Inspection on 08/01/07 for The Brambles

This inspection was carried out on 8th January 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

The Brambles 05/06/07

The Brambles 25/09/06

The Brambles 18/11/05

The Brambles 24/05/05

The Brambles 22/11/04

The Brambles 02/06/04

The Brambles 05/08/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Brambles 69a Vicarage Road Amblecote Stourbridge West Midlands DY8 4JA Lead Inspector Mrs Cathy Moore Key Unannounced Inspection 8th January 2007 07:35 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 The Brambles DS0000024978.V323860.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. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Brambles Address 69a Vicarage Road Amblecote Stourbridge West Midlands DY8 4JA 01384 379034 01384 396892 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) Mr Boota Singh Khangoure Mrs Melanie Mansell Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 35 service users in the category of OP 14 can be PD(E). Date of last inspection 28/09/06 Brief Description of the Service: The Brambles is a residential home providing 24-hour care and support for up to 35 people over the age of 65, 14 of which can have a primary diagnosis of physical disability. The home is located in a residential area of Amblecote opposite Corbett Outpatients Department and close to Stourbridge town centre. It is easily accessible by local public transport networks and there are a few parking spaces at the front and attractive gardens to the rear. A major refurbishment and extension has been undertaken to improve the homes environment and increase the occupancy. This has increased communal space and enhanced bedrooms. Thirty bedrooms now have en-suite facilities. The weekly fees for this home range from £300-£399. Additional charges are applicable for services from the hairdresser and private chiropody. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on one day between 07.35 and 15.30 hours. One inspector carried out the inspection. A Commission pharmacist assessed the homes medication systems and was on site between 09.40 and 13.30 hours. The inspection process assessed the entire key National Minimum Standards for Older People. As with the previous inspection the majority of the inspection was conducted in living areas where care practices and staff/resident interaction could be observed. During the course of the inspection two service users files were looked at and one other in less detail. This process involved looking at their records and care plans. Three staff files were also examined to make a judgement on recruitment and training processes. The premises were part assessed to include the communal areas, toilets, bathrooms, laundry and garden. A Commission pharmacist assessed medication systems and records. Both breakfast and the main meal of the day were partly observed. Six service users, four staff and one relative were spoken to during the inspection day. The manager and owner were involved in the inspection process. To gain the views of as many service users and relatives as possible the Commission sent questionnaires prior to the inspection for completion, unfortunately only six were returned. The manager was active in that she gave the questionnaires to residents and relatives and encouraged them to complete however, they chose not to. The questionnaire gives service users and relatives the opportunity to request to speak to the inspector. Only one relative requested this; who has been spoken to via the phone. What the service does well: The home has plenty of communal space divided into different rooms to offer privacy and choice to service users. Over the last eighteen months the home has been mostly totally refurbished. It is well maintained regarding décor, fixtures and furnishings. Thirty bedrooms have en-suite facilities. The home has aids and equipment to enhance safety and independence. The home continues to have a friendly, welcoming atmosphere. As with the previous inspection, staff were seen to be kind and caring. The registered owner spends time every day on site to be involved in the functioning of the home. Meal provision offers a wide range of choices for each resident at each meal this to include; a full cooked breakfast each day for those who want this. Meals looked attractive and the portion size was good. The majority of staff employed by the home have achieved N.V.Q level 2 or above in care. The manager has achieved her N.V.Q awards and the Registered Managers Award. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 6 The home welcomes and encourages visitors. Positive feedback about the home was received from service users and relatives and included the following; “The staff are always on hand. Always welcomed- better than some places”. ”Very happy with the care provided. I don’t know of anything that could be improved on”. “The staff are always attentive and approachable”. “ The staff are always very helpful”. “The manager is very helpful”. “ Care at all times of an excellent standard”. “ I always find the girls friendly and supportive”. “ Far better than others that have been seen”. What has improved since the last inspection? What they could do better: A number of concerns were raised which fall within the Health and Personal Care section of the National Minimum Standards for Older People. There was no evidence to demonstrate that risk assessments have been reviewed since August 2006 even though a number of service users have deteriorated or risk has increased. The medicine policy will need to be reviewed and updated to reflect how medicines are controlled and handled and to make sure that resident’s medicines are looked after safely. