. Observation during breakfast and lunch on the first day showed that people did not have a choice of what drink they had. All the people in the dining room were given orange squash at lunch time. In the kitchen a choice of flavours of squash were available but these were not offered to the people living there. One person was offered and given a cup of tea. They said that staff do not usually offer hot drinks at lunch time. It was observed that none of the other people in the dining room were offered a hot drink. One person said that they did get a choice of what they ate. A rotating four week menu was in place so that this offered variety. Alternative choices were available on the menu and meals were varied. Most meals reflected the cultural background of the British people who live there although there was some rice and curries. Staff said that they offer culturally appropriate food where people prefer this. Kitchen staff spoken with were aware of people’s dietary needs and had a list of what meal people had chosen. They did not have a list of the foods that individuals liked or disliked but said that they could do this. DS0000024892.V373208.R01.S.doc Version 5.2 Page 19 At breakfast people were eating different cereals but it was not clear who they had made this choice as they were not asked what they wanted but were given these by staff. Staff may know what cereal people prefer but this may change from day to day depending on how the person feels when they get up. Food records sampled showed that people had one or two different cereals during the week. Which cereal they had seemed to depend on whether or not they were on a soft diet. For example people on soft diets alternated between having weetabix or porridge. People who were not at risk of choking were given toast. No jam or marmalade was offered with this and butter had already been put on it. Most of the women living there were wearing socks rather than tights with dresses or skirts. One person’s records stated that they preferred to wear socks. It was not clear whether the other women had made this choice. At both of the mealtimes observed the radio was playing in the background. The choice of radio station did not seem appropriate to the cultural background or age of the people in the dining room. One staff at lunch time turned the radio off and put a CD on that was more appropriate. Some people were seen tapping their feet to the music so appearing to enjoy it. In the kitchen there were good stocks of fresh fruit and vegetables as well as a lot of tinned fruit. This ensures that people can be offered a healthy and nutritous diet to help them keep well. Menus showed fruit juice for breakfast. Obseravtions showed that people were given orange squash not juice. The manager said no fruit juice was available in the home but she had spoken with the cook that day and asked her to order some. Some people were observed coughing when they were eating or drinking which could mean that they are at risk of aspiration impacting on their well being. Generally staff did not seem concerned about this apart from one staff who changed the type of cup that the person used which reduced their coughing. Records sampled for people who coughed did not show that a referral had been made to the Speech and Language Therapist who could do an assessment to ensure that the risks of them choking would be reduced. Their daily records did not indicate that they coughed when eating and drinking but this was observed. The manager said they would ensure that referrals were made. Few friendly interactions were observed between staff and the people living there at both mealtimes. When staff did speak to people this was about tasks rather than pleasant chat. For example staff told people that their dinner was on the table or told them that this was their drink. Some tasks were done with no interaction. Staff were observed taking people’s plates from the table when they had finished their meal with no interaction. Staff were observed taking DS0000024892.V373208.R01.S.doc Version 5.2 Page 20 people’s aprons off when they had finished eating with no interaction. This does not make mealtimes a pleasant, social occasion. Some people needed assistance to eat. Generally staff sat with people to assist them although this was not always so. Two staff were observed sitting at a table each assisting a person to eat their meal. The staff chatted about what they had been doing and their social life without including the people they were assisting to eat. This does not show respect or dignity for individuals, which could affect their well being. Staff were generally not observed sensitively assisting people to eat. Having to be fed food and drink can be a frightening and undignified experience. The attitude of staff that were observed did not help to reduce people’s anxieties or respect people as individual’s. Staff were observed giving people their food but not saying what it was. Some people’s meals were liquidised as they are at risk of choking if they eat solid food. It was not clear when looking at the food what all the liquidised food was so people may not have known what they were eating. People who were on soft diets were given their dinner in a bowl while other people had plates. This does not show that all people are valued and respected in the same way but are treated differently depending on their ability. One person was observed having difficulty in loading their spoon without using their fingers to do so. No aids were provided to help people to eat so they can maintain their independence in a dignified way. After this was fedback to the manager she ordered some aids so that this was possible. Food records did not state what each person ate apart from for breakfast so it was not clear that people are offered a healthy and varied diet that meets their individual tastes and dietary needs DS0000024892.V373208.R01.S.doc Version 5.2 Page 21 