Inspection on 20/03/08 for St Lawrence

This inspection was carried out on 20th March 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 Lawrence 18/09/08

St Lawrence 23/07/07

St Lawrence 02/06/06

St Lawrence 01/11/05

St Lawrence 12/05/05

St Lawrence 25/01/05

St Lawrence 28/07/04

St Lawrence 25/03/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Lawrence Churchill Drive Crediton Devon EX17 2EF Lead Inspector Dee McEvoy & Louise Delacroix Unannounced Inspection 09:00 20th & 26 March 2008 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 St Lawrence DS0000033100.V359725.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. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Lawrence Address Churchill Drive Crediton Devon EX17 2EF 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) 01363 773173 01363 774121 http/www.devon.gov.uk Devon County Council Position Vacant Care Home 29 Category(ies) of Dementia - over 65 years of age (29), Old age, registration, with number not falling within any other category (29), of places Physical disability over 65 years of age (29) St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th January 2008 Brief Description of the Service: St Lawrence is a purpose-built care home, owned and managed by the local authority, Devon County Council (DCC). It is situated on the edge of the small, busy town of Crediton. St Lawrence provides a range of services for older people but cannot admit anyone with nursing needs unless the district nursing service can meet the needs. The home has 29 rooms spread over three floors. An intermediate care and short stay unit is located on the ground floor. The aim of the intermediate care unit is to help people to regain their independence so that they can return to their own homes. Rosella is a designated dementia wing and is situated on the top floor. Each floor has its own lounge and dining room, bathroom and toilets. Access from outside is level, and there is a connecting lift to all floors. The home has limited garden space and parking. A provision for residents to smoke has been made under the porch by the front entrance. This home also provides a fifteen place day service for local older people on weekdays. This facility is not regulated by CSCI, and is run as a separate service. On certain mornings residents from the home are welcome to join a card group at the day centre. The average cost of care is £556.57 per week at the time of inspection. Additional costs, not covered in the fees, include chiropody, continence products, hairdressing and personal items such as toiletries and newspapers. Current information about the service, including CSCI reports, is available to prospective residents. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This was the second key inspection of this service during the inspection year and was undertaken to follow up serious concerns found at a random inspection on 15th January 2008. (A copy of this report can be obtained from the Commission for Social Care Inspection). Following that inspection a statutory requirement notice was issued due to significant breeches in regulation, which put people living at the home at risk. The purpose of this key inspection was to review all the key National Minimum Standards, check progress in meeting the requirements and recommendations made at the previous inspection and to ensure that people living at St Lawrence are safe and properly cared for. At the time of our visit there were 18 people living at the home. Admissions to the home had been temporarily stopped. The visit to the home was carried out over two days and we spent a total of 17 hours there. On the first day of the visit two regulatory inspectors and the South West Regional Lead Pharmacist inspector spent time speaking with people living at the home, two relatives, two GPs and staff. We also reviewed systems and records. On the second day more records were looked at and again we spoke with people living at the home and staff. As part of this inspection a number of surveys were sent to people living at the home, their relatives and outside professionals, to get their view of the service provided. We received surveys from 11 people living at the home, 9 relatives and 3 health and social care professionals. Three staff surveys were also returned to the Commission. Their comments and views have been included in this report and helped us to make a judgement about the service provided. To help us understand the experiences of people living at this home, we looked closely at the care planned and delivered to six people. The home provides care for people with a dementia related illness and some people do not have the capacity to communicate fully or understand the inspection process. During the inspection, we spent two hours observing the experience of people using a communal area of the home. This helps us make a judgement about the wellbeing of people who may not verbally be able to tell us what life is like in the home, and enables to see how staff are supported to carry out their work. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 6 A tour of the premises was made and we inspected a number of records including assessments and care plans and records relating to medication, staff recruitment and training, and health and safety. What the service does well: What has improved since the last inspection? The overall ethos of the home is changing providing a more flexible approach to the delivery of care and the general routines in the home. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 7 There have been improvements to care records and guidance for staff to follow to ensure people get the care they need and prefer. However there is still work to be completed (see What they could do better). Peoples’ weights are recorded more consistently now, which helps staff to monitor people’s overall health needs. The management of medicines has improved and medicines are now handled safely, with the records reflecting what has actually happened. The security of the medicines cupboards has been improved and now complies with current legislation. Since the last inspection a key worker system has been introduced, which encourages staff to develop meaningful relationships with people and enables them to spend more one to one time with people. It also gives staff more responsibility for meeting individual needs. Some staff were positive about their key worker role. More activities are now being provided and some people have enjoyed trips to town or visits to the garden (also see what they could do better). Some staff have attended a short course in working with people with dementia which helps them to understand and meet people’s needs in a person centred way. Some staff have had training about the protection of vulnerable adults, which helps to protect people living at the home (also refer to what they could do better). What they could do better: 13 requirements and 18 recommendations have been made as a result of this inspection. Some people told us they were not given information before they moved to the home to help them decide if the home would suit their needs. At the random inspection in January a recommendation was made to ensure initial assessments of people’s needs were detailed to make sure the home could meet individual needs, preferences and expectations. Although slowly improving, care plans and associated records must continue to be developed to reflect the care that is needed and given. Plans of care should be used as a working document by all staff to help communication and promote consistency for the people who receive care. In order to promote and monitor good health, better records are needed of people’s health care needs, for example their nutritional needs, the care to be provided to people with diabetes and skin care needs. We have recommended that staff work to promote and protect people’s privacy and dignity at all times, and that improvements continue to ensure that peoples’ social and leisure needs are met and recorded, especially those with limited capacity or specialist needs. We have asked the home to seek advise about best practice for making food attractive and appetising for people with St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 8 dementia, and to ensure that fluids are freely available in communal areas of the home for people to have when they please. The home has been asked to make sure that people living there, and their family and friends are aware of the complaints procedure. In order to fully protect people living at the home from the risk of harm or