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 7 Information relating to the medication needs of resident’s must be kept up to date in the care plans to ensure that healthcare needs of residents are safeguarded, particularly for ‘ when required’ medicines. It is acknowledged positively that a new care plan system has been purchased and that it will take time to transfer information from one system to another. However, it would be expected that where service users have deteriorated or new concerns have been identified that their care plans would have been addressed as a matter of priority, which is not the case. Record keeping in general needs improvement. To monitor required improvements in these areas the Commission intend to undertake a further random inspection in the very near future. ‘Fine tuning’ is needed in a number of other areas examples being; infection control, menus, staff induction processes and night staffing levels. A major shortfall at the present time is staff mandatory training, which needs urgent attention. Staffing levels need to be further reviewed particularly during early mornings when a number of service users need attention or want to get up at the same time. Also recruitment must be continued to reduce the need and usage of agency staff. 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. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 8 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 The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 9 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): 2,3 Quality in this outcome area is adequate. Service users terms and condition / contract documents need updating. No service user moves into the home without having their needs assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although not all standards in this section were assessed the following feedback was received about the home concerning ‘ The choice of home’; Five of six completed questionnaires confirmed that they had received a contract. Five of six confirmed that they had been given enough information prior to admission to enable them to make the decision that the home would be right for them. Two service users terms and conditions documents were examined. It was clear that they have not been revised since the last inspection. Fee rates were The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 10 not applicable to this financial year, reference to the NCSC was still detailed rather that the CSCI as it is now. Not many new service users have been admitted to the home since the last key inspection. None that have been admitted have stayed due to various reasons. One file examined held evidence that an assessment of need had been carried out and information from the funding authority obtained as should happen. The manager was reminded during the inspection that any new service user offered a place must not have any needs other that those related to old age. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 11 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 poor. The standard of care plans at the present time is poor even for those who have deteriorating health and complex needs. The control and handling of medication has improved in some areas, but this must be further developed in order to maintain service users health and wellbeing. Risk assessment processes are poor with no review or update even when service users deteriorate. Service users feel that they are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback from questionnaires confirmed the following; Six of six said that they always receive the care and support they need. Five of six confirmed that they receive the medical support they need, one answered usually to this question. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 12 It is acknowledged that the home has purchased a new care planning system to improve processes. However, it was very concerning that no real care plans were in place for the two service users who were case tracked. One of whom has developed pressure sores and has deteriorated, the other who had two falls at the latter end of 2006 and continues to lose weight. It was concerning also to discover that although a fluid balance chart had been put in place for one service user who is not well, all nothing was being done to scrutinise the records or make accurate records every 24 hours of input and output to enable the determination of possible dehydration, to report to the doctor if concerns present. Risk assessment processes have deteriorated. There was no evidence to show that new risk assessments had been carried out for example; for nutrition where weight loss had been recorded or tissue viability where pressure sores have developed. It was a further concern to note that where weight loss or other had been identified referral to an appropriate professional had not been made. It was pleasing however, to note that generally a wide range of healthcare services examples being; doctor, nurse and optician are accessed when needed or on a regular basis. Care workers who administer medicines to residents’ have completed certified training from Wolverhampton College on the safe handling of medication. Only members of staff who have been agreed as competent by the manager are able to administer medication to the residents’. A list of competent members of staff was available, however there was no list of signatures or initials for identification available. One member of staff was responsible for the administration of the morning medicines from the medicine trolley in the dining room. The member of staff was kind and caring and always took time to speak to the residents and checked that the medicine had been taken before signing the medicine records. The medicine trolley was left unattended and not secured during part of the medicine round, which is not good practice in ensuring that residents are safeguarded from harm. The member of staff sometimes seemed unsure of the correct dose of medication to administer and on one occasion could not locate some eye drops. On all occasions the member of staff did ask for support and advice to ensure the correct medicine was administered. The member of staff sometimes asked carers if a resident had their cream applied that morning and then would sign the chart on behalf of that member of staff, which is not good or safe practice. The morning medicine round was completed in 2 hours 15 minutes. The member of staff informed the inspectors that she had recently completed the certified medicine training and also had shadowed other members of staff but this was her second time doing the morning medicine round. There was a medicine policy available, however it lacked detail particularly for the receipt and administration of medication. There