CARE HOMES FOR OLDER PEOPLE
Stainsbridge House Gloucester Road Malmesbury Wiltshire SN16 0AJ Lead Inspector
Malcolm Kippax Unannounced Inspection 12th December 2006 9:20 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 DS0000028415.V323719.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. DS0000028415.V323719.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Stainsbridge House Address Gloucester Road Malmesbury Wiltshire SN16 0AJ 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) 01666 823757 West Country Care Limited Vacant Care Home 24 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (24) of places DS0000028415.V323719.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The maximum number of service users who may be accommodated in the home at any one time is 24 Only the named female service user with dementia referred to in the application dated 29 November 2004 may be aged between 18 to 64 years. No service users except the one named service user in room 34 are permitted to live on the second floor of Stainsbridge House until the next phase of building work on the second floor is complete and has been passed as safe. 9 June 2006 (key inspection) Date of last inspection Brief Description of the Service: Stainsbridge House is situated on a main road close to the centre of Malmesbury. There are grounds at the rear of the property. The home specialises in the care of people who have dementia. Stainsbridge House is a Victorian property that has been extended over the years. Refurbishment and building works, including the construction of a new extension, was taking place at the time of this inspection. The accommodation available to service users has changed over the last year and the home has had a reduced occupancy as a result of these works. The majority of the sixteen service users accommodated at the time of this inspection had newly refurbished rooms with en-suite facilities. There were two communal rooms on the ground floor. Other facilities were being brought into use as the work progressed. Mr S. Cooney has been appointed as manager during the last year. The managing director of West Country Care Limited is in the role of ‘responsible individual’ for the home. The range of fees at the time of the inspection was between £390 - £475 a week. DS0000028415.V323719.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second key inspection to have taken place within the last year. It focussed on following up matters that had been raised at the previous key inspection in June 2006 and during more recent visits to the home. The inspection included an unannounced visit, which took place on 12 December 2006 between 9.20 am and 5.10 pm. A second visit was made to the home on 14 December 2006 between 9.15 am and 4.20 pm. Service users were met with during the visit on 12 December and there were individual meetings with three care staff and with a cook. Mr Cooney was present during both visits and the managing director was also available and present when feedback was given on 14 December. The accommodation was looked at during the visit on 12 December. Records were examined, including examples of the service users’ personal records. A pharmacist inspector from the Commission inspected the home’s medication arrangements. Other information and feedback about the home has been received and taken into account as part of this inspection: • • • • Prior to the visits, Mr Cooney provided information about the changes in occupancy and staffing that had taken place since the inspection on 9 June 2006. 14 of the service users’ relatives and visitors completed comment cards about the home. Two health professionals who have contact with the home completed comment cards. After the visits, the managing director provided some further information about staff training, quality assurance and the running of the home. The judgements contained in this report have been made from all the evidence gathered during the inspection, including the visits. What the service does well:
A needs assessment form, which includes a ‘Carer’s Profile’, is completed before a service user moves into the home. The ‘Carer’s Profile’ gives a personal account of a prospective service user’s home situation. This is an addition to the assessment form that provides useful information for staff when helping a new service user to settle into the home. Individual care plans are drawn up and reviewed at least monthly, which helps ensure that they are updated to reflect any changes in the service users’
DS0000028415.V323719.R01.S.doc Version 5.2 Page 6 needs. The service users’ weights are regularly recorded, which enables staff to follow up any changes at an early stage. This is particularly important when a change in a service user’s weight may be a cause for concern. There is a procedure in use that includes the more frequent monitoring of weight and nutritional intake when a service user is identified to be at risk. There are arrangements in place for the storage and recording of medicines that help to protect service users. Two staff members check when a medication administration sheet is hand written or amended, which reduces the chances of an error being made. The meal arrangements are flexible and service users are given the time they need when seated in the dining room. This room is a pleasant area and the menus on the dining tables are a nice touch. There is a choice of dishes for breakfast and one service user was enjoying a full cooked breakfast when the home was visited on 12 December. Staff were seen to be dealing with service users in a friendly and individual manner during both the meals that were observed. A cook who was met with during the visits was knowledgeable about the service users’ particular likes and dislikes and the meals that are popular. The service users’ relatives and visitors receive information about complaints, which helps to ensure that any complaints can be appropriately followed up. The accommodation is kept clean and tidy, with no unpleasant odours evident at the time of the visits. Risk assessments relating to the on-going building work are being undertaken to help ensure that hazards are identified and action taken to safeguard the health and safety of service users. The service users’ relatives feel that staff have worked hard to overcome difficulties encountered with the on-going building work and to reduce the impact it has on service users. The relatives and the health professional who completed comment cards are satisfied with the overall care that service users receive. Some people have commented very positively about how staff go about their work and care for service users. What has improved since the last inspection?
