Inspection on 23/07/07 for St Lawrence

This inspection was carried out on 23rd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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 20/03/08

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 Unannounced Inspection 23rd July 2007 06:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Lawrence DS0000033100.V341864.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.V341864.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/adoption.htm Devon County Council Mrs Lynne Beer 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.V341864.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15 February 2007 Brief Description of the Service: St Lawrence is a purpose-built care home, owned and managed by the local authority, Devon County Council. 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. A designated dementia wing 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.V341864.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection the manager completed an Annual Quality Assurance Assessment (AQAA), which contained general information about the home and the people living there. With the information provided, CSCI surveys were sent to people living at the home, their relatives, staff and outside professionals, prior to our unannounced site visit. Staff at the home helped two of the three people returning completed CSCI surveys. Surveys were received from 3 people living at the home; six relatives, nine health and social care professionals, including four GPs, two social workers, an occupational therapist and physiotherapist, and twelve staff members. Their comments and views have been included in this report and helped us to make a judgement about the service provided. Our visit to the service was started early in the morning to give us an opportunity to speak with night staff, as some concerns had been received about the working patterns at the home. We spent a total of 12 hours at the home. At the time of our visit there were 24 people living at the home. To help us understand the experiences of people living at this home, we looked closely at the care planned and delivered to four people. Most people living at the home were seen or spoken with during the course of the day and six people were spoken with in depth to hear about their experience of living at the home. During our visit we also spoke with one health professional and 10 members of staff, including the manager, assistant managers and care and domestic staff, to hear what they think about this service. 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. We spent time observing the care and attention given to these people by staff. Since the last key inspection the Commission has received some concerns about staffing levels, the management of medication and other areas of practice within the home. Our pharmacist inspector visited the home on 19 July 2007 to look specifically at how medicines are looked after and given to people. The outcome of his visit is in this report. Since the last key inspection the registered manager has left the home. Temporary arrangements are in place and Devon County Council (DCC) is actively recruiting for this post. A random inspection was carried out on 15 February 2007 in order to look at the improvements required at the last key inspection. A copy of this report can be obtained from the Commission for Social Care Inspection. St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 6 We will be carrying out another random inspection in the near future to monitor the progress made by the home to meet the requirements set in this report. What the service does well: What has improved since the last inspection? St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 7 Since the last key inspection improvement have been made with regards to the quality of information provided to the home by referring professionals. A number of staff have completed or are completing a specialist long distance learning course about dementia to help staff understand the diverse needs of people with this type of condition. Hand washing facilities have been fitted in the laundry room to ensure that good infection control practice is promoted. The provider Devon County Council are in the process of reviewing the deployment of staff and some shift patterns have been changed to help meet people’s needs early in the morning. What they could do better: 10 requirements have been made as a result of this inspection, two relating to health and safety issues. Four requirements are outstanding from previous visits. The home must ensure that plans of care, including care plans and risk assessments are detailed with relevant information for staff to follow to ensure people’s needs are consistently and safely met. The home must ensure that accurate records are kept of people’s nutritional care needs and ensure that people are weighed regularly to monitor health needs properly. Aspects of the management of medicines must be addressed so that practices are safe and peoples’ wellbeing is ensured. Some people living at the home, relatives and staff felt that activities and occupation at the home could be improved. Activities need to be personfocussed and better planned. The home must help people get involved in more activities and outings and provide stimulation appropriate to their individual preferences and capabilities. 