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Arrangements do not always ensure that people’s complaints will be listened to and acted on and they are safeguarded from abuse. EVIDENCE: A copy of the complaints procedure is available in all bedrooms. It contains enough information to guide people in how to make a complaint and how long they can expect to wait for an outcome. It was recommended at the last key inspection that the procedure is available in large print or audio format so that it is in a suitable format for people unable to understand the current format, this has yet to be done. The homes annual quality assurance assessment did not indicate if this is planned to be done in the next twelve months. We spoke with two people who live at the home about complaints. One said they had no complaints they look after you, if you have any problems you can press the buzzer and they come and help . Another person told us ‘if I have any complaints the manager tells me to talk to her’. The home has received one complaint in the last twelve months, this was made before the new manager started working in the home. It was about clothing going missing and also clothing being put in the wrong persons wardrobe. There was no log of the complaint in the home or outcome of the investigation, however the home did have a copy of the original complaint from DS0000024892.V373208.R01.S.doc Version 5.2 Page 22 the social worker. The manager told us that she thought the operations manager had responded to the complaint. We have not received any complaints about the home since the last key inspection but were made aware about the complaint regarding clothing. Since our visit to the home there has been an allegation made about poor manual handling practice. This is being dealt with under social services safeguarding procedures. Following our visit we spoke with the social worker who said they had received an acknowledgement to their complaint but had not yet received an outcome to any investigation and had recently written to request one. The home needs to improve the time it takes to respond to complaints and ensure a record is kept of any received and action taken in response. This will mean that people can be confident their complaints are taken seriously and are properly investigated. Our key inspection in April found that the home has written policies about restraint and charter of rights for people. These contained enough information to give staff instructions on how to respond if abuse is witnessed or suspected. We spoke with two staff about what they would do if they witnessed abuse, one staff demonstrated good knowledge on what to do to keep people safe. However the other staff spoken with did not demonstrate that their knowledge of what to do would safeguard people appropriately. Training records showed that the majority of staff had received training in safeguarding adults from abuse. However arrangements will need to be made to ensure all staff receive this to make sure they all know how to keep people safe from abuse. The manager told us that she was booked to attend a workshop on the Mental Capacity Act, with regards to people’s deprivation of liberty but that none of the staff had received this. The manager told us that she hoped to arrange some training in the future for staff. This Act came into force in April 2007. It requires an assessment of people’s capacity to be done if there is any doubt that they do not have the capacity to make a decision about their health and welfare. If they need help with making a decision an Independent Mental Capacity Advocate (IMCA) can be appointed on their behalf. All staff should be aware of this legislation and the implications it may have for the people living there. DS0000024892.V373208.R01.S.doc Version 5.2 Page 23 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are provided with a warm, comfortable and clean environment to live in. EVIDENCE: In recent months work has been undertaken to improve the environment and the home’s annual quality assurance assessment (AQAA) records that further work is planned. Décor throughout the home was generally of an adequate standard, although there were some communal areas where paintwork was worn. Attempts had been made to make dining rooms and lounges look homely however more could be done in these areas. This is recognised in the AQAA, this says they could ‘improve on the general ambiance of the home’. DS0000024892.V373208.R01.S.doc Version 5.2 Page 24 Access to the home is gained by the lower ground floor and a passenger lift gives access to the ground and first floors. There is a lounge and dining room situated on the ground floor and a combined lounge/dining room on the first floor. We saw that rooms, hallways and doors throughout the home were all generally the same colour. This could be confusing to someone who has dementia and does not help them to establish what part of the home they are in. The manager told us that she is hoping to assist people to know which is their bedroom by personalising the doors to their room. The AQAA stated ‘all bedrooms have new furniture; hi/low beds with pressure relieving mattress commensurate to their individual needs, wardrobes, dressing and bedside tables are also being replaced as necessary’. We looked at several bedrooms during our visit. They were found to be tidy, clean and personalised with people’s belongings, although bedrooms were very alike in that they were all painted the same colour. Where people share a bedroom we saw that screening was provided for privacy. Call bells were within easy reach of people’s beds so that they could call for assistance if needed. The space in the en-suite facility in each room consisting of toilet and wash hand basin was noted to be quite small and restrictive to wheelchair users. users or people requiring staff assistance. However as noted at the key inspection in April communal toilets have been successfully converted into larger