The procedure for monitoring the service users’ weight and nutritional needs has developed and more widely applied to ensure that all service users benefit from this. Linked to this, there is now a better record being kept of the meals that are provided for service users. A new, computer based system of care planning and recording has been introduced, which has been specifically designed for use in a care setting. When fully up and running, the system will provide a comprehensive database and recording tool that covers all aspects of the service users’ personal details, assessments, individual plans and day to day care. The system includes the recording of ‘Care evaluations’, which highlight the support that service users require in different areas such as mobility, behaviour and different aspects of
DS0000028415.V323719.R01.S.doc Version 5.2 Page 7 personal care. The new system is addressing the shortcomings and requirements concerning care planning that were identified at the last key inspection. The service users’ privacy and dignity are being promoted through the provision of new en-suite toilets and wash hand basins. Screening is being made available for service users who have shared rooms and new furniture is provided as part of the refurbishment of the bedrooms. Floor pressure mats, connected to the staff call alarm points, have been installed in several bedrooms. This alerts night staff if a service user, who may not be able to summon staff themselves using the call alarm system, is out of bed and might be in need of some assistance. There is a new weekly activities plan, which is displayed in one of the communal rooms. Staff awareness of the need to support service users with activities is increasing and books have been obtained, which provide ideas about suitable activities for people with dementia. The home’s complaints procedure has been updated and is displayed in the front hall, which ensures that relatives and visitors have information readily at hand about how to make a complaint. The last inspection report is also available. Service users are better protected following the guidance and training that staff have received since the last inspection about the prevention of abuse and what to do if abuse is suspected. Service users are now benefiting from the work that has taken place within the original building. The refurbished rooms have provided service users with better space and lay out and there is a more settled atmosphere within home. Builders are no longer working within the main part of the house and there is a clearer separation between the service users’ accommodation and the area where the building work is continuing. As discussed at the last inspection, the fly screens in the kitchen have been secured to the windows and an extractor fan has been installed, which produces a more hygienic environment. Staff members have attended training events, which means that they are better able to meet the service users’ needs. The training has covered a range of subjects, including those that were identified as being in need of attention at the last inspection. Several staff members have attended an appointed persons course in first aid, which was a requirement at the last inspection. Additional staff have enrolled for a National Vocational Qualification (NVQ), which when completed, will take the percentage of the staff team with NVQ at level 2 or above to over 50 . No new carers have been employed since the last inspection although a cleaner has been appointed. Requirements were made at the last inspection about the need to receive written references as part of the recruitment process and also to carry out a Criminal Records Bureau check and Protection of Vulnerable
DS0000028415.V323719.R01.S.doc Version 5.2 Page 8 Adults check. This was in order to ensure that service users are protected from unsuitable staff. References had been obtained and checks undertaken in respect of the new cleaner, who had completed an induction and also attended a training event about abuse, in conjunction with the care staff. There is a greater awareness of the need to notify the Commission of certain matters, including events that affect the well-being of service users. This ensures that the Commission is kept up to date with significant events affecting the safety of service users and can look at whether these have been responded to appropriately. The managing director is producing a report each month on the conduct of the home and is sending a copy to the Commission, which was a requirement from the last key inspection. The managing director visits the home regularly and provides support, which has been important in the absence of a registered manager. A recent audit of standards has been useful in identifying areas that can be improved for the benefit of service users. A requirement was made at the last inspection about the need to undertake fire safety checks as prescribed in the fire safety log book. These checks were up to date. What they could do better:
The home’s pre-admission ‘Specialist Mental Health Assessment’ form should be amended in order that different areas of need are separately identified and so that there are headings that more clearly reflect the specialist nature of the assessment. This would provide staff with better and more detailed information about a new service user’s individual needs, particularly in relation to their mental health. Once a decision has been made that the home is suitable for meeting a person’s needs, this must be confirmed in writing with the service user or, where appropriate, with their representative. The new system of care planning and recording will need to be fully implemented as soon as is practicable to ensure that service users benefit from the system’s features and the how it is designed to be used. It will be important that everybody who uses the system is given the training and the time that they need to ensure that records are consistently maintained and provide clear and detailed guidance in respect of the service users’ care. Risk assessments are linked to the service users’ care plans, except where the assessments are recorded on separate forms, as in the case of the nutritional and moving and handling assessments. A system of cross-referencing should be used when there is a need for staff to be aware of information that is not recorded on the computerised system. When new facilities and equipment are brought into use, there needs to be a better awareness of the need to assess its safety for service users and to produce guidance for staff, when appropriate. One service user was using