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. Although some increase was noted to staffing levels this was not consistent and current staffing arrangements do not always ensure that people’s needs are met, for example their social, emotionally and psychological needs. Staff must receive relevant training to enable them to meet the needs of people with mental health needs. Staff should also receive a structured induction training to help them understand how the home works and how to care for people respectfully and safely. Some staff require mandatory training such as food hygiene to ensure good standards are maintained in this area. The home must promote good fire safety by ensuring that all fire doors close properly when the fire alarm is sounded. St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 8 12 recommendations have been made to ensure good practice and standards are maintained. The home has been asked to improve the information in their initial assessment of people’s needs to ensure that needs can be adequately planned for and met. In order that people can make decisions and choices about their daily lives, the home has been asked to review their routines and working practices, which are currently described as “institutionalised”. The home has been asked to make sure that all relatives are kept informed of important matters concerning their relative at the home. In order to maintain a safe environment for people the home has been asked to ensure that all repairs to equipment and facilities be attended to in a timely way. The home should have a routine programme of maintenance. The home has been asked to make the garden secure and safe for all people to enjoy. To build a strong staff team at the home, it is recommended that communication between managers and all staff be improved. The provider has been asked to improve the information currently provided in their regular required monitoring, to ensure people are receiving an appropriate service from the home. The home has been asked to monitor the long hours worked by assistant managers and the effect of poor or disturbed sleep on their ability to do a safe job. 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.V341864.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.V341864.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 good. This judgement has been made using available evidence including a visit to this service. There is good information available about the home and this is shared whenever possible with people considering a stay at St Lawrence but some initial assessments do not contain sufficient information to enable staff to fully plan care. The intermediate care service successfully supports people to regain their independence and to return home where possible. EVIDENCE: The Statement of Purpose and Service User Guide contain detailed information about the home and the service it offers. The Statement of Purpose needs minor amendments to ensure it is accurate in respect of the management of the service. A copy of both documents is kept in the reception area, along with the latest CSCI report. Surveys showed us that most people had received enough information about the home before moving in. Due to the admission St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 11 process of some people, for example unplanned admissions and intermediate care users; information available does not always inform choice but gives people an idea of what the home offers. People responding with CSCI surveys said that they had received contracts, which helps them to understand their rights and responsibilities. Three outside professionals said care assessment arrangements “usually” ensured that accurate information was gathered about people’s needs and that the right service is planned and given to individuals. The local PCT or social services departments refer all admissions to the home. We looked at two assessments, including one for a person admitted for intermediate care. Referring professionals complete an assessment of individual needs, which is shared with the home, in order to ensure needs can be met. Assessments looked at contained good information covering aspects of personal and health care needs. A pre-admission assessment is also completed by the home, which contained basic information relating to people’s needs. Not all areas of these assessments had been completed fully, for example some sections relating to mental health needs, communication, allergies, and social needs were less fully detailed than other areas, which could result in care needs not being adequately planned for. Where possible the manager will visit people before they move into the home to talk about their needs and the services offered. This is not always possible due to the nature of the intermediate care and respite service provided at the home. One person said that the acting manager had visited her in hospital prior to admission and this was “helpful and reassuring”. Five of the 12 staff surveyed by us said they had been asked to care for people outside of their area of expertise, suggesting the home may admit people inappropriately at times (refer to standards 7, 8 and 30). The home provides intermediate care and a short stay/respite service for people requiring recuperative or rehabilitative care. A separate unit is sited on the ground floor and a small team of staff are allocated to care for and support these people. Health and social care professionals involved with this service recognised the important role the home played with the intermediate care and short stay service. One told us, “The intermediate care beds are very important for our community clients. They work excellently for hospital discharges or to prevent hospital admission”, another wrote about the service, “St Lawrence is a huge asset to Crediton Town”. Various professional people are involved in the care of people on this unit and evidence was seen of Occupation Therapist and Physiotherapist intervention in the care plans. Professionals told us, “Intermediate stays are generally good. Staff follow care plans and specific instructions”. St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 12 Care is generally well planned and delivered. One person told us about the support they were receiving and how it was gradually helping them to build their strength and confidence. St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although most people’s needs are adequately met, some people are not having their needs met in an appropriate way and outcomes for them can be