was a procedure to follow in the event of a medication error but it failed to ensure that any medication The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 13 error should be reported as an incident to CSCI. A copy of the Royal Pharmaceutical Society of Great Britain’s guidance document ‘The Administration and control of medicines in care homes and children services’ 2003 was available for reference. An up to date medicine reference book (British National Formulary September 2006) and patient information leaflets were available for staff to use as a useful reference source. Medicines requiring cold storage were stored in a dedicated refrigerator for medicine storage, however it was not locked at the time of the inspection, which is not good practice in ensuring that residents are safeguarded from harm. A thermometer was available to check the temperature of the refrigerator, which was within the correct temperature range of 2-8°C and daily records were kept to ensure the safe and correct storage of residents’ medicines. Controlled drug medicines were stored in a metal cabinet that met the Misuse of Drugs (Safe Custody) Regulations 1973. There was a Controlled Drug Register available in the home to record and document the administration of controlled drugs. The pharmacist inspector checked the records and agreed that the balances were accurate, which shows that staff are keeping up to date controlled drug records. External preparations, for example creams & ointments were not stored separately from internal medicines, for example tablets and liquid medicine in the medicine trolley. This increases the possibility of contamination of an external preparation onto internal medication and puts residents’ health and welfare at risk. This had been raised at a previous inspection. Medicines given to residents’ were recorded onto the medicine charts by trained care staff to ensure there was an accurate record of medicine administration. The majority of the medicine charts seen were an accurate record of the medicine administered to residents’. There were omissions on one resident’s medicine chart at 8.00am with no staff signature for the administration of the medicines or a code with reason to explain why the medicines had not been given. The pharmacist inspector checked the blister packs for all of the medicines and saw that they were missing from the pack for that date and time. This means that there was no record to show if the resident had actually received and taken the medicines or if they had been refused. This is poor practice. Residents’ allergy status was recorded on the medicine charts, which ensured that important medical information relating to a resident was immediately available, and therefore helped to protect residents’ from harm. Sometimes trained staff have to hand- write residents’ medicine charts for any new medicine or a change to the directions of an existing medicine. The The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 14 majority of the medicine charts were double- checked and signed by a second member of staff to agree that the medication details recorded were correct. Medicine requiring ‘one or two’ doses was not always accurately recorded onto medicine charts. This means there was no accurate record of the amount of medicine given to residents’. One resident was prescribed ‘lorazepam 1mg, half to one tablet to be given three times a day when required’, however there was no documented record of the actual amount of lorazepam given to the resident. This is poor practice and means that the welfare needs of the resident are not being safeguarded. One resident was prescribed warfarin. Staff checked the yellow ‘anticoagulation book’ provided by the clinic and recorded the daily warfarin dose on a separate recorded sheet, which was also signed by the member of staff. This showed good practice. The medicine chart was documented ‘warfarin 1mg’ and the chart was signed daily by the member of staff, however staff were not documenting the dose administered onto the medicine chart and it therefore appeared that the resident was receiving warfarin 1mg on a daily basis and not the actual dose administered. This means that records did not accurately show what the resident had received. Three residents’ were prescribed a ‘when required’ medicine for behaviour control, however there was no detailed written procedure or assessment available in the care plan to inform staff under what circumstances the medicine should be given. For example; • One resident was prescribed ‘lorazepam 1mg, half to one tablet to be given three times a day when required’, however the medicine records showed that the lorazepam was being given regularly three times a day. Lorazepam was administered during the inspection at the morning medicine round. There was no assessment or reason why it was given to the resident who was sitting quietly in a chair in the lounge. The member of staff did not appear to know when the lorazepam should be given ‘I think it is because she gets agitated and confused. I’m not really sure’. The care plan was very poor and did not list lorazepam as a prescribed medication and there was no information available for the care staff. The daily records also documented many occasions where the resident was ‘sleeping’ and ‘napping’ throughout the day, which is a side effect of lorazepam. This means that service users healthcare needs could be at risk due to a lack of understanding of the medication and also the availability of up to date and detailed records. Errors involving medicines had not been properly recorded with detailed information. The service failed to inform CSCI of a medication error when it occurred. There was no action taken to prevent the risk of the error happening again. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 15 The date of opening on the original container (box or bottle) was recorded, which ensures that some medicine audit checks can be undertaken. No balances of medicines were carried over on to new medicine charts, which means a full medicine audit could not be done to ensure that medication had been given to residents’ as prescribed by the GP. Two residents were self administering their own medicines as follows: • One resident used eye drops independently of the care staff. The resident explained that he wished to administer his own eye drops as there had been an occasion when the eye drops had not been available for a week and also that on one occasion the eye drops had not been put in his eye correctly. There was a detailed risk assessment available of the resident’s preference, which was easily accessible next to the medicine records. This was good practice and provided good support for the resident. It was therefore disappointing that the medicine record was being signed for the administration of the eye drops, which indicated that staff were either not aware the resident was self-medicating or were signing the record retrospectively, which is not good practice. In contrast another resident self medicated some of her medication, which was recorded as ‘self administration’ on the medicine chart. However, there was no risk assessment available and the medication was not listed in the resident’s care plan. There was no mention in the care plan that the resident self administered some of her medication, which is poor practice. This means that the health and welfare of this resident was not safeguarded. • It was pleasing to observe that service users looked well cared for clean clothes, tidy hair, tights and slippers or shoes on. This was confirmed by one relative who said; “ he is always kept clean, with clothes and bedding changed everyday”. Recording of personal care delivery daily could be better as some days no records are made at all, GT 7/1/07. Concerns have been raised about the lack of evidencing of personal care previously and were a cause of complaint from a relative. Staff observed during the inspection were polite and showed respect to the service users in their care. One service user said; “ The staff are nice and polite”. It was pleasing to see records of each service users preferred form of address had been made. Toilet and bathroom doors were seen to be shut when in use. The doctor during his rounds, saw service users individually in their bedrooms. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. Generally, service users find that the lifestyle in the home meets their needs. Service users are very much encouraged to maintain contact with family and friends. They are encouraged to exercise choice and control over their lives. Mostly, service users are offered wholesome, appealing meals in pleasant surroundings improvement is needed in terms of meal recording for those who have lost weight or at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At least ten service users were up and dressed in the lounge at 07.35 when the inspection commenced. Three were asked if it were their choice to get up that early- all confirmed it was. One service user said; “ I like to get up as soon as I wake. At home I used to get up earlier”. Another said; “ I always like to get up early, don’t like lying in bed”. It was pleasing that service users files seen had preferred waking and retiring times recorded. Activity provision was discussed, as the person who used to provide activities has left the home. One staff member said; “ It helps now that we have more staff because we can provide more activities”. A staff member has been The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 17 identified as a potential to offer future activities in the mornings. Another carer will cover her work to avoid depletion in care hours. Staff were reminded how important it is to ensure that records of activity provision are maintained at all times as records at the present time are not being made as they should be. Activity provision will be reassessed during the next key inspection. Completed questionnaires confirmed the following about activities. Three of six said that; there were always activities arranged by the home that they could take part in, Two answered usually and one sometimes to this question. It was encouraging to see that the chosen religion of each service user had been recorded on their files. For one service user records stated; “ She enjoys the visits to the home by the vicar”. The home encourages service users to maintain contact with family and friends. All service users spoken to confirmed that they have visitors. One said; “ My daughter comes to visit me regularly”. Another said; “ My son and grandchildren come and visit me”. Visitors were seen coming into and going out of the home during the inspection. Information concerning advocacy services was seen in the home. Service users can being into the home personal possessions if they want to. Documentation to prove that service user information is made available to the Local Authority to enable them to vote if they wish was seen on file. It was pleasing during this inspection to see that a large board in the dining room was used to detail all meals for the day which included; breakfast, lunch, tea and supper. Food provision within the home is good. This enhanced further by an evening cook being employed in addition to the day time one. It was pleasing on entering the home at 07.35 to see mugs by each service user to indicate that they had been given a early morning drink. All service users spoken to confirmed that they had, had an early morning drink. The meal times were seen to be better managed than those observed during the previous inspection, with staff on hand to give assistance. Breakfast offered consisted of a range of cereals, toast bread and butter with honey, jam or marmalade and numerous hot options including full cooked breakfast for those who wanted one. Lunch time offered a choice of lamb shank or chicken pie, potatoes, leeks and peas or cheese salad as a vegetarian option .Tea was roe or fish cakes and bread and butter . The food smelt very appetising and was attractively served. Tables were nicely laid with condiments and serviettes. One service user was given a plate guard to aid independent eating. During meals staff gave service users choices and ensured that they had enough to eat. A concern remains where service users have been identified as being nutritionally at risk or who have lost weight that accurate records of food intake are not being made. This issue was raised during the previous inspection and has not to date been addressed. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 18 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. The home does have a written complaints procedure which has been accessed by one relative since the last key inspection. Policies and procedures are in place to enhance the protection of service users however,training in protection is outstanding. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is in place within the home which one relative has accessed since the last inspection. The relative referred the complaint to the Commission because of lack of satisfaction with the homes’ feedback and action. The Commission did look into the complaint which in one area was upheld, others as there was a lack of evidence could not be, but requirements were made as a preventative measure. It was a concern during a random inspection carried out in November 2006, to discover that this complaint had not been recorded in the complaint book as it should have been however, it has been recorded now in retrospect. Completed questionnaires confirmed the following; Four of six said that they know how to make a complaint, two answered usually to this question. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 19 There have been no allegations made to the home or the Commission. Processes are available in the home to enhance service user protection. A past requirement made for staff to receive abuse awareness training has not yet been met and needs to be addressed. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Quality in this outcome area is good. Service users live in a safe, well maintained environment which has ample of space internally and nice gardens externally. Some further improvement is needed however, in terms of infection control processes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the last eighteen months or so the home has had a full refurbishment this had enhanced the overall environment considerably. The home has two lounges and a conservatory and a dining area to allow service users choice in where they spend their day. Bedrooms are all of a good standard, thirty have en-suite facilities. The home is well maintained. Décor, furniture and fixtures are of a good standard. The home has car parking space at the front and nice gardens to the rear. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 21 Overall the home looked clean and no offensive odours were detected which is positive. As stated in previous inspections additional cleaning and laundry staff have been recruited since the last inspection which has had a positive impact overall. Improvements have been made concerning infection control processes as liquid soap, paper towels and hand wash signs have been provided in bathrooms, toilets and other high risk areas. A separate sink for staff hand washing purposes has been provided in the laundry and bags for soiled laundry have been purchased that can go straight into the washing machine to prevent handling and sluicing which is all positive. The laundry is relatively small, to this end policies must be produced to ensure contamination of dirty to clean washing does not occur. Information needs to be widely available to staff on how to recognise and treat communicable infections examples being; Clostridium difficile, MRSA and Scabies. The home has had a number of outbreaks of scabies during the last few months. During the inspection the doctor advised that measures be taken as; ‘a precaution’ as some residents had a skin rash. Part of the complaint highlighted previously was about the inadequate management of scabies and the non-informing of relatives of scabies outbreak requirements have been made for this to be addressed. All six completed service user and relative questionnaires received by the Commission confirmed that the home is always fresh and clean. Comments received included the following; “ Far better than others I have seen”.” The home always looks and smells really pleasant”. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate . Night staffing levels need further consideration. A high percentage of staff have attained N.V.Q level 2 or above. Recruitment processes in the future need to be dealt with diligently. Evidence was lacking to confirm that staff are trained and competent to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is extremely positive to determine that staffing levels have improved since the last key inspection this has had a positive impact on service users. During the inspection no service user was asked to “ wait” as observed previously and staff were seen to be available at all times. All staff spoken to confirmed that things are better now. One said; “ We have more time to care”. Another said ; “ We have more time as we don’t have to do other tasks so staff are on the floor at all times”. However, further recruitment of staff is needed to reduce agency usage. One staff member said; “ Some agency staff are useless, they don’t want to do anything”. A night staff member commented ; “ Things can be difficult early mornings when everyone needs to be seen to or got up at the same time”. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 23 Problems caused by a possible inadequate number of staff early mornings were highlighted in the staff communication book with entries made such as; “ found wet”, “Covered in faeces sorry couldn’t clean it all off as it was dried on”. It is extremely positive that apart from four staff all have achieved N.V.Q level 2 or above. No new staff have been recruited since the last inspection. Previous inspection evidence found recruitment practices to be inadequate. It is vital that future recruitment processes are stringent to protect service users and that all of the required staff records are obtained before new staff commence employment. An outstanding requirement remains for a new CRB to be applied for in respect of staff member JH. It is very disappointing to determine that although requirements have been made since 2004, the home is still not ensuring that new staff receive formal induction training within six weeks of their commencement of employment at the home. All six completed relative and service user questionnaires confirmed that; staff always listen