DS0000028415.V323719.R01.S.doc Version 5.2 Page 9 bedrails at the time of the visits, but the use of this equipment had not been risk assessed, to ensure that these were safe for the service user concerned. Guidance for staff should also be produced in connection with the use of the floor pressure pads in the service users’ rooms. The home’s procedures for safely handling medication needs to be constantly reviewed and new guidance implemented, to ensure that service users are fully protected. The way that activities are provided for service users should be reviewed in order that service users benefit from a more individual and specialist approach and that their different needs are met. Building work has continued in the grounds, which affects access to the home’s entrance. This has proved difficult for some people and as the work progresses consideration should be give to ways in which access can be improved to ensure that all the service users’ visitors can reach the home conveniently and safely. The accommodation is now more homely, but service users will benefit further from the implementation of advice received about environments that best meet the needs of people with dementia. A change in the deployment of staff has affected how well service users are supported in the afternoons and could put service users at risk. The staffing arrangements at this time need to ensure that staff are available to respond to the needs of individual service users without compromising their support for other people. An appropriate tool needs to be used when dependency levels are calculated, based on the staff time that is needed to complete certain tasks with service users. The ‘Dependency Level Review’ form and guidance being used did not take into account the different needs of people with dementia and the time that would be needed because of this. There should be further developments in respect of staff training to ensure that service users benefit from staff members who have all received the necessary training. A training needs assessment and plan for the staff and management team should be produced, which sets out the priorities for training and how this will be provided. In general, when there are further developments in respect of care planning, the home environment and staffing, these should take into account the needs of people with dementia and be based upon specialist advice as far as possible. The home’s system of quality assurance needs to be fully implemented to ensure that the home’s development plans are based on the views of service users and their representatives. 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
DS0000028415.V323719.R01.S.doc Version 5.2 Page 10 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000028415.V323719.R01.S.doc Version 5.2 Page 11 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 DS0000028415.V323719.R01.S.doc Version 5.2 Page 12 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): 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including the visits to the home. Service users move into the home after an assessment of needs has taken place. However they are not formally assured that their needs will be met. Service users would benefit from a change in the assessment procedure to ensure that more detailed information is available about all areas of need. Service users do not receive intermediate care in the home. EVIDENCE: The personal records were looked at for two service users who had moved into the home since the last key inspection. Each had an assessment record, which Mr Cooney said he had completed with each person before they moved into the home. The assessment record form was titled ‘Specialist Mental Health Assessment’, but covered a broad range of needs such as physical, psychological, social and communication. The section on physical care needs contained relevant information, for example about skin care, mobility, medication and the person’s experience of pain. Other areas, such as foot
DS0000028415.V323719.R01.S.doc Version 5.2 Page 13 care, history of falls and continence were not highlighted on the assessment form. It was agreed with Mr Cooney that the form would be amended in order that these and other specialist areas of need are identified under separate headings. The assessment forms included a ‘Carer’s Profile’, which provided a more personal account of the service users’ recent home situations. This was a useful addition to the other information that was recorded on the assessment form. Mr Cooney said that one new service user who was self-funding had not received a letter to confirm that their needs could be met in the home. DS0000028415.V323719.R01.S.doc Version 5.2 Page 14 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including the visits to the home. Individual care plans are drawn up and there has been an improvement in how certain health and care needs are monitored and followed up. Further guidance for staff in particular areas would be beneficial and improvements are anticipated as a new system of care planning is developed. This will help ensure that the service users’ individual records provide a good reflection of their needs and the care they have received. The home has procedures for safely handling medication, however these need to be constantly reviewed and new guidance implemented, in order to fully protect service users and staff. The service users’ privacy and dignity are respected and being promoted through the development of the accommodation and facilities. EVIDENCE: There were three requirements made at the last inspection concerning the service users’ individual care plans. One requirement concerned the service
DS0000028415.V323719.R01.S.doc Version 5.2 Page 15 users’ nutritional needs and a system has since been introduced for monitoring the service users’ needs in this area. There was a procedure in place, which enabled service users who might be at risk to be identified and then to receive increased support and more frequent monitoring. The nutritional assessments and recording forms were contained within a separate file, as were the service users’ moving and handling assessment records. Other care matters were being recorded on a new computerised system that had been set up since the last inspection. The system had been specifically designed for use in a care setting and when fully up and running would provide a comprehensive database and recording tool, covering all aspects of the service users’ personal details, assessments, individual plans and day to day care. This was ‘work in progress’; some parts of the system had not yet been completed, although the system was addressing key areas and the shortcomings and requirements that had been identified at the last inspection. The records for four service users were looked at. Each person had an individual care plan recorded, which included several ‘Care evaluations’. These reflected different areas of need and the action that needed to be taken by staff. The evaluations covered areas such as mobility, behaviour and different aspects of personal care. The records showed that the service users’ individual plans were being reviewed monthly, as was recommended at the last inspection. The system enabled a range of topics to be highlighted, for example, ‘Disorientation’ was identified as an area in which one new service user would require support due to being in unfamiliar surroundings. There was some variation in the standard of recording and guidance for staff. One service user’s records included clear guidance for staff about what to do if he misses a meal. Other guidance was less specific, such as where staff support for one service user with going to bed was recorded as ‘needs 2, sometimes 3 to help’. Where staff were making a daily entry under a ‘General Progress’ section, this did not always reflect the actual care that was given. For example, one service user’s care plan included an instruction to staff about four-hourly turns during the night. The service user’s record contained entries such as ‘A good night’ and ‘Slept well’, but did not refer to the action that staff had taken during the night. The computerised system included sections for the recording of health matters and of physical changes that could be a cause for concern. Each service user’s weight was recorded monthly and other checks, for example in connection with pressure sore prevention, were carried out when assessments identified that a particular service user was at risk. Details of visits by GPs and health professionals were recorded under the ‘General Progress’ section. Risk assessments were linked to the service users’ care plans, except where the assessments were recorded on separate forms, as in the case of the nutritional and moving and handling assessments. Bed rails were in use on