poor. The management of medicine has the potential to place people at risk of harm. EVIDENCE: Surveys from people living at the home showed that two of the three people responding felt they were not receiving the care and support they needed. People spoken with during our visit praised the majority of staff for their attitude and approach but felt that individual care needs were not always met, mainly due to staffing levels (refer to standards 12, 14 and 27). The majority of relatives responding with CSCI surveys felt that the home provided the care and support their relative needed, one wrote “Personal care & empathy is excellent”, another said “Wonderful, couldn’t be better. They all give love and affection & keep mum fresh & clean.” One relative identified some areas for improvement with regards to the care provided, “There is a St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 14 lack of anticipation of changing needs. Better reviews of care needs, my mother is a person, not a task in a routine”. We looked at four plans of care to help us understand how people’s needs were being met. Each person has a care plan, which informs staff about their basic needs and the action to be taken to meet those needs. Information relating to areas of personal care were well documented in the care plans and showed what assistance people required to maintain their personal care. Some preferred routines were recorded to ensure that care and support could be delivered as chosen (refer to standard 12). However, the information in care plans is not always accurate or sufficient to ensure that individual needs can be met appropriately or as preferred, particularly relating to people with a dementia type illness or mental health problem. People’s ability to communicate had not been fully explored and staff struggled at times to engage with some people living at the home (refer to standard 12). Nutritional screening and assessments had not been completed in the plans looked at and people’s weights are not regularly monitored, which could affect their health. Information in care plans about people’s diabetic needs is not sufficient for staff, staff told us that one person has glucose in their room, but they were unsure when this should be used. No clear instructions are available in care plans. Some care plans and risk assessments lacked detail about people’s mental health needs, for example one person was referred to as having a dementia type illness but was actually experiencing mental health problems. Little useful information was available to staff about how to respond to conditions, such as aggression, frustration or depression. Generally statements such as, “extra monitoring” “or stay calm and protect others” were written for action to reduce harmful or difficult situations. Triggers were not considered nor were positive actions in place to deal with difficult situations. The language used to describe people’s difficulties was unprofessional at times, for example “Bad tempered outbursts”. It was evident that not all staff were successfully dealing with these difficult situations, and a lack of clear instructions and consistent approach puts people at risk. Care staff spoken with felt that they did not have the relevant training to help them to care for people with mental health problems safely. Incidents reported to CSCI show that staff feel “stunned and frightened” by some incidents at the home. One staff member said they feel “completely useless” when trying to help some people. One staff member told us about the training she had received and found “very helpful”, which included conflict resolution, and described strategies she used to diffuse difficult situations. These are not consistently applied to ensure that St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 15 people get the understanding and support they need. One person said that staff were “nice” but that some staff didn’t understand them. Care staff were aware of people’s care plans but three said there wasn’t enough time to read them regularly. Some care plans contain a sheet for staff to record that they had seen and understand the care, one was signed by staff but another, for a person with complex needs, had not been signed by any staff to indicate that they were aware of this person’s needs. Six staff surveys said the manager “sometimes” gives them clear instructions about the job they are expected to do, three said “always” and two said they are “never” given clear instructions, suggesting that communication could be improved. 4 staff surveyed said care plans did not allow enough time for them to provide the care required (refer to standard 27). Care plans had not been regularly reviewed to reflect changing needs; one had not been reviewed since May 2006, although the home had requested support and treatment from the GP. Daily records are kept and some had good details about the care delivered, some daily comments were demeaning for example “bad temper outburst”. Health and social care professional’s felt that people’s care and support needs were “usually” met “when full staffing levels” were in place, and were satisfied overall. Concerns were raised about the care provided to people with a dementia or mental health problem. One GP felt that communication was the main problem and told us, “There is no way that clients who are EMI (have a dementia type illness) should be placed in this home. They (staff) request sedation as a means of controlling behaviour”. One community psychiatric nurse (CPN) met during our visit was providing regular support to people living at the home and advice and support to staff about people’s needs. The CPN felt that things had improved at the home recently and staff were “trying to provide good care”. We found that the storage of medicines in some peoples room as not secure as the keys to the drawers were not secure. Also for people having their medicines administered to them by visiting professionals no record was made of the