abuse all staff must be aware of the adult protection procedures. Where restrictive equipment is used the home should get consent for this and ensure there are clear guidelines for using things like lap belts. The manager needs to make sure that all parts of the home are clean, in particular the sluicing areas. The home needs to improve infection control practices through staff training and a comprehensive policy to guide staff about good standards when dealing with soiled pads and other waste materials. Although some increase was noted to staffing levels this was not consistent and staffing arrangements at times do not always ensure that people’s needs are met. Staff must receive relevant training to enable them to meet the needs of people with a dementia type illness. New staff should be given structured induction training when they start work at the home. This will help them to understand how the home works and how to work safely and respectfully with people using the service. The current recruitment practices at the home are poor and put people at risk. Staff should receive regular one to one supervision in order to review their practice and learning needs. There is no registered manager for this home and a requirement has been made to ensure that an application to register with the Commission is received; this is intended to ensure the home is consistently well managed. The home has been asked to review the current arrangements for keeping people’s cash to ensure that people’s money is handled correctly. In order to maintain good health and safety practices staff require mandatory training in manual handling, food hygiene and infection control. In view of the number of accidents, which result in serious injury to people, it is recommended that an audit of accidents and incidents be made to help the manager identify any trends and allow her to put measures in place to reduce risks. 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. St Lawrence DS0000033100.V359725.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 St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People do not always have the information needed to make a decision about whether the home can meet their needs. Individual contracts help to protect people’s rights. People’s needs are assessed before they move to the home to ensure the home can meet their needs. EVIDENCE: Six of the 11 people responding with surveys told us they had been given enough information about the home before moving in. One person told us they had visited the day unit and had a general idea of what the home provided. Other people told us their relatives had helped them choose this home. One person who has lived at the home for a year told us that they had chosen not to visit the home, as they trusted that their son had made the right decision for them. They did not remember being visited by anyone from the home or being given any information about the home. Another person told us they had not been involved in the decision to move to St Lawrence and that social St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 11 services had chosen the home. We were told, “They didn’t really tell me anything about this place”. The majority of relatives told us they “usually” had enough information about the home and two said they “sometimes” had enough information. One relative was particularly happy with their first impressions of the home and told us, “When I went to St Lawrence first with my Mum it was the warmth shown to us both & the cleanness everywhere. I thought this is for my Mum...” The home has a Statement of Purpose, which gives people information about what to expect of the home. Although the majority of people spoken with had not seen this, we saw copies in some bedrooms we visited and in the hallway. Most people told us they had been given a contract of residence, which ensures their rights are protected and they are aware of the rights and responsibilities. We saw individual service contracts in people’s care files, and the individual or their representative had signed these. As a result of safeguarding issues, the care all people living at the home had been reviewed by health and social care professionals. There have been no new admissions to the home since the last inspection, therefore this standard could not be inspected. The home is not currently providing intermediate care. St Lawrence DS0000033100.V359725.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has made progress to improve care planning and risk assessments but areas still lack detail about individual needs to ensure that consistent care is delivered in a way that people need and prefer. People’s privacy and dignity is not always promoted by staff practice. The management of medicines has improved and medicines are now handled safely. EVIDENCE: We asked people if they received the care and support they needed; 6 people told us they “always” get the care they need, 4 said “usually” and one said “sometimes”. Their comments included, “The staff are always kind and helpful”, “They are good to me here” and “Regular staff know how I like things done”. Two other people told us, “Some staff couldn’t care less” and “They pull me about sometimes – I tell them but they take no notice”. Five relatives felt that care needs were “always” met, four said “usually” and the majority felt that the home “always” gave the support and care expected St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 13 and agreed. Three relatives said this was “usually” the case and one felt this was “sometimes” the case. One relative wrote, “They take good care of my mother. I know that she is safe and kept clean”, another said, “The care is very good” and a third commented, “Could not be better”. Four relatives were concerned about the use of agency staff, which they felt had a negative affect on the care delivered (refer to standard 27). One relative told us, “my mother has the perception, right or wrong, that the young agency staff do not have the skills & experience”, another wrote, “I am alarmed by the ridiculous amount of agency staff used. I am even more alarmed to hear people say at the meeting that agency staff did not know what to do”. A third wrote, “Have more permanent staff who are familiar with requirements of residents & less agency workers”. At the last inspection (15 January 2008) we found significant shortfalls in care planning and the delivery of care, which put people at risk. A statutory requirement notice was issued to ensure that improvements were achieved and people living at the home were safe. It was pleasing to see that a considerable amount of work had been completed to ensure that care plans were more reflective of people’s needs. However, more work is needed to ensure that staff have all the information they need to deliver care in a person centred way. Several staff told us that the new care plans were more informative. However, three staff said they did not always get the time to read care plans fully. One member of staff told us that they had been given conflicting advice regarding the use of care plans and we saw that none of the staff on duty (on the top floor) had signed to say they had understood the content of them. Staff responding with surveys recognised some improvements and two said they were “usually” given up to date information about people’s needs. One wrote, “This has improved & new care plans are in place and new ways of recording”. One staff member said this was “sometimes” the case. We were told, “There isn’t generally time to read up on care plans before a shift so information given at hand over is important for up date information. Sometimes due to lack of communication not all information is given. But it is improving”. We looked at six plans of care to see what guidance staff were given to meet people’s physical and psychological needs. This is particularly important when people are not able to verbally communicate their wishes or preferences. We saw that people or their relatives had been asked to contribute information about the person’s life history and this was generally well recorded. Other parts of the care plans would have benefited from a stronger focus on the individual needs of the person. One person has a high risk of developing sore pressure areas on their skin. Although there are now guidelines for staff to follow should this person decline assistance, there was no clear guidance about the actual care to be given to prevent skin breaking down. No St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 14 instructions were written about the