DS0000028415.V323719.R01.S.doc Version 5.2 Page 16 one service user’s bed although this had not been the subject of a risk assessment. Mr Cooney said that a padded cover was fitted to the rails when in use. Each of the service users’ relatives and visitors, except one person, confirmed that they are satisfied with the overall care provided. One person said that their relative in the home was ‘as happy and well cared for as we think she could be’. Others commented that they were ‘extremely pleased with the care’ and ‘pleased with the excellent standard of care’. The health professionals who commented also confirmed their satisfaction with the care provided and confirmed that staff demonstrated a clear understanding of the care needs of their clients in the home. One commented that care plans are used for all service users and that the plans are reviewed with reference to the appropriate professional. Medication was stored and recorded appropriately. The medication administration sheet for a new service user had been hand written and checked by two members of staff. It cross-checked with records obtained from the discharging service, which were kept on file. Medication prescribed ‘as required’ did not have protocols or care plans for use and for one person was being given regularly. The time of administration was written on the chart as if for a regular medication which may lead to it being given that way. Care staff were involved in blood testing for diabetic service users. Incorrect equipment was being used, despite information about the correct type being displayed in a prominent position in the medication room. The expiry date of one box of lancets was obscured. Service users have limited capacity to comment directly on their care and the manner in which they are supported. The people who completed comment cards confirmed that they can visit in private and are consulted when their relative in the home is not able to make decisions about their own care. Interactions between service users and staff were observed during the lunch meal on 12 December. Staff responded to service users politely and in a respectful and individual manner. In the minutes of a recent staff meeting it was recorded that staff should always talk to service users, without it needing to be a two-way conversation. The refurbishment of the accommodation has resulted in all the current service users, except one, having their own en-suite toilet and wash hand basin. Eventually, every room will have this facility. There were two shared rooms in use. One room had privacy screen in place and a second screen was being arranged at the time. DS0000028415.V323719.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is mainly adequate and good in respect of standard 15. This judgement has been made using available evidence including the visits to the home. The service users’ experience of daily life in the home is improving, with better outcomes in respect of meals and diet, in particular. Service users would benefit from a more individual and specialist approach to the provision of activities, to ensure that their different needs are met. The service users receive good support with maintaining contact with their family and friends, although access to the home has proved difficult for some people. The service users’ relatives are welcomed into the home and they help service users with their day to day affairs. EVIDENCE: It was recommended at the last inspection that there is a weekly plan of activities that are suitable for all service users and that there should be consultation with organisations that have specialist knowledge in this area. This had been responded to with the introduction of a weekly activities plan, which was displayed in one of the communal rooms. The plan included activities on weekday afternoons, such as board and ball games, art and craft,
DS0000028415.V323719.R01.S.doc Version 5.2 Page 18 reading, music and movies. The plan referred to ‘Family Activities’ at the weekend. A care assistant was in the role of activities co-ordinator, although she had not received training in this area. Books had been obtained providing ideas about suitable activities for people with dementia. It was evident from discussions with staff that they were motivated to involve service users in activities and encouraged to do this, but they felt that what was currently on offer was not meeting each person’s needs. This was either because the activity was not suitable or because it was not being provided at the best time. Staff members mentioned that some service users prefer to be entertained, rather than to be participants in a group activity at a set time. It was also suggested that for some service users a short individual activity, such as being accompanied on a walk, would be preferable. In their comment card, one relative reported that they would feel happier if the service users were stimulated more regularly. Each of the service users’ relatives and friends confirmed that they felt welcome to visit at any time and are kept informed of important matters. Two people commented on the difficulties that had been encountered in visiting the home because of the building work that is taking place (see ‘Environment’ section). As reported under Standard 3, the service users’ assessment forms included information that had been gained about their previous home situation. This helped staff to get to know the service users’ usual routines. The assessment forms also had a ‘Social / Occupation’ section which included information about spiritual and religious needs. The new computerised recording system will provide the opportunity to include further and more up to date information about the service users’ interests and emotional needs. The priority since the last inspection appears to have been on the service users’ nutritional needs and on ensuring that procedures are in place for identifying service users who may be at risk and that they receive the necessary support. During the visit on 12 December, service users were seen to be receiving good support with their meals and to be enjoying the food. Upon arrival at the home, some service users were finishing their breakfast. One service user was having a cooked meal, which included bacon, eggs and tomatoes. Other service users were having cereal and bread or toast, with different spreads. Mr Cooney said that at least one cooked dish was available to service users at each meal. It was recorded in the minutes of a staff meeting in August 2006 that there would be a ‘restaurant style’ approach to meals. This was reflected in the practical arrangements; there were menus on each table, which some service users looked at when seated for lunch. The day’s menu was also displayed on a board. Prior to lunch, service users were offered a choice of cold drinks and tea and coffee was served at the end of the meal. Service users were able to take their own time with the meal. Staff were aware of service users who