supply of the stock bottles of these medicines by the homes staff. We found that the medicines refrigerator is kept locked and although the current temperature of the fridge is monitored there is no record of the range of maximum and minimum temperatures of the fridge. We observed that some people had signed agreements that they wished to have their medicines left with them to take. However on observing the administration process it was apparent that other care staff were being asked to observe the medicines being taken and then reporting back that the medicines had been taken. The carer administering the medicines then records them as having been taken. St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 16 We found that for one person the medicines brought into the home had been checked as correct using the hospital discharge sheet. However for another person the home had received a bottle containing white tablets and with a hand written label that did not indicate the name of the supplying pharmacy. The home had not made effort to identify these tablets but were administering them. We also found that for one person prescribed eye drops to be administered at night that on 3 occasions this month and on 15 occasions the previous month the person was recorded as being asleep. No action had been taken to contact either the prescriber or the supplying pharmacy to check if the administration time could be changed. We also found for one person prescribed a medicine with a variable dose that the record only indicated that they had been given some medicine but not the actual dose. Care plans did not direct staff when to use as ‘required medicines’, such as sedatives, laxatives or pain killers. This could result in people getting these medicines inappropriately. Three GPs were satisfied with the management of people’s medication, one was not. People told us that staff were generally respectful when delivering care. Staff were heard to address people in a friendly and respectful way. Health and social care professionals felt that staff “usually” respected people’s privacy and dignity, one told us, “Encourage to speak with client in quiet area or their room and drinks provided”. GPs said they always see people in private. People wishing to have their hair done can see the hairdresser who visits regularly. This is a service enjoyed by several people. St Lawrence DS0000033100.V341864.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 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Opportunities for people to participate in social activities have been variable and do not offer people full and flexible choice in how they spend their day. The meals offered generally provide choice and variety and meet nutritional needs. EVIDENCE: Concerns have been raised with the Commission about the “institutional routine” at the home. People felt that some routines were rigid and did not take people’s preferences into account. Several staff told us that they were working to “complete tasks” and had little time to provide care, as people would prefer. One person told us that a member of staff had denied them a cup of tea, as “it was too late”. Another person said they couldn’t get up or go to bed when they chose, as they required the help of staff, we were told,” I get the help when they can get to me”. This person accepted that staff had “other people to see to”. Another person was very pleased to be able to plan and cook simple dishes once a week with support from one staff member but really wanted the opportunity to “have more input when choosing when to cook”. We were told that this depended on staff levels (refer to standard 27). The home is St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 18 trying to encourage more flexible routines by changing shift patterns and staff attitudes. People’s interests and hobbies are not consistently or accurately recorded to ensure that people’s social needs and preferences can be met – for example one care plan said the person enjoyed watching TV but when spoken with this person told us they did not watch TV as they were partially sighted and “much preferred the radio or music”. Two people responding with CSCI surveys said there was “always” an activity they could take part in; one person said there were “sometimes” things to take part in. People we spoke with felt activities could be improved. One person told us, “There is not much going on to keep you busy and fill your day”, another person said they were not aware of any activities or trips/outings organised by the home. During our visit no social activities were seen for people living on the top floor, and several people were sleeping in front of the TV during the morning on both floors. One said they would prefer it if the TV wasn’t on all day in communal areas. Staff on the first floor did organise a brief quiz for 4 people just before lunch. Although some people enjoyed this, one person was left confused and anxious by the questions, saying, “I’m useless at this – I don’t remember”. There seems to be a lack of direction and management of meaningful activities, suitable for all people at the home. One person told us about the plans they had to take up a much-loved interest in gardening. They had been encouraged by staff to “get involved” in the garden; designs had been made and materials bought but we were told “It’s just theory at the moment as staff don’t have the time to help me”. Relatives recognised activities at the home as an area for improvement, one told us, “Mum was involved in cards & games not sure if this is still the case. She needs stimulation” and another wrote, “Few activities & therapeutic focus. TV & radio are not substitutes for face-to-face social contact. If social needs were fully met my mothers’ mental deterioration would be delayed”. Currently one member of staff is providing 6 hours of ‘activities’ a week, such a quizzes and games. A further 6 hours are available for an activities organiser and the acting