rooms to ensure ease of access and that people’s privacy is maintained. Other recent improvements have included the installation of level access showers ‘wet rooms’ so that people can have a choice of bath or shower. However one bathroom was seen to be quite cluttered and needed attention to the décor where a shelf had been removed from the wall. The home has four hoists to assist people to change their position and there are special mattresses for people who are at risk of developing sore skin. Discussion with a member of staff indicates that any repairs needed are quickly carried out. During our visit one person switched on his bedroom light and the bulb blew, staff said they would get the handyman to replace it. The following day we were told by the person that the bulb had been replaced. In general the home was seen to be clean. There were unpleasant odours in some parts of the home, this was more noticeable on the top floor of the home. One staff told us that this is being addressed and that new products have been bought to try and reduce the odour. The AQAA stated that plans to ‘replace carpets and furniture will improve the well-being of the residents and help to reduce odours’ DS0000024892.V373208.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing, their support and development are variable, which could impact on the health and welfare of the people living there. EVIDENCE: The manager said and rotas showed that on the early shift there are six care staff and two qualified nurses. On the late shift there are five care staff and one qualified nurse. At night there are three care staff and one qualified nurse. The manager said they have identified that another care staff is needed during the night and have requested that the organisation provide another staff to ensure the health and welafre of people during the night. The manager said that they only use agency where they are unable to cover staff sickness by using bank staff or staff working extra hours. There were no agency staff on duty during our visit. This helps to ensure that staff know the people living there. In the week before rotas showed that on three nights there had been an agency staff covering the shift. In addition to care staff and nurses cleaners, laundry, kitchen and maintenance staff are also employed so that care staff are able to concentrate on providing care to the people living there. An activities co-ordinator is also employed. DS0000024892.V373208.R01.S.doc Version 5.2 Page 26 The manager said that she has identified that the skill mix of staff needs to be looked at to ensure that staff can meet the needs of the people living there. The manager said that they are employing an experienced senior sister who can lead staff by example to improve how staff meet the needs of the people living there. Staff said and observations showed that staff are allocated to different areas of the home so they know which people they are working with and consistency of care can be provided. However, at lunch time on the first day it was observed that different staff were in the dining room at different times. Some staff then went and did another task and another member of staff came into the dining room. This meant that some people were assisted in eating their meals by two or three different staff. This does not help to provide consistency or ensure that people are valued and respected while eating their meals or make it a pleasant experience for them. Staff meeting minutes showed that the last meeting was in June this year. Nurses had a meeting in October. The manager said that a meeting for all staff was planned for the next week. Staff meetings should be held more regularly to ensure that all staff are kept updated about the changing needs of the people living there, ‘best practice’ and changes within the organisation. The AQAA stated that 52 of staff had achieved National Vocational Qualification level 2 or above in Care. This meets the standard that at least 50 of staff have achieved this qualification and should ensure that they have the skill and qualifications to meet the needs of the people living there. We spoke with the manager about recruitment records, she said that all the required information was there but that files needed organising. We looked at the records for four staff. They confirmed that the appropriate checks were being carried out before a position was confirmed. For two nurses there was no evidence that follow up checks had been carried out after the expiry dates for their fitness to practice. The manager checked with the Nursing and Midwifery Council that these nurses were still on the nurses’ register during our visit when this was brought to her attention. The home had well maintained staff training records and a training matrix was available to show the training completed by all staff. This had recently been updated. The matrix and discusions with staff and the manager indicate that staff get most of the training they need however observation of staff practice shows that some staff need to know how to communicate effectively with people who have communication difficulties. Mandatory training includes fire safety, health and safety, moving and handling, adult protection and abuse awareness. DS0000024892.V373208.R01.S.doc Version 5.2 Page 27 Other training that some staff have attended includes basic first aid, food hygiene, medication, care planning, dementia awareness, continence management, risk assessment, stoma care, fluid balance, coronary heart disease, wound care and falls. Two staff, including the cook had recently attended nutrition training. At the random inspection it was identified that staff needed training in catheter care, training records showed that since then two nurses have done this training. The manager said that she would be trying to arrange training in this for more staff. We spoke with the activities co-ordinator who is quite new to the role. Discussions indicate that it would beneficial for her to receive training specifically related to her role, for example activities re dementia care. This is recognised by the home as their annual quality assurance assessment records that they will be sourcing training for the activity co-ordinator. DS0000024892.V373208.