DS0000028415.V323719.R01.S.doc Version 5.2 Page 19 wanted their courses as soon as possible and of the different levels of support that service users required with eating. Two staff sat alongside two service users to provide physical support with eating. One of the home’s two cooks said that none of the current service users required special diets, although she felt able to provide these if needed. The cook was aware of the meals that were popular with service users and judged the success of meals by the amount of food that was left. The cook knew the service users’ individual preferences, for example a service user who had a small appetite but was keen on puddings. Cooking duties during the week were shared between two cooks. The main cook who was met with said that the menus were kept under review and alternatives provided, which were recorded in a food diary. A record was kept of the meals served and the nutritional records provided more information in respect of particular service users. DS0000028415.V323719.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including the visits to the home. The service users’ relatives and visitors receive information, which helps to ensure that any complaints are appropriately followed up. Service users will be better protected as a result of improvements that are being made in the training of staff and the home’s procedures. EVIDENCE: A copy of the home’s complaints procedure was displayed in the front hall. This provided information about how people could complain within the home and how a complaint would be dealt with. Contact details were given for the Commission and a copy of the home’s last inspection report was also available. 13 relatives and visitors who completed comment cards confirmed that they were aware of the home’s complaints procedure. Mr Cooney said that each of the services users’ next of kin had been given a copy of the procedure. The two health professionals who completed comment cards confirmed that they had not received any complaints about the home. There were forms in the home for the recording of complaints. There was also an ‘Issues and Concerns’ book, which was being used to record matters that had been raised but did not constitute a complaint. Both Mr Cooney and the managing director said that they hoped to be able to deal with any issues at an
DS0000028415.V323719.R01.S.doc Version 5.2 Page 21 early stage and that people would feel able to approach them with their concerns. There were two requirements made at the last key inspection in connection with standard 18. One requirement concerned the need for staff to receive training in adult abuse and protection. The three staff met with said that they had received training since the inspection in June and been given a copy of the Wiltshire and Swindon No Secrets guidance. The staff training file showed that the staff had received training entitled ‘Abuse in the Care Home’ and further details about this were received after the visits. The training was facilitated by Mr Cooney, using audio visual material provided by an outside provider of training for the care sector. Mr Cooney said that staff would also be attending further training involving a session with a police officer from the local Vulnerable Adults Unit. The managing director confirmed in information received after the visits that this had been arranged for January 2007. It was reported at the last key inspection the Commission had not been notified of certain events effecting the well being and safety of service users, as is required under Regulation 37 of the Care Homes Regulations. A requirement had been made in connection with this although there continued to be a lack of appropriate notifications, which resulted in the Commission issuing a statutory notice in October 2006. The managing director has since informed the Commission of the action that will be taken to ensure that events are appropriately notified. Guidance on Regulation 37 and the need to notify the Commission of certain events was displayed in the home’s office. The staff members met with said that they had read the guidance and they described how they would report incidents involving physical aggression to Mr Cooney. One staff member said that there was better awareness now of the need to report incidents and to include these in the service users’ individual records. A risk assessment for challenging behaviour was included in each service user’s record. There was discussion with Mr Cooney about the best way to record the guidance for staff within the appropriate section of the computerised system. DS0000028415.V323719.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 and 26 Quality in this outcome area is adequate and improving in particular areas. This judgement has been made using available evidence including the visits to the home. After a period of refurbishment work and changes within the accommodation, the benefits for service users are now being seen, although access to the home continues to be affected by building work. Service users will benefit further when advice about environments for people with dementia is followed. Subject to the impact of the building work, service users live in a clean and pleasant environment. EVIDENCE: Stainsbridge House has been undergoing major refurbishment during the last year and inspectors from the Commission have made a number of visits to the home in connection with this. Requirements were identified as a result of the visits, in order to ensure that the environment was being maintained in a safe
DS0000028415.V323719.R01.S.doc Version 5.2 Page 23 condition for service users. A significant stage in the refurbishment work was reached in October 2006, when bedrooms on the second floor were brought back into use. This enabled all the current service users to be accommodated within the original building and to be less affected by building work taking place in other areas. The refurbished rooms have new en-suite facilities and changes in the lay out of rooms on the second floor have created more space and improved access. In their comment cards, a number of relatives commented on the building work and the impact that this has had. Relatives referred to ‘a difficult time’ and a ‘a difficult period of renovation’. It was also reported that staff had ‘coped very well’ and that the needs of service users had been ‘of paramount importance to staff’. Outside building work on a new extension was continuing at the time of the inspection. In their comment card, one relative described access to the home’s entrance as being ‘awful’. Another relative commented that there had been ‘no consideration for visitor