manager was hoping to recruit someone for this post. The home does have access to a mini bus and a new member of staff to be appointed is qualified to drive the bus. The acting manager is hoping to organise outings and trips in the near future. There is a monthly communion and a hymn service held at the home to help meet some people’s religious and spiritual needs. St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 19 Relatives felt that the home either “always” or “usually” kept in touch about important issues affecting their relative, one wrote, “Communication has improved over the past few years”, another said “Staff seem very informed when I phone and asked how my mother is”. One relative felt that the home did not always inform them about falls or accidents, which they felt, were important. Two relatives said that it would be nice if the home helped or encouraged their mother to contact them sometimes. Relatives told us they feel welcome at the home, one wrote “When I visit they are always friendly & helpful to me” and another told us, “They make us feel very welcome. Nothing is too much trouble”. 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. However, not all people are supported in this positive way. Surveys received from people living at the home showed that 2 felt staff listen and acted on what they said, one person felt that staff did not listen to them or act on what they said. The challenge for the staff is to ensure that less able people and those with diverse needs are given choices and encouraged to communicate their wishes and views, particularly in relation to meaningful activities and daily routines. People responding with CSCI surveys told us they “always” or “usually” enjoy the food served at the home. People we spoke with said the food was “excellent”, “Most of it is very good” and “There is always enough to eat here.” People are given a choice and this is recorded on a board in the dining room to remind them what they have ordered. Although dietary preferences are not routinely recorded, special diets are catered for and kitchen staff have a list of dietary requirements and basic preferences to ensure that people receive a diet they enjoy and need. Drinks and snacks are offered throughout the day and these often include homemade cakes. Breakfast, lunch and tea-time was observed. People are offered choices; tables are laid with individual napkin rings and napkins, as well as condiments. Meals were generally pleasant with staff at hand to help where needed. Some staff sat with people during meals. St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 20 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. The home has a good complaints procedure but unless staff are aware of the adult protection procedures people may not be fully protected from harm or abuse. EVIDENCE: People living at the home and their relatives told us they generally knew who to speak with about concerns or problems and most were aware of the complaints procedure. Two relatives were not aware of how to complain. People told us that the home “always” or “usually” responds appropriately when concerns have been raised. The Commission has received one complaint since the last key inspection and a number of concerns have also been brought to our attention. The providers, Devon County Council, looked into these complaints and concerns and satisfactory responses have been received and action has been taken to address some concerns. One professional told us that it can take some time for a concern to be addressed due to communication difficulties between managers & staff but eventually the response is appropriate. Five staff spoken with had attended adult protection training to help them protect people living at the home from neglect or harm and were aware of the St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 21 procedures to follow to report any concerns. Two staff returning CSCI surveys said they were not aware of the adult protection procedures, which could place people at risk. Training records were difficult to audit to verify if all staff had received this essential training (refer to standard 30). St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. St Lawrence provides a clean and generally comfortable and safe environment for people. Improvements to ensure that repairs and maintenance are promptly addressed will promote safety and infection control. EVIDENCE: There have been no significant improvements to the environment but generally standards have been maintained. Some areas are beginning to look a little tired and shabby and need redecorating and some carpets are stained and need replacing. This work has been identified in the home’s quality assurance assessment for improvement. The communal space at the home consists of a lounge and dining room on each floor. All bedrooms are single occupancy and rooms visited were personalised with sentimental items, photographs and small pieces of St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 23 furniture. People were generally happy with their accommodation and one person told, “I have a very comfortable bed”. There are a number of pieces of equipment at the home which need replacing or repairing. For example, a broken bed rail had been reported but not fixed for nearly two weeks, we were told the fryer in the kitchen had been “condemned” and equipment in the top floor sluice “had not worked for weeks”. A part-time maintenance person is employed but it was unclear how repairs were attended to in his absence or in the long term. As noted in previous reports, the lack of an enclosed and secure garden may prevent a safe and enabling environment for all of people, particularly for those with a dementia type illness. This has yet to be addressed by the home to ensure that all people have an opportunity to enjoy being outside. Measures are in place to protect people from burns and scalds, hot water temperature are regulated and monitored and radiators have