care to be given if the skin was red or broken, the care plan said, “skin care routine must be maintained”. Some care plans now contain more information about the approach staff should take when assisting people who have dementia or other mental health problems. This information is very useful in parts if followed by all staff and should result in staff being able to provide the care needed. We found that the emotionally and psychological needs of some people were not fully addressed. We saw during our time at the home that one person drew great comfort from a soft toy and used the toy as an extension of them self when completing a task. Staff confirmed the significance of the toy to the person’s well-being but it was not documented in the person’s care plan. For example, what was the significance of the toy i.e. who gave it to them or what to do if it was lost or needed washing/replacing? One newly developed risk assessment was excellent and described triggers and actions staff should take to manage anger and frustration, which has lead to violet outbursts in the past. But other risk assessments were not as well developed and some risks and behaviours had not been considered. Recent daily notes showed that one person had pinched a staff member and a another staff member told us during the inspection that this had just happened to them too, however this risk was not identified in the risk assessment. By the second day of the inspection a detailed and thoughtful support plan had been developed, which guided staff about their approach to avoid such incidents. Under medical history for one person, it was recorded that the person was registered blind but in the health needs assessment it asked ‘do you have any eye problems’ with the recorded response ‘none at present’. There was no mention in the care plan about how staff should support the person with their sight loss, although one member was very attentive during the main meal to ensure that the person was able to eat all the food on their plate. A risk assessment showed that the person was at risk of falling but not how to reduce this risk. It was identified in another person’s care plan that they needed support with their mobility using a range of equipment but there were not clear instructions as to how this task should be completed or whether they needed a particular type of sling. Although it was recognised elsewhere in the care plan that good communication was vital to gain the person’s trust and cooperation as well as going at the person’s own pace. Staff felt that some instructions such as “Staff must be aware of whereabouts at all times” were “unrealistic” and told us they could not possible manage this and look after other vulnerable people on the unit. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 15 We watched staff assist people with their mobility. Staff were generally skilful with equipment and spoke to people during the procedure to ensure they knew what was happening. However, during one move, one carer omitted to check the person’s feet position, which were incorrectly placed. The person looked in pain for a moment during the move (refer to standard 38). Daily notes had improved since the last inspection and gave more of a picture of the care provided and the choices people made daily. Since the last inspection a key worker system has been introduced, which encourages staff to develop meaningful relationships and enables them to spend more one to one time. It also gives staff more responsibility for meeting individual needs. Seven people responding with surveys told us they “always” receive the medical support they need. Three people felt they “usually” received the medical support needed and one person felt this was the case “sometimes”. One relative told us the home… “Looks after general health & welfare” another said, “They look after my mother so well”. One relative wrote, “As far as I am aware there is no agreement on care. Physical care is ok but mental care is questionable. I think a lot more could be done”. Four GPs told us the home “usually” seeks advice and acts upon it; they also felt that people’s health care needs were “usually” met. One told us, “Health on the whole is met and people seem reasonably happy”. The GPs main concern was an apparent lack of understanding of the needs of people with dementia. One GP felt that sedatives were sometimes “inappropriately requested” and that staff “struggled to cope at times”. We looked at the care plans for two people who have diabetes to see what advice the staff were given to support these people. We were told these were the only care records. The diabetes was mentioned in their medical history but there was no diabetes care plan in place by the community nurse, which would be good practice. Under the foot care section in the care plan it refers to a chiropodist taking care of the people’s feet but there is no further advice about what to check for in between these visits or the importance of good foot care. Under diet, the care plan states that the person should be assisted to eat appropriately, although a health assessment directs staff to provide a low fat low sugar diet. During the inspection, a staff member asked if they could give the person a particular type of biscuit, another replied they did for ‘a treat’ but this was not mentioned in the care plan and the staff were given no written guidance in this area. Nutritional assessments are not completed but some people’s food preferences and dietary needs are briefly recorded. We found at the last inspection that people’s weights were not being monitored regularly, which put people at risk. Since the beginning of March regular weights are being monitored for most people to ensure any significant changes can be addressed. Daily notes contain St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 16 some information about people’s daily dietary intake so that staff can check where people may be at risk. People’s personal care was generally well attended to. One relative told us, “Personal care is good – Mum is always clean”, another said the home does…“Everything to keep my mother clean, happy and with no worries”. One person told us they were not having their baths as frequently as they would like and this caused them some anxiety. We looked at the care records, which suggested they hadn’t had a bath for two weeks. We spoke with staff about this but they couldn’t confirm if records were accurate. We found that the system for administering and recording medicines had been reviewed. There are clear plans present to support the administration of medicines prescribed with variable doses and also those prescribed, to be given when required and also that there are clear records available to show what dose has actually been administered. We found that the recording of administration of eye drops and creams had improved and these records were now complete. We saw that the medicines fridge had recently developed a fault and there was good evidence that this situation had been well-managed and new supplies of the medicines affected obtained. A replacement fridge had been ordered and safe interim storage had been provided. We saw medication being given to someone living at the home. The staff member did not follow the recommended approach described in the person’s care plan, which another staff member told us was in place to help the person feel safe. Instead, they stood over the person and invaded their personal space. We also saw in this person’s room that a tube of cream had been left on the bedside table, which was unnamed, which is not good practice. Each person who has been prescribed a cream now has a file, which staff sign to record that it has been administered. We saw a senior carer checking the files as part of their role and saw that recently staff had started completing these records. Overall we found that the requirements made in the Statutory Requirement Notice in relation to medication had been met. People told us that most staff were polite and respectful, although one person said “not all” staff were respectful. One health professional felt people’s privacy and dignity was “usually” respected. During our time spent on the top floor we saw that at times some staff spoke about people living at the home, who were in the same room as them, despite other staff members acting as role models by providing a more person centred approach. This meant that they talked about people to a colleague rather than St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 17 to the person, which treats people as objects, rather than