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements do not always ensure that the home is run in the best interests of the people living there ensuring their safety and well being. EVIDENCE: The home has had several managers in recent years so staff and the people who live there have not benefitted from having a settled management structure. Since our last key inspection the previous manager had left the home and for a time the home was being managed by one of the nursing staff. One staff told us that there had been five or six managers in the time they had worked there, ‘they never seem to stay’. In recent months a new manager has been recruited who has been working there for a month and a half. DS0000024892.V373208.R01.S.doc Version 5.2 Page 29 Discussion with the new manager indicates that she has previous management experience and is a qualified mental health nurse. The new manager showed she had an awareness of most of the things that needed to be improved at the home. Discussions also indicated that she is person centered in her thinking and wants to improve outcomes for people at the home. Feedback from this inspection was given to the new manager and also a senior manager within the company, both showed a willingness to put things right. We spoke with two care professionals, one said ‘manager takes on board what I say and I am impressed with the new manager’s plans’. The other said they found the new manager ‘ to be keen and knowledgeable’. The new manager is not yet registered with us but has applied for registration. We received the home’s annual quality assurance assessment (AQAA) when we asked for it. This had been completed by the operations manager for the home. The AQAA did recognise some of the areas where the home needs to improve and did include some plans to make things better for people. However the AQAA was not fully reflective of the current experiences for people at the home. At the key inspection in April some of the files relating to quality assurance could not be found. At this visit information was available to show that questionnaires had been sent to peoples relatives in January this year and that an analysis of the results had been completed. Some of the questions and answers were unclear and discussion with the new manager indicates that it is intended to review the format. Consideration should be given to including care professionals when the format is reviewed. There was evidence of regular visits being carried out to the home by the operations manager. The reports were noted to be comprehensive and included discussions with people who live in the home and staff. A variety of in-house audits are completed to include the medication and care planning system. Audits sampled were generally detailed and issues for improvement had been identified. The home is not the appointee for people’s money but does have the facility to look after small amounts of money for people. The personal finances of four people were checked. Money in people’s wallet matched their records and two staff had signed all the entries. Receipts showed that people had not bought items that the home should pay for. Receipts for expenditure were generally available however people had chiropody treatment in September and the receipt for this was not available. Staff had counted and checked people’s monies in November. This check should be extended to include checking receipts so that the safeguards in place are improved. DS0000024892.V373208.R01.S.doc Version 5.2 Page 30 Accident and incidents were well recorded. The manager completes a monthly audit to ensure that any follow up is undertaken and to monitor any trends. Records of servicing, tests and maintenance in respect of health and safety for utilities, appliances and equipment such as electricity, fire, emergency lighting and hoists are well maintained. This should ensure they are safe to use. Water temperatures are checked monthly to make sure that the water is at a safe temperature for people to use. Records showed that the water temperatures for the new showers were not being tested. This needs to be done to make sure people are not at risk of being scalded. We hand tested one of the showers during our visit and found the temperature to be safe. The manager said she would ensure the showers were tested. The fire alarm and emergency lighting was being regularly tested and the results recorded to protect people from harm in the event of an emergency situation. Records showed that the majority of staff had completed fire training in 2008 and additional training had been booked for December. The home has a fire plan and risk assessment in place but these were overdue for review. The manager said that these would be reviewed soon, following the member of staff responsible for them receiving the appropriate fire risk assessment training. Records showed that fire drills are regularly carried out, however the evacuation time recorded seemed inaccurate as it indicated that people are evacuated within seventy five seconds to a minute and a half. This seems surprisingly quick given the number of people living there and their mobility and health needs. The manager agreed to look into the procedure for the fire drills to establish that records were accurate. Given that some people in the home have high mobility needs and some spend their time in bed then individual fire evacuation plans should be completed so that staff know the best way of keeping each person safe should a fire occur. At the last key inspection it was noticed that some bedroom doors failed to close properly and put people at risk should there be a fire. Bedroom doors sampled closed correctly, the manager confirmed that doors had been repaired We saw staff assisting several people to transfer from chairs to wheelchairs and vice versa. Sometimes this included the use of a hoist. The majority of practice we saw was safe but on two occasions staff failed to apply the brakes to the wheelchair. Staff need to make sure the brakes are applied to reduce the risk of injury to people at the home and themselves. Staff were observed ensuring that people’s footplates were fitted to their wheelchairs before they moved so ensuring that the risk of injury to the person is reduced. As stated earlier in this report social services are now instigating safeguarding proceeding following an alledged incident of poor manual handling practice. DS0000024892.V373208.