low heat surfaces. The maintenance person told us that all windows on the first and second floor were restricted and windows checked during our tour of the building were safely restricted to prevent falls. People told us the home was “always” clean and fresh. During our visit the home was free from offensive smells and cleaners are employed to ensure standards are maintained. Since the last key inspection the provider have spent a considerable sum improving laundry and sluicing facilities at the home. The laundry has been fitted with hand-washing facilities to promote good infection control. The laundry assistant told us that the improvements had made her job easier. The laundry is well equipped and well organised. The staff member responsible for the laundry in the home was knowledgeable about her job and had received infection control training to ensure the correct procedures were followed. The home has a good system for dealing with any soiled laundry to reduce the risk of infection. People living at the home said the laundry service was generally good, but one person told us about items that had gone missing, which was up setting for them. A new sluicing area has been completed on the ground floor since our last inspection, and includes a sluicing sink and commode washer to allow staff to deal with commodes in a suitable manner. However we were told that the new commode washer on the ground floor was “not in use yet”. The new bed-pan washer/macerated on the third floor is not working and staff did not know when it was to be repaired. Liquid soap and paper towels are freely available in all bathrooms and toilet to promote good hygiene and infection control. Staff used the appropriate protective clothing, such as gloves and aprons when necessary. St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 24 Clinical waste, including continence pads, is currently kept for two weeks in the sluicing area on the top floor. A contractor empties the two large bins fortnightly but staff told us that the smell of waste could be very unpleasant. On the day of our visit, one bin was full and there was an unpleasant odour. The room is small and the clinical waste bins take up a lot of room. This was discussed with the acting manager, who said she would review the arrangements. St Lawrence DS0000033100.V341864.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff on duty are not always meeting the diverse needs of the people living at this home. The procedures for the recruitment of staff are robust and therefore protect people living at the home. EVIDENCE: People we spoke with generally had positive things to say about the staff’s attitude and approach, comments included, “They are polite, respectful and helpful”, “most staff are wonderful” and “Staff are friendly”. One relative told us, “My mother is very happy and loves all the staff”. Surveys received from people living at the home show that people have a varied experience of staff availability. One person told us staff were “always” available when needed, one person said staff were available “Usually” and a third said staff were “sometimes” on hand when needed. One person spoken with told us they felt staff were busy, saying, “sometimes you can’t get hold of staff when you need them”. Another person said, “Staff come when I call them”. During the morning there was a lack of staff presence in communal areas to assist people One person on the top floor we spent time with was complaining about a draught coming from an open window but no staff were available to assist and there was no easy access to the call bell. There was little evidence that staff had sufficient time to meet residents social care needs (refer to standard 12). St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 26 Information provided to us by the home shows that the majority of people need assistance with daily activities, such as washing, dressing and going to the toilet. Nearly half of the people living at the home have a dementia type illness or mental health need. 10 people require the assistance of two staff during the day to provide safe care and 16 people at night require two staff to deliver their care. 17 people have a physical disability. This information would suggest that the home looks after people with complex and diverse needs. Staff spoken with said that people had high care needs and their care took time to deliver properly. Staff told us they did not have the time to do more than the “basics”. Following concerns raised by staff about the early morning routine at the home, new staffing arrangements have been introduced. From 07.00 two care staff are on duty to assist the two night care staff to ensure that people are receiving the care they need and prefer at this time. During the day there are generally 7 care staff and one manager on duty; two care staff on the ground floor, three on the first floor and two on the second floor. This reduces to 6 care staff in the afternoon and early evening, two on each floor. At night there are two waking care staff and one sleeping-in assistant manager. Concerns have been raised about the long hours worked by assistant managers and the effect of poor or disturbed sleep on their ability to do a safe job. The acting management at the home is reviewing how often assistant managers are disturbed at night to ensure that they are fit to carry out their duties. General staffing levels are also being reviewed, along with the dependency levels of people living at the home to ensure that sufficient staff are duty to meet people’s needs. We were told that night staff tend to spend their shift on the top floor of the home, however, several incidents, such as people wandering into other people’s rooms, and accidents, such as falls happen on the first floor. It is recommended that this arrangement be reviewed. The recruitment files of four members of staff were inspected. These contained all the necessary checks, including references and police checks, required to keep people safe. Surveys received from staff showed that they received induction training to help them understand the way the home works and how to care for people safely and respectfully. Records we looked at were brief and the current induction programme for staff does not meet nationally recognised standards for induction (Skill for Care). One member of staff employed at the home for 2 years told us their induction lasted just half an hour. Staff surveys also showed that the home provided funding and training for relevant training. However, four staff spoken with told us they find it very St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 27 difficult to deal with the ‘challenging behaviour’ of some people living at the home. One said some experiences could be “very frightening”. 