equals, and does not maintain their dignity. Some staff were patronising in their approach when they spoke with people living at the home, which means that they spoke to them as if they were small children. On one occasion, a staff member drew attention to the fact that someone was singing along to a song, the person then stopped singing and looked uncomfortable. This appeared to be done with good intentions but again showed a lack of awareness about how the people might feel when they are talked about. At other times, staff and people living in the home all sang along together in unison, which created a positive atmosphere. Some staff spoke about their breaks and concerns about staffing levels in front of the people they cared for without thought to how this might make people feel. For example, one person looked anxious when staff expressed concerns about the staffing levels. This shows that some staff are not considering that the people they care for are still able to respond to other people or to other people’s tone of voice or body language. When we visited people’s bedrooms we saw that stocks of continence pads were not stored discreetly, which does not promote people’s dignity and privacy. We asked members of staff about the home’s policy on dignity and privacy. One person said they thought they had seen it several years ago and a newer member of staff was not aware if there was one. We looked for the privacy and dignity policy and asked senior staff if they were aware of the policy but no policy could be found. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 18 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 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there are some activities, and contact with family and friends, social and leisure needs are not well organised and do not ensure that their individual needs are met. People usually enjoy the food, which takes their dietary needs into account. EVIDENCE: The routine is the home is changing and one staff member told us, “we are doing things differently now, people are given more choice”. Daily notes contain details of choices made by individuals, such as when to get up, go to bed or what they want to eat. This is good to see. Personal preference sheets have been up-dated and clearly state people’s preferred routine. These have been completed with the individual or a family member to ensure they are accurate. During conversation with people they confirmed that they could choose when to go to bed and when to get up. Six people responding to CSCI surveys told us there were “usually” activities they could take part in; two said this was “always” the case and one said there were “sometimes” activities to do and one person felt there were “never” activities they could take part in. We spoke with several people about the St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 19 activities and opportunities to get out of the home. One person told. “We don’t do anything spectacular and I only get out when my family take me”, another person told us, “Nothing much expect bingo and quizzes”. Three relatives told us that activities and stimulation was area of improvement they would like to see. Their comments included, “Used to have bingo and quizzes but this has stopped for past year or so. They are just put in the lounge and left”, “Not enough mental stimulation”, “More activities suited to people’s age, mental health and mobility” and “I think the residents get bored because nothing is ever going on although I believe this is now being addressed”. We spent two hours observing the lives of people using the communal lounge and the dining room on Rosella unit. This showed us that during this time people were engaged with staff and what was going on around them, apart from one person who was asleep. Their general mood was positive and that there was a high level of staff interaction. We saw four people agreeing to participate in a group exercise game with one person opting out but still observing. The mood was light hearted and people’s body language and tone of voice showed people were relaxed. One member of staff was particularly good at picking up on people’s changing moods and responding appropriately, which acted as a positive role model for other staff. After some gentle physical exercise, this staff member read out questions from a quiz, while another member of staff supported a person on a one to one basis with their responses. Sometimes people living at the home responded with information of their own triggered by the quiz, and the first staff member took this seriously and paused to listen and respond. Staff told us that they were being asked to provide more activities, and that some new equipment and games were available. When we looked at records for three different people living on Rosella, which showed people’s opportunities to engage in meaningful activities varied. We saw that recently people had not accessed other parts of the home or left the home, despite it saying in one person’s records that they should be given ‘regular opportunities to go outside’. We spent time observing activities on Bluebell unit, which is on the middle floor. Several people were involved in a quiz organised by staff for a short while and one person was engaged in a game of dominos with one carer. This game was interrupted and the person was left for some time alone until they wandered off and the game was left unfinished. One person told us how delighted they were to be able to tend a part of the garden, although they hadn’t been provided with the tools to help them do all the jobs they wanted to. This was a source of frustration for them but overall they were very happy with this activity. This person’s care plan also St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 20 highlighted the enjoyment they got from making simple cakes and biscuits. It was planned that cooking should be made available once a week. This person told us they never knew when they would be able to cook, as they needed the support of a member of staff. They had bought ingredients to make cookies several days before our visit and were concerned that the ingredients would be spoilt if they weren’t used soon. Staff could not confirm when they were going to be available to assist this person. This caused frustration and anxiety for the person. One member of staff described how the key worker system had enabled her to organise a trip to town for one person, who had not been out “for ages”. We were told the outing was a success and was greatly enjoyed. One member of staff told us they felt people were now “forced” to take part in activities but we didn’t see any evidence of this during our visit. This remains an area for development in the home, both in the range of activities including external resources and accessing the local community, as well as the use of meaningful occupation. Most relatives told us that the home kept them up to date with any changes or events affecting their relative. One relative told us, “I get a phone call right away with full details”. However three relatives felt communication could be improved. One wrote, “It’s a lottery as to whether they answer the phone, we often can’t get through”. Visitors are welcome to visit at any time and we saw several people coming and going freely during our visit. Two visitors spoken with during our visit told that us that staff could update them about their relatives’ well-being and were approachable. They said they were always welcomed, including being made tea by staff. They were positive about the quality of care provided at the home. Daily notes now contain more information about the choices people make in relation to their daily lives. We also saw staff taking time to offer people a choice of drink and a choice of biscuit, which were offered on a plate. We saw a choice of pudding being offered to people after their meal. People chose where they sat in the lounge and where they ate their meal, and whether they wished to join in with a quiz and gentle exercise. We saw that staff respected the choice of a person not to have bath and provided an alternative. People were offered a choice of pudding but it may help to show people the choice to help people with dementia make a decision. Some restrictions on people’s choice were put down to ‘staffing levels’, for example when they could take part in their chosen activity such as cooking. Although at risk, one person is supported and encouraged to continue to be as independent as possible, which is his choice. The home has consulted with this person and other professionals in order to highlight risks and develop some strategies to support this person’s decisions. This is to be commended. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 21 We asked people if staff listen and acted on what they said, the majority of people said staff “always” listen and act. Two people said this was “usually” true. One person wrote, “Some staff do, some don’t” The majority of people responding to CSCI surveys (6 of 11) told us they “usually” enjoyed the meals at the home, three said they “always” enjoyed the food and two said they “sometimes” enjoyed the meals. One wrote, “Don’t like cold sandwiches at teatime”. During our visit we spoke to people about the meals at the home. One person on Bluebell unit said they were happy with the food and two people said it was OK. Another person described the food as “excellent” and told us that the special diet they require was always provided and staff knew exactly what was needed. People are offered a choice and the daily menu is displayed on a wipe board in the dining rooms. Kitchen staff have a list of dietary requirements and basic preferences to ensure that people receive a diet they enjoy and need. The meal we observed was unhurried and the atmosphere quiet. In the top floor dining room, plain white crockery was used against a dark tablecloth, which is seen as good practice in caring for people with dementia, it provides a good contrast especially for people a visual impairment. People were provided with condiments, which helps maintain choice and dignity. We saw that some people eating their meals ate very little of their main course. Staff told us this was because they enjoyed their breakfast and often had toast and cereal. We saw this was the case from daily notes. However, people may benefit from different choices of main meals presented in different ways to encourage people to eat throughout the day. One relative was concerned that their relative was not assisted or encouraged to eat their meal. We saw staff coax this person and offer different things as an alternative. Where food was declined a record was made in daily care notes and a more substantial supper was offered if lunch was declined. It was noted that fluids, such as juice, squash or water was not freely available to people on Bluebell, which may encourage people to help themselves. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 22 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are not always sure how to make their concerns known and some people are not confident that their complaints or concerns will be taken seriously. Unless staff are aware of the adult protection procedures people may not be fully protected from harm or abuse. EVIDENCE: Three of the 11 people responding with CSCI surveys told us they did not know how to make a complaint. Eight people told us they knew who to speak with should they have any concerns but two others indicated they were not always sure whom they could speak with. Seven relatives responding to surveys were clear about the complaints procedure but two were not. Most felt the home “always” responded if they raised concerns but two felt this was “usually” the case and one relative said this was “sometimes” true. One relative wrote, “I have never had a reason for concern, but I’m sure if I or my brother had reason they would respond”. Another relative was less sure about the home’s response and was not completely satisfied with how the home had responded previously. The home told us they had not received a complaint since the last key inspection in July 2007. The Commission has received one anonymous complaint since the last inspection about the management arrangements and recruitment at the home. This was sent to the provider’s representative to respond to. A timely response was received and some areas of the complaint St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 23 were answered in full. However it appeared that a full investigation of the issues raised was not completed, for example, none of the people living at the home were spoken with and no staff were interviewed to get their experience. During the random inspection in January 2008 an alert of possible abuse or poor practice was disclosed to the manager. The manager took steps to ensure this was investigated. An Adult Protection investigation is being conducted at the home concerning allegations about poor care practice. Since our last visit in January 2008 several staff have attended workshops provided by the home to help them recognise abuse or poor practice. This session includes watching the video “No secrets” and discussing possible abusive practices. Staff have also been given information about their role as possible alerters of abuse or poor practice. According to records provided by the home a significant number of staff still need to attend these sessions to ensure people are properly protected. We talked to six staff members about their understanding of what is abusive care practice and therefore unacceptable. One newly appointed person had not been told about the home’s safeguarding policy. All staff members recognised what was bad practice and could give hypothetical examples. They talked about confronting the perpetrator and pointing out the poor practice, and recognised that it was their duty to report concerns to somebody in a managerial position. But there was a lack of clarity over how many times poor practice needed to happen before they reported it to a manager. Three people were unclear of the external agencies, such as CSCI or Social Services that they could also contact about concerns. This was despite one person’s training records showing that they had attended safeguarding training in February 2008. One entry in the daily notes described an allegation made by one person. We spoke with staff about this. Two members of staff said this person is “always accusing us of hurting her when we are not”. This behaviour was not recorded in the care plan or in a risk assessment. The action taken at the time of this allegation was for the carer to withdraw – there was no evidence of further investigation or strategies for dealing with it. One person we met uses a lap belt when in their wheel chair. During our visit she became uncomfortable and requested that the lap belt be undone. We looked at the care plan and manual handling assessment but there was no mention of the lap belt to indicate whether consent had been given for it’s use, or when it should be used. Staff spoken with were unclear. The accident records showed that this person sustained a laceration from the lap belt whilst being transferred into the bath. Clear guidelines about the use of the belt may avoid accidents in the future. As a lap belt is viewed as a form of restraint the decision to use it should be clearly documented. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 24 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, 22, 23 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally comfortable, free from odour and safe but parts of the building are beginning to look tired and worn. Some practices and a lack of detail to cleaning do not promote good infection control. EVIDENCE: The intermediate care and short stay unit located on the ground floor was not in use at the time of our visit. We spent time on Bluebell and Rosella units. Accommodation is provided in single rooms. Each unit has a lounge and dining room and sufficient toilets and bathroom to meet people’s needs. We looked around the home and saw that it was generally well maintained, although in the lounge and in the dining room wallpaper borders were torn on Rosella unit. The lounge areas appeared homely with pictures and ornaments with a range of armchairs, although one was worn on the arms. On the day we visited there was a display linked to Easter. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 25 Bedrooms visited were generally pleasant and homely, many had been personalised by photos, pictures and pieces of furniture. One relative felt the environment could be improved, especially for people with dementia. We were told, “Interior décor could be much improved and should be user friendly for people with Dementia e.g. door frames and skirting in a contrasting colour, no “busy” wallpaper, pictorial signs for sitting room, dining room, bathroom and WCs”. It has been noted in previous reports that the environment for people with dementia is not ideal. People with a dementia type illness are mainly cared for on the top floor, but there is a risk of isolation for this client group because of its location. This may limit opportunities for people to spend time in other parts of the home. The manager told us there are plans to move the dementia unit to the ground floor. Staff told us they had the necessary equipment to help them assist people safely. There are assisted bathrooms, and some toilets have raised seats to assist people with mobility problems. People returning CSCI surveys told us the home was “always” or “usually” clean and fresh. One relative told us, “Air freshener machines need to work properly”. Generally the rooms we visited were odour free. The sluice room on Rosella unit had an unclean floor; mop heads looked unclean and a bedpan on top of the sluice had dried excrement on the side of it. A staff member told us that excrement had wrongly been emptied into the sluice the night before. Staff told us that the machine used for disposing of incontinence waste had not worked for a long time. The lid of this machine looked soiled and unclean. In the communal bathroom, there was a dirty toilet raiser on the floor of the cupboard. A member of staff told that us that they had been unaware that a person they had been providing personal care for had an infectious condition. Another member of staff told them about this person’s care needs rather than the staff member being formally informed before working with the person. Two members of staff told us that staff routinely placed soiled pads on the floor until they are placed in domestic bins in people’s rooms. Plastic bags were being introduced on the day of the inspection by one member of staff so that soiled pads could be put in them and disposed of in the sluice room to help prevent cross infection. We were told that gloves and aprons were available for staff to use. We saw that gloves, liquid soap and paper towels were available in bathroom and toilets, and people’s bedrooms. The laundry was clean and well equipped. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 26 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 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The number of staff on duty can vary and therefore does not always meet people’s individual needs. Recruitment procedures are poor and do not fully protect people from the risk of unsuitable workers. The training offered to staff is slowly improving, which means that they are beginning to develop the skills to look after people with diverse needs. EVIDENCE: People told us staff were “very good”, “they are good to me” and “You can’t really fault them”. Some relatives also spoke highly of staff saying, “Every one of the staff are wonderful to my Mum and to all others”, “Nothing is too much trouble, that goes for all the personnel that work at St Lawrence” and “…excellent staff…” Surveys received from people living at the home show that they have different experiences of staff availability; six people told us staff were “always” available when needed, two people said staff were “usually” available and two told us staff were “sometimes” available when needed. People spoken with during our visit said staff generally came quickly when they were needed. Mixed responses were received from staff surveys when asked if there were enough staff to meet people’s needs: one person said “usually”, one said “sometimes” and one said “never”. When asked what could be improved, one St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 27 wrote, “Staffed properly – always short of workers, not advertised well enough”. The home is experiencing staff difficulties at present. Sickness levels are high and the home is relying on regular agency staff to cover sickness. Sickness levels are beginning to be addressed by the management team and human resources personnel. Three relatives commented on the instability within the staff team and the high use of agency staff. Comments included, “A lot of agency staff are being used. We appreciate you need to use them if short staffed but agency staff don’t know what to do”, “Constant managerial changes & staff changes are very unsettling for people of my mother’s age. A speedy resolution for the current changes and return to a period of stability is needed”, and “Have more permanent staff who are familiar with requirements of residents & less agency workers”. There were 18 people living at the home at the time of our visit. We looked at staff rotas, which showed that staffing levels could vary during the day but that the number of staff on duty had increased since the last inspection at certain times of the day. Records showed there could be between 9 and 7 care staff on an early shift; and this could drop to 4 or 5 care staff between 3pm and 9pm. Between 9pm and 10pm rotas showed staffing levels could fall to 3 or 4 staff. Staff told us these variations could cause problems, particularly on Rosella where people needed a lot of supervision and care. During the inspection, Rosella unit generally had three staff members on duty for the five people living there. One person attended a training workshop and was replaced by an assistant manager. Staff told us this was a suitable number and the usual staffing ratio. It allowed for the cover of breaks for staff, met the needs of the people they cared for as some people needed two staff members to help them get in and out of their chairs or wheelchairs and reflected the needs of one person whose mobility was poor and needed one to one care. On the second day of the inspection the number of staff working on this unit had reduced to two for the morning shift. Staff told us it was difficult to fully meet people’s needs and monitor the whereabouts of people who were assessed as being at risk of falls. One staff member felt that the guidelines in care plans were “unrealistic” when there were only two staff on duty on this unit. Staff work throughout the home and one staff member felt this led to a lack of continuity, although all three staff we spoke to confirmed that there was always a handover before each shift, which gave them the information that they needed to support people living at the home. The recruitment files of three new members of staff were inspected. These files did not contain all the necessary checks. Application forms were poorly St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 28 completed in places and did not have full employment histories. There was no confirmation of identification in recruitment files. Records showed that two people started working at the home before Criminal Records Bureau checks (CRB & POVA first) were received. One person was still working without this important clearance. The manager and assistant manager were to chase the outstanding CRB through Devon County personnel department. An immediate requirement was issued to ensure that people living at the home were protected. Following the inspection a satisfactory response was received from Devon County Council, explaining the arrangements in place to ensure recruitment is robust in future. Staff surveys showed that two of the three people responding did not find the training provided relevant to their role. One told us, “Training doesn’t always fully cover the understanding to meet individual needs of service users and is not always up-dated –but it has improved. Need more focused training on particular needs rather than general”. We spoke to staff in depth to find out about their training, their approach to the people they cared for and how they were supported to do their job. Two people had worked at the home for a number for years and one had recently joined the care team but was experienced in working with older people. Two staff members told us that they had attended training relating to the care of people with dementia. One person had completed a one-day dementia awareness course, which they said provided insight into the behaviour of one of the people that they had worked with for a number of years. Another person had participated in a more intensive long distance learning course, and they could tell us about the main points of this training and gave us an example of person centred care, which is best practice. A third person had also received training in the care of people with dementia in their previous job. Their own personal value base, which they discussed with us, also clearly showed through in their compassionate and sensitive way of working. Our observations found that some staff were more skilled than others when caring for people with dementia or mental health problems. Training records showed that a considerable number of staff did not have training to help them understand the needs of people with dementia. We