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 1 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X 3 X X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 2 2 X X 2 DS0000024892.V373208.R01.S.doc Version 5.2 Page 32 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 OP3 Regulation 14 Requirement The assessment process must be improved to ensure that individuals needs can be met at the home before they move there. Ensure care plans are in place for each person that reflect their needs and that are reviewed and updated to reflect people’s current needs. Timescale of 14/02/08 has not been met. 3. OP8 12(1) The service must make proper provision for the health and welfare of people who live at St Clements to ensure that they receive the health care and monitoring that their conditions require. Arrangements must be in place to ensure that there are systems in place to reduce the risk of choking. Complaints must be dealt with appropriately to ensure that the views of the people living there and their family and friends are DS0000024892.V373208.R01.S.doc Timescale for action 28/02/09 2. OP7 15 28/01/09 21/01/09 4. OP15 12 (1) 21/01/09 5. OP16 22 28/02/09 Version 5.2 Page 33 6. OP18 13 (6) 7. OP38 13(4) listened to and acted on. All staff must be aware of what to do if they witness abuse or an allegation is made so they know how to safeguard the people living there. People should be moved safely at all times to avoid the risks of injury to themselves and the staff moving them. 28/02/09 28/01/09 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. Refer to Standard OP3 Good Practice Recommendations The admission procedure checklist should include whether the person had been given a copy of the service users guide and complaints procedure and if staff had explained these to them. This will ensure that people have all the information they need about the home. Care plans should include how staff are to support people with their leisure and social needs. This will help people to experience a lifestyle of their choice that meets their individual needs. End of life care plans should be individual and reflect the wishes of the person so they are supported to die with dignity and have their wishes granted. A range of activities should be provided that meets individuals needs so ensuring their well being. People who live in the home should be offered a choice of what they drink so ensuring their well being. Kitchen staff should be provided with a list of what foods each person likes or dislikes so they can offer choice to individuals in the meals prepared. Individuals should be assisted to eat their meals in a way that respects their dignity so ensuring their well being. Food records should clearly state what each person has eaten. This will help to ensure that people are offered a healthy and nutritious diet that meets their needs. It is recommended that the complaints procedure be produced in large print and/or audiocassette for the DS0000024892.V373208.R01.S.doc Version 5.2 Page 34 2. OP7 3. 4. 5. 6. 7. 8. 9. OP11 OP12 OP14 OP14 OP15 OP15 OP16 10. 11. OP18 OP20 12. OP26 benefit of those persons who are partially sighted. All staff should be aware of the Mental Capacity Act 2005 and the implications this legislation may have for the people living there. It is recommended that the home introduce a signage system for the benefit of persons suffering from dementia are assisted to identify communal rooms and their own bedroom. It is recommended that a mechanical sluicing system be installed on the upper floor to assist in appropriate transportation of waste products for disposal to prevent risks of infections from developing. (Previous recommendation, not assessed at this visit). It is recommended that the programme of installation of suited bedroom door locks be completed. (Previous recommendation, not assessed at this visit). Staff meetings should be held more regularly to ensure that all staff are kept updated about the changing needs of the people living there, ‘best practice’ and changes within the organisation. Appropriate training should be provided for each member of staff so that they have the skills and knowledge appropriate to their role and ensure that the needs of the people living there are met. The quality assurance system should be reviewed and consideration should be given to including the views of care professionals. This will ensure that the views of the people living there are represented and can be used to improve the home. Audits of people’s finances should be extended to include checking receipts so that the safeguards in place are improved. The fire risk assessment should be regularly reviewed to ensure that all action is taken to minimise all risks of there being a fire. Individual fire evacuation plans should be completed so that staff know the best way of keeping each person safe should a fire occur. 13. 14. OP24 OP27 15. OP30 16. OP33 17. 18. 19. OP35 OP38 OP38 DS0000024892.V373208.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000024892.V373208.R01.S.doc Version 5.2 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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