access to the home’. A temporary path had improved the situation although this was not suitable for a person using a wheelchair. The refurbished accommodation in the original part of the home was looked at in detail and approved for use during a visit in October 2006. It was agreed at the time that a shower would be installed in order to provide another facility until a new bathroom had been completed. The managing director had identified a space and a timescale for the installation of the shower, although the shower was not yet in operation at the time of this inspection. The managing director said that the shower was now expected to be completed before the end of the year. The bedrooms were seen again during the visit on 12 December. The rooms looked well maintained, although some joins in the carpet outside the rooms were not secured and could lift up over time. This was brought to Mr Cooney’s attention. There had been recommendations made at the last inspection that screening in double bedrooms should be considered to improve the privacy and dignity of service users, and that service users who share bedrooms should have individual chests of drawers in their rooms. These matters have been addressed. Of the two double rooms in use, one had a screen in place and Mr Cooney said that another screen had been ordered for the other room. New furniture has been provided in several of the rooms. It was also recommended at the last inspection that information about lockable spaces and keys to bedrooms should be included in the statement of purpose and service user guide and individual risk assessments, especially where this is not provided. This has been included in a welcome pack about the home. Floor pressure mats, which were connected to the staff call alarm points, had been placed in several of the service users’ rooms. A recommendation was
DS0000028415.V323719.R01.S.doc Version 5.2 Page 24 made at the last inspection that the call points should be accessible to service users from their bedside. The call alarm points were adjacent to the beds. However, the pressure mats were being used to alert night staff if a service user, who may not be able to summon staff using the call alarm system, was out of bed and might need some assistance. A call alarm point was tested from a bedroom and a member of staff responded to this appropriately. The floor pressure mats were seen during the day and were in different modes of operation, for example some were in working use and others were unplugged or only half plugged in. When discussed with staff they were aware of the need for the mats to be connected at night, but had different views about how to leave the mats during the day. A requirement was made at the last inspection that the kitchen windows fly screens must be fully secured to the sides of the windows. This work had been carried out and an extractor fan installed in the kitchen, as has been recommended at previous inspections. It was reported at the last inspection that there has been some consultation with a specialist organisation that provides advice on suitable environments for service users with dementia. The décor generally, although in good order, was not reflective of a specialist environment for people with dementia. The advice received should be taken into account as part of the on-going building and refurbishment work. Since the visits, the Commission has received the summary findings of an initial quality assurance audit. Under the ‘Service User’s Environment’ section of the findings, it is stated that the home is ‘Mostly complying (subject to ongoing building work) but: - Board with photographs of staff would help service users and visitors - Toilet doors could be colour coded’. The domestic arrangements were not looked at during the inspection. However the accommodation was seen to be clean and tidy. The builders were now only making occasional intrusions into the occupied parts of the home and staff said it was much easier to keep the premises looking clean and homely. There were no unpleasant odours in any area of the home. Upon arrival at the home it was seen that the lid of an outside clinical waste bin was not closing fully and Mr Cooney was advised to fix this. The bin was sited close to a pavement, where it could have an impact on people walking past. DS0000028415.V323719.R01.S.doc Version 5.2 Page 25 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is mainly adequate and improving in respect of training, but poor in respect of how staff are deployed (standard 27). This judgement has been made using available evidence including the visits to the home. Service users benefit from the approach of individual staff, however, a change in the deployment of staff has affected how well service users are supported and could put service users at risk. Staff members have attended training events since the last inspection, which means that they are better able to meet the service users’ needs. Service users will benefit from further developments in respect of staff training and development. The home’s recruitment practices help to protect service users from unsuitable staff. EVIDENCE: It was reported at the last inspection that staffing levels were sufficient to meet service users’ needs, but would need to be re-evalualted to ensure that this remained so. There was a requirement that staffing levels must be reviewed to ensure that there are sufficient staff on duty at any time to meet the current assessed needs of service users.
DS0000028415.V323719.R01.S.doc Version 5.2 Page 26 During this inspection, staffing levels were discussed again with the managing director, who said that they had been kept under review. In their comment cards, 13 relatives and visitors confirmed that, in their opinion, there were always sufficient numbers of staff on duty. One person commented that staff were ‘on duty’, but added a proviso that they would feel happier if staff interacted with service users more and did not leave them in the lounge area without a member of staff present. Another person commented that the ratio of staff to service users had improved greatly over the last year. The person who did not think that there were sufficient staff on duty did not elaborate on this. In practice, staffing levels had reduced since the previous key inspection in June 2006. The managing director said that an additional carer had been deployed while building work was taking place in the main area of accommodation, but this person was no longer required. The rota showed that there were three care staff on duty each day between 7.30 am and 9.30 pm, except on weekdays, between 2 pm and 5pm, when there were two. Mr Cooney said that he provided hands-on care at this time, but that they could also do with another carer on duty. The staff members met with spoke about the afternoon shift and gave examples of events that arose at this time that could have an impact on how well they supported service users. These included needing to spend time away from service users, such as to use the computer, or in the case of Mr Cooney, needing to respond to callers or to be in the office. Staff members also mentioned the service users’ dependency levels and behaviour as a significant factor. If a service user needed two people