asked health professionals if they felt staff had the skills and experience to support individuals, they felt physical needs were “usually” met but felt staff needed further training and guidance to care for people with dementia and mental health needs. One wrote “Increased health care training for staff” would be an improvement. At the last inspection a requirement was issued to ensure that all staff have access to relevant training in relation to dementia and mental health. At the time of this inspection the timescale for meeting the requirement had not St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 29 expired. In view of the number of staff to be trained this requirement has been extended. Induction for new staff appears minimal, with people being left feeling initially unclear about their responsibilities. They felt this had hindered their role, and left them unsupported to introduce change. Staff surveys showed that people had a varied experience of induction. One person felt induction covered what they needed to know very well. Two others felt induction “partly” covered the areas they needed to know about to help them work safely and respectfully with people. Senior staff could not confirm which induction materials were in use and induction records were not available. One new member of staff told us she was well supported when she first started work. Shadow shifts were arranged to introduce her to the working of the home and help her understand the needs of the people living there. She had not been given any written record to complete as part of her induction, making it difficult for us to assess the quality of the home’s induction programme. At the last key inspection the home was working towards maintaining 50 of care staff holding a nationally recognised qualification in care, (NVQ). St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 30 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, 32, 33, 35, 36 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of the home is beginning to stabilise and new ways of working are slowly improving standards. However, people are not fully protected by some administrative processes. There are arrangements in place to encourage people to ‘have their say’ about the running of the home. Not all aspects of health and safety ensure people living at the home and staff are safe and protected. EVIDENCE: The home has been without a registered manager since May 2007. A new manager was appointed and took up her post in November 2007. During this time she has worked hard to address some of the issues raised at the last inspection. The home had struggled without proper systems and management St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 31 in place and high staff sickness levels. Since our last visit in January significant resources have been put into the home to raise the standards and develop new systems of working. These are starting to have a positive affect in some areas. Three relatives were concerned about the changes in management and felt this affected communication, one wrote, “Communication is poor… we feel as if no one knows what’s going on…” Another told us they had not been kept informed, as promised, about the impending changes at the home. One relative wrote, “Information concerning the impending transfer has been sketchy. Promised letters and information to the residents including my mother, have not been received”. One heath professional told us, “Change of management – still bedding in. Not functioning as smoothly as we’d like – hopefully will improve”. Other relatives had a more positive experience; one wrote “I think St Lawrence is a very well run care home… and a pleasure to visit”, another told us, “Couldn’t fault it in any way”. Most staff members were positive about the changes that are taking place in the home to ensure that carers respond to the individual needs of people living at the home by being more flexible in their approach. However, two acknowledged that for some staff this was quite challenging and one person felt that the care staff team had previously lacked managerial support and therefore had not known their approach was not best practice. The home has a range of ways of checking the quality of the service. Annual questionnaires are used to get people’s opinions and experiences as part of Devon Council Council’s quality assurance. Resident’s and relative’s meetings are beginning to happen and give people an opportunity to talk about issues and raise any concerns. Activities and outings were the topic of discussion at the last meeting and improvements were identified to be achieved. This will be monitored at the next inspection. The quality assurance reports completed by Devon County Council’s representative (regulation 26 reports) have been irregular and have not picked up on some of the problems at the home. We have discussed the importance of these visits and the legal obligation to complete these visits monthly with the Council’s representatives. Additional resources have been allocated to ensure that these visits and subsequent reports are useful to the management team and help to identify any areas for improvement. CSCI will monitor future visits and reports. Although improvements have been achieved since the last inspection, the home has been unable to meet several requirements within agreed timescales. The management of the home have failed to ensure there are robust recruitment practices in place, which puts people living at the home at risk. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 32 The home assists some people with personal finances. We looked at how three people are supported to manage their finances. Records clearly account for any purchases made on behalf of a people living at the home and receipts are kept. Transactions are signed by two people to ensure accuracy. The home will also hold people’s bank/cheque books in the safe. We found that people’s cash is held in one ‘pool of money’, rather than separately, which would be good practice. Staff supervision is beginning to happen more frequently, which is important during this period of change at the home. Supervision provides an opportunity to discuss aspects of care practice, and training and development needs. The manager has a programme for staff supervision, although some staff told us they do not meet regularly with their manager. Some areas of health and safety are not being met to ensure people are safe and staff work as safely as possible. The home’s management has not ensured that staff have received the necessary training to ensure that people’s needs are safely met. There is a training matrix which showed that many staff are out of date in receiving mandatory training, such as infection control, food hygiene, manual handling and fire safety training. We have referred the issue of fire safety training to Devon Fire and Rescue for action. We accompanied a member of staff around the top floor to check on the standard of cleaning and safety, and saw that the sluice room was not locked so people living in the home could have access to clinical waste bins. Inside an unlocked cupboard in the sluice room, we saw a bottle of spray disinfectant; this was also the case in an unlocked cupboard in the communal bathroom. This is unsafe practice. An immediate requirement was issued to ensure that action was taken to secure the sluice and store hazardous substances safely. The majority of electrical plugs did not have portable electrical testing stickers so it was not clear whether they had been tested recently and were safe. One bedroom was currently empty and being used as storage for equipment and staff files but was not kept locked. Information received by the Commission and accidents records show that there are a significant number of accidents, which result in serious injury to some people living at the home. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 33 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 2 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X 3 3 3 X X 1 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 2 2 X 1 St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 34 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 15 (1) (2) Requirement 1. You must ensure all service users have a care plan that is compiled by the home. 2. The care plan must be up to date and reviewed when required. 3. The plan must provide staff with up to date, detailed information on service users’ needs and wishes. 