5 of the 12 staff returning CSCI surveys said they were expected to care for people outside of their expertise. Although a number of staff have undertaken a dementia course recently, two felt that the course was not suited to their learning needs. Staff also said that if training opportunities were missed due to other commitments, alternatives dates not always offered. Staff had not received training in relation to mental health needs or conflict resolution, which could support them to care for people with confidence. The home is working towards maintaining 50 of care staff holding a nationally recognised qualification in care, NVQ” or above. 2 health care professionals felt that staff “always” had the right skills and experience to support people; this was referring to staff supporting people receiving intermediate care. 2 social care professional felt that staff “usually” had the skills necessary and one felt staff “sometimes” had the right skills and experience to support people. One GPs comments indicated that staff would benefit from further training in relation to dementia and mental health needs. We looked at training certificates and records but these had not been collated or systematically recorded to show when up-dates are needed. St Lawrence DS0000033100.V341864.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, 35, & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The short-term management arrangements are adequate. There are arrangements in place to encourage people to be involved in the running of the home and the management are working towards ensuring that the home is run in people’s best interest. Not all aspects of health and safety ensure people living at the home and staff are safe and protected. EVIDENCE: The registered manager of the home left earlier this year. A temporary manager was in post for a short while but resigned, and now recruitment of a new manager is underway. Devon County Council, the provider of this service, have appointed an acting manager for 2 or 3 days a week, she is experienced, and is supported by a team of assistant managers. Many staff felt morale was low and had declined since the manager’s departure, one told us, “It is very St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 29 unsettling. Not sure who to go with problems”, another wrote, “No manager in place long enough”, and another described the situation as, “No captain for the ship”. Regular quality assurance surveys are circulated to the range of people at St Lawrence. This includes, people living permanaently at the home, and those admitted for intermediate care or short stay/respite care. For people living permanently at the home this is undertaken yearly, and for people receiving intermediate care, a satisfaction questionniare is completed and sent at the end of their stay. We looked at the most recent survey resluts. Generally the responses were postive especially with regard to the overall service, such as food and cleanliness, and staff approach. Residents and relatives meetings do happen occassionally but not regularly, which would provide the home with an opprotunity to share information and listen to peoples’ thoughts and ideas for the development of the service. Several staff said they would like communication between management and staff and different staff teams to be improved. Staff meetings are held but not regularly. They tend to be for the different staff groups, such as managers, night staff, day staff and ancillary staff. The acting manager is planning a full staff meeting, which will help to improve communication and allow people to discuss their problems and difficulties openly. The quality assurance reports completed by Devon County Council representative (regulation 26 reports) highlight some improvement and outstanding issues about the environment and some health and safety issues. However these monitoring visits appeared to have failed to pick up on the care practice issues in the home, for example poor care planning and management of medications. The home does assist some people with personal allowances. Monies are held securely and 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 provider has a good auditing process in place to ensure the system remains robust. The home will also hold people’s bank/cheque books in the safe. During our visit the fire alarm was sounded and we saw that staff responded appropriately, however the door to the office, which contains computers, photocopy machine etc, did not close appropriately. This was discussed with the maintenance person and manager, who agreed to address this immediately. The fire log was looked at and showed that regular checks had been completed and equipment has been regularly serviced. We were told that all staff had undertaken recent fire safety training so that they know what to do in the vent St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 30 of a fire. Staff spoken with confirmed that they had attended training in April. Training records did have some gaps but these were explained as staff on sickness or maternity leave. Records show that fire safety information was also share with residents of the home at their last meeting