to support them with toileting, this could mean a staff member leaving the lounge where they were supervising service users or providing an activity. Mr Cooney said that he was looking at dependency levels and at the staff time that was needed to complete certain tasks with service users. A ‘Dependency Level Review’ form was being used, in conjunction with a list that had been obtained showing different tasks and allocated time for these. For example, ‘Activities’ was given as five minutes per day and ‘Assistance with eating’ as 10 minutes each time. This appeared to be an inflexible tool and one that did not take into account the different needs of people with dementia and the time that would be needed because of this. There was a requirement at the last key inspection that there must be evidence of how at least 50 of the staff team will attain National Vocational Qualifications (NVQ) at Level 2. This has been responded to by the managing director who has reported that 4 care staff have since enrolled on NVQ training and that when they complete their courses the home will have 9 members of staff with NVQ 2 or 3, representing 75 of care staff. During the inspection, Mr Cooney said that two night staff were also due to start their NVQ shortly. Staff recruitment was discussed at the last key inspection. There had been requirements made concerning the need to obtain two references as part of
DS0000028415.V323719.R01.S.doc Version 5.2 Page 27 the recruitment process and concerning how Criminal Record Bureau information is held. Mr Cooney reported that no new care staff had been appointed since the last key inspection although a new cleaner had been appointed in October 2006. Their recruitment records were looked at. An application form had been completed and two written references received. A Criminal Records Bureau check and a Protection of Vulnerable Adults check had also been made prior to starting. Other documentation was obtained concerning proof of identity. There was a record of attendance at an ‘Abuse in the Care Home’ training session that took place in November 2006. It had been recommended at the last inspection that all staff should receive an induction within one month of appointment and an in depth induction within six months of appointment. A checklist had been completed to show that the cleaner had completed an induction on their first day. They had also been issued with a terms and conditions statement. The care staff met with described the training events that they had attended since the last key inspection. These included the subjects of food hygiene, first aid, medication, abuse, challenging behaviour, dementia awareness and moving and handling. Staff said that some training had been given by Mr Cooney using training videos; other sessions, including dementia awareness, had involved an external trainer. Two staff were reported to be assessors in moving and handling. The staff training records were looked at. These listed the subject of the training attended and the date, but lacked detail about the type of training, its duration and whether it was a certificated course. A first aid certificate was displayed in the home, confirming that a number of staff had attended an appointed persons course in August 2006. There had been a requirement made at the last key inspection that there must be at least one person on duty at all times who has a current first aid certificate. This requirement was being met at the time of the visits. Two other requirements had been made at the last key inspection concerning the training of staff. One was a general requirement concerning the need for staff to be trained and competent to carry out the duties they perform. The other requirement concerned training in infection control and the moving and handling of service users. After the visits to the home, further information was received from the managing director about the training that staff had received. This provided more details about the type of training that had been undertaken and was planned, for example that infection control training had been provided ‘inhouse’ using workbooks from Swindon College followed by an exam and that an external trainer would be conducting a session on infection control in the home during January 2007.
DS0000028415.V323719.R01.S.doc Version 5.2 Page 28 There was evidence that training had taken place in the areas identified as shortcomings at the last key inspection. The managing director acknowledged that not all staff had yet attended training in all the areas and confirmed dates in January when further training was due to take place. There was no training plan for the staff team although staff members’ individual training needs were discussed during supervision sessions. DS0000028415.V323719.R01.S.doc Version 5.2 Page 29 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): 33 and 38. (Standard 31 was not looked at on this occasion. The Commission’s Central Registration Team has received an application for Mr Cooney’s registration as manager, although the outcome of the application had not been determined at the time of this inspection). Quality in this outcome area is adequate. This judgement has been made using available evidence including the visits to the home. A recent audit of standards has been useful in identifying areas that can be improved for the benefit of service users. The home’s system of quality assurance needs to be fully implemented to ensure that the home’s development plans are based on the views of service users and their representatives. Checks are being undertaken which help ensure that the service users’ health and safety is protected while building work continues within the home environment. DS0000028415.V323719.R01.S.doc Version 5.2 Page 30 EVIDENCE: A requirement was made at the last key inspection that regulation 26 visits must be unannounced, take place at least once a month and that the local Commission office must be sent a copy of the report. The Commission has been receiving reports from the managing director, which cover a range of issues concerning the conduct of the home. It was recommended at the last inspection that, as part of the monthly regulation 26 monitoring visits, the managing director should spend time observing the interactions between staff and service users. The reports referred to conversations that the managing director had with service users, staff and occasionally visitors, but observations were not recorded. Mr Cooney said that he saw the reports each month, but did not have a copy. Since the inspection visits were made to the home, the managing director has confirmed that the monthly reports were being kept in the home. The managing director has continued to take an active role in the home and was visiting on a regular basis. There had been discussion with the managing director at the last key inspection about a quality assurance system that was to be used in the home, but had not yet been implemented. It had been reported that it was the managing director’s aim to have Mr Cooney assess groups of the quality standards every month, so that all of the standards in the organisation’s quality assurance manual were assessed in one year. Two requirements had been made at the inspection concerning the