4. The plan must provide clear instructions to staff on what they need to do to care for service users safely and consistently. (Previous timescale of 03/07/06, 12/04/07, 17/09/07 & 14/03/08 not met) You must ensure that unnecessary risks to the health and safety of people are identified and so far as possible eliminated. Risk assessments must identify behavioural, situational and environmental risks and describe the measures in place to reduce harm. DS0000033100.V359725.R01.S.doc Timescale for action 21/05/08 2. OP7 13 (4)(1) 21/05/08 St Lawrence Version 5.2 Page 35 3. OP8 17 (1) (a) Sch 3 3M 4. OP8 17 (1) (a) Shc 3 (n) 5. OP18 13 (6) 6. OP26 13 (3) 7. OP29 19 (1) (Previous timescale of 17/09/07 & 14/03/08 not met) You must keep a record, which includes information relating to each person’s nutritional care needs and ensure accurate records are kept in order to monitor people’s health needs properly. (Previous timescale of 17/09/07 & 14/03/08 not met) You must keep a record incidence of pressure sores and the treatment provided to individuals who may have pressure sores or who are vulnerable to sore skin. You must make arrangements, by training staff or by other measures, to prevent people being harmed or suffering abuse or being placed at risk of harm or abuse. Appropriate training must to be given to all staff to ensure adult procedures are followed and people are protected. The manager must ensure that staff report poor practice without delay, either internally or to external agencies to help protect people living at the home from abusive practice. (Previous timescale of 01/10/07 & 14/03/08 not met). Suitable arrangements must be made to prevent the spread of infection by ensuring that incontinence waste is disposed of appropriately, sluice rooms and equipment in them are kept clean and staff are informed of the need for specialist precautions. You must ensure that you DS0000033100.V359725.R01.S.doc 21/05/08 21/05/08 18/06/08 21/05/08 03/04/08 Page 36 St Lawrence Version 5.2 (a)(b) 8. OP30 18 (1) operate a robust recruitment procedure in order to protect people living at the home. (Previous timescale of 14/03/08 not met) An immediate requirement was issued at this inspection. You must ensure that all staff are adequately trained to look after people living at the home, with particular regard to those people with mental health problems or challenging behaviour. (Previous timescale of 15/10/07 not met). Timescale issued at last inspection not expired at time of this inspection. You must ensure that the home is managed by a person who is fit to be in charge and able to discharge his or her responsibilities fully. An application to register a manager with the Commission must be made as soon as possible. (Previous timescale of 18/04/08 not expired at this inspection). You must ensure that unnecessary risks to the health and safety of people are identified and as far as possible eliminated. Substances harmful to people’s health must be stored securely. You must ensure that staff working in the kitchen preparing food have received the necessary food hygiene training. You must ensure that safe working practices in relation to infection control are up-held. Staff must have training to help them maintain safe practice. DS0000033100.V359725.R01.S.doc 18/04/08 9. OP31 9(2) 18/04/08 10 OP38 13 (4) (c) 21/03/08 11 OP38 18 (1) 18/06/08 12 OP38 16 (2) (j) 18/06/08 St Lawrence Version 5.2 Page 37 13 OP38 13 (5) You must ensure that suitable arrangements are in place for a safe system for moving and handling people. This includes staff training. 18/06/08 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 OP1 Good Practice Recommendations It is recommended that prospective residents and their representatives be given information about the home to enable them to make a decision as to whether the home will suit their needs. It is recommended that all initial assessments be comprehensively completed prior to the person moving into the home and that assessments are reviewed to ensure that individual needs can continue to be met. (Not assessed on this occasion as no new admission to the home since the last inspection) 2. OP3 3. OP8 4. OP9 5. OP10 7. OP12 To ensure that staff have all the information they need to care for people, it is recommended that diabetic care plans clearly state how needs are to be met. In order to promote and maintain people’s personal care, the home should ensure that people receive baths as and when they prefer. In order to ensure people receive the care they need, staff should follow communication guidance in care plans, which reflects the individual needs of people. Creams should be labelled and stored correctly and with one method of recording. In order to promote privacy and dignity staff practice should be observed by suitably trained staff to ensure that staff communicate in a non-patronising manner and do not talk about people living at the home in their presence. This should be addressed in supervision. Incontinence pads should be stored more discreetly in people’s rooms to help maintain their dignity. To ensure people’s preference and expectation regarding activities are met, it is recommended that you continue to develop meaningful and stimulating activities and outings DS0000033100.V359725.R01.S.doc Version 5.2 Page 38 St Lawrence 8. 9. OP13 OP15 10. 11. OP16 OP18 12. OP19 for people. Staff should ensure that all people have access to activities, whether on a one to one basis or in a group. Their choices should be recorded. People living in the home should be supported to use the garden and to access the local community. It is recommended that the home improve communication with families and visitors to ensure they are informed of events affecting their relative. In order to ensure people with a dementia type illness receive the nutrition they need, advice should be sought on best practice for making food attractive and appetising. Fluids should be freely available in communal areas to allow people to help themselves. To fully protect people’s rights, it is recommended that everyone living at the home and/or their relatives are aware of the complaints procedure. In order to protect people from restrictive practices, it is recommended that where restrictive equipment such as lap belts are used, consent is obtained and a risk assessment is completed. It is recommended that the home have a written programme for routine maintenance to ensure that a homely environment is maintained for people. Consideration should be given to relocating the rooms for people with a dementia type illness to a more central position within the home. Consideration should be given to relocating the rooms for people with a dementia type illness to a more central position within the home. (Recommendation carried over from the last inspection) 13. 14. OP27 OP30 It is recommended that consistent staffing levels be maintained particularly on Rosella unit to ensure people’s needs are met safely and in a timely way. It is recommended that all members of staff should receive a structured induction period, in line with Skills for Care, to ensure they are competent to do their jobs. (Recommendation carried over from the last inspection) 15. OP31 It is recommended that the home promote and maintain good communication between managers and staff, to ensure better team work. (Recommendation carried over from the last inspection) 16. OP33 It is recommended that you improve the information currently provided in the regular required monitoring (regulation 26 reports), to ensure people are receiving an appropriate service from the home. (Recommendation carried over from the last inspection) 17. OP35 In order to protect people’s finances, it is recommended that people’s cash be kept separately and polled together. DS0000033100.V359725.R01.S.doc Version 5.2 Page 39 St Lawrence 18. 19. OP36 OP38 It is recommended that all staff receive supervision sessions at least 6 times a year. In view of the number of accidents, which result in serious injury to people, it is recommended that an audit of accidents and incidents be made to help the manager identify any trends and allow her to put measures in place to reduce risks. The sluice room should be kept locked in line with Health Protection Agency advice. Rooms being used for storage should be kept locked to help maintain confidentiality and to help maintain the safety of the people living in the home. St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 40 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 St Lawrence DS0000033100.V359725.R01.S.doc Version 5.2 Page 41 - 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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