in December 2006. Some staff are in need of mandatory training to ensure they can do their jobs safely. One fairly new person working in the kitchen preparing food had not had basic food hygiene training “for years”, although she showed a good understanding of basic good practice. Some concerns were raised with us about the level of accidents and incidents at the home and whether all incidents are recorded and reported appropriately. We looked at records kept; accidents and incidents appear to be recorded, and the Commission is informed appropriately of any adverse event affecting the well being of people living at the home. There were a number of accidents, including falls, and incidents recording for July – 10 in all. The majority of these appeared to happen in the early hours of the morning, for example before 08.00. Reports are sent centrally to DCC but staff were not sure if an audit of accidents is completed and had not received feedback about reports sent to help them identify trends and look at ways of reducing accidents. St Lawrence DS0000033100.V341864.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 3 2 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 2 X X X X 3 2 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 St Lawrence DS0000033100.V341864.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 OP7 Regulation 15 (1) (2) Requirement You must ensure that plans of care contain sufficient information about individual’s needs and how these needs are to be met. Care plans must be reviewed regularly to accurately reflect people’s changing needs. Where possible, you must consult with people or their representatives when planning and delivering care. (Previous timescale of 03/07/06 & 12/04/07 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. You must keep a record, which includes information relating to each person’s nutritional care needs. You must weigh people regularly and ensure accurate records are kept in order to monitor people’s health needs DS0000033100.V341864.R01.S.doc Timescale for action 17/09/07 2. OP7 13 (4)(1) 17/09/07 3. OP8 17 (1) (a) Sch 3 3M 17/09/07 St Lawrence Version 5.2 Page 33 4. OP9 13 (2) properly. To ensure that medicines are kept securely the access arrangements for visiting healthcare professionals to people’s medicines must be reviewed. To ensure that people receive medicine, as prescribed action must be taken when medicine is regularly recorded as not administered. To ensure that people receive the appropriate dose of medicine prescribed with a variable dose the actual dose administered must be recorded. (Previous timescale of 12/04/07 not met) You must consult with people about their social interests and make arrangements to enable them to engage in a range of activities inside and outside of the home. Particular consideration must be given to people less able to organise their own social activities. (Previous timescale 24/05/07 not met). 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. You must ensure that sufficient staff are on duty at all times to meet people’s the needs and ensure their safety. (Previous timescale of 12/04/07 not met) DS0000033100.V341864.R01.S.doc 19/09/07 5. OP12 16 (m) 01/10/07 6. OP18 13 (6) 01/10/07 7. OP27 18 (1) (a) 17/09/07 St Lawrence Version 5.2 Page 34 8. OP30 18 (1) 9. OP38 18 (1) 10. OP38 23 (4) 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. You must ensure that staff working in the kitchen preparing food have received the necessary food hygiene training. You must ensure that all fire doors close appropriately when the fore alarm is sounded. With particular reference to the office door on the ground floor. 15/10/07 15/10/07 03/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations 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. It is recommended that an agreed range of acceptable levels for blood sugars be recorded in care plans to ensure that staff are aware of the appropriate action to take should levels fall outside agreed levels. It is recommended that the home review the medicine administration process so that the person confirming that people have taken their medicines records this on the Medication Administration Record Chart. It is recommended that relative be kept informed of important issues affecting their relative at the home. It is recommended that people’s preferred routine is recorded and that staff ensure choice and autonomy is promoted for less able people. It is recommended that all repairs to equipment be attended to promptly to ensure that safety of people living and working at the home. It is recommended that the DS0000033100.V341864.R01.S.doc Version 5.2 Page 35 2. OP8 3. OP9 4. 5. 6 OP13 OP14 OP19 St Lawrence 7. 8. 9. OP20 OP26 OP27 10. 11. 12. OP30 OP31 OP33 13. OP38 home have a written programme for routine maintenance. Consideration should be given to relocating the rooms for people with a dementia type illness to a more central position within the home. The home should have an enclosed garden, which is safe and accessible to all residents. In order to maintain and promote good infection control measures, it is recommended that the storage of clinical waste in the top floor sluice be reviewed. It is recommended that the shift pattern currently worked by the assistant managers be reviewed and monitored to ensure that they are fit to undertake the duties expected of them. It is recommended that the deployment of night staff be reviewed to ensure that people at the home remain safe. 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. It is recommended that the home promote and maintain good communication between managers and staff, to ensure better team work. 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. It is recommended that accidents, particularly falls, are analysed and a pro-active approach to preventing accidents is taken. St Lawrence DS0000033100.V341864.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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