introduction of the quality assurance and the need to gain feedback from service users and other parties. The arrangements for quality assurance were looked at again during this inspection. The managing director said that there had been limited success with surveys of service users because of the client group. Two ‘Relatives and friends’ meetings had been held, the last one taking place in October 2006. The minutes of this meeting were looked at. The managing director confirmed that healthcare professionals had not been surveyed and acknowledged that this requirement had only been partly met. Mr Cooney had undertaken an audit of the accommodation. A report of the first complete quality assurance audit was not available at the time of the visits, although a report giving a summary of the findings has since been received from the managing director. The report commented on different aspects of the home and identified areas that could be developed and where improvements could be made. The managing director has stated that the areas identified will now be addressed in a systematic way. DS0000028415.V323719.R01.S.doc Version 5.2 Page 31 The arrangements being made for health and safety were looked at during the last key inspection. A requirement was made that fire safety checks must take place as prescribed in the fire safety log book. The managing director reported that these were now being done. The fire log book contained an up to date record of ‘in-house’ tests and checks of the fire precaution systems. The fire alarm system was tested on 12 December when outside contractors were working in the home. Mr Cooney said that contractors maintained the system as part of the on-going building works. A daily risk assessment was being undertaken in respect of the building work and the impact of this on the service users’ safety. DS0000028415.V323719.R01.S.doc Version 5.2 Page 32 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score N/A X 2 X X X X 3 DS0000028415.V323719.R01.S.doc Version 5.2 Page 33 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(d) Requirement The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so – … the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. In order to show compliance with this regulation, evidence must be available in the home to show that the service user, or where appropriate their representative, has received written confirmation that the home is suitable for the purpose of meeting the service user’s needs. 2. OP7 15(1)(2) Care plans must accurately describe the way in which care is to be given. This must include guidelines for managing challenging behaviour, or
DS0000028415.V323719.R01.S.doc Timescale for action 15/12/06 15/12/06 Version 5.2 Page 34 management of any mental health issues. (Requirement met in part since the last key inspection) 3. OP7 13(4)(c) The registered person shall ensure that – Unnecessary risks to the health or safety of service user are identified and so far as possible eliminated. In order to show compliance with this regulation, a risk assessment must be undertaken in respect of the use of bed rails and safety measures implemented, where indicated by the assessment. 4. OP9 13(2) The registered person must make arrangements for the safe administration and recording of medication that is prescribed for ‘as required’ use. The registered person must make suitable arrangements to prevent the spread of infection by avoiding needle-stick injuries. The home must follow the advice of the Medicines and Healthcare products Regulatory Authority MDA/2006/066. 15/12/06 21/12/06 5. OP9 13(3) 15/12/06 6. OP27 18(1)(a) The registered person shall, 31/01/07 having regard to the size of the care home, the statement of purpose and the number and needs of service users – Ensure that that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the heath and welfare of service users.
DS0000028415.V323719.R01.S.doc Version 5.2 Page 35 In order to show compliance with this regulation: • There must be evidence that the staff and, where applicable, the manager are deployed in a way which ensures that the needs of all service users can be fully met. • An appropriate tool must be used when assessing the service users’ dependency levels and the level of staff support that is required. 7. OP30 18(1)(a) (c)(i)(ii) Staff must be trained and 31/01/07 competent to carry out the duties they are to perform. This includes specialised knowledge in the field of dementia, challenging behaviour, communication and provision of activities. (Requirement met in part since the last key inspection). 8. OP30 13(3) Staff must receive training in infection control. (Requirement met in part since the last key inspection). 9. OP33 24(1)(2) Surveys of the views of service users, relatives, health and social care professionals must be obtained in order to form a view about the quality of the service. A report must be sent to the CSCI on completion. (Requirement met in part since the last key inspection). 28/02/07 31/01/07 DS0000028415.V323719.R01.S.doc Version 5.2 Page 36 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 That the ‘Specialist Mental Health Assessment’ form is amended in order that different areas of need are separately identified and that the headings more clearly reflect the specialist nature of the assessment and the needs of service users. That the new system of care planning and recording is fully implemented as soon as is practicable to ensure that service users benefit from the system’s features and how it is designed to be used. That a system of cross-referencing is used when there is a need for staff to be aware of information, such as the nutritional and moving and handling assessments, which is not recorded on the computerised system. That the way in which activities are provided for service users is reviewed in order that service users benefit from a more individual and specialist approach and that their different needs are met. That consideration is given to ways in which access can be improved to ensure that all the service users’ visitors can reach the home as conveniently and safely as possible. That advice received in respect of environments for people with dementia is implemented as work progresses with the refurbishment and redecoration of the home. That written guidance is produced in connection with the use of the floor pressure mats in the service users’ rooms, to ensure that there is a consistent approach from staff. That a training needs assessment and plan for the staff and management team is produced, which sets out the priorities for training and how training will be provided in the future. That the records of staff training included further details
DS0000028415.V323719.R01.S.doc Version 5.2 Page 37 2. OP7 3. OP7 4. OP12 5. OP19 6. OP19 7. OP24 8. OP30 9. OP30 about the type of training that has taken place and how it was provided. 10. OP33 As part of the monthly regulation 26 monitoring visits, the managing director should spend time observing the interactions between staff and service users. (Recommendation outstanding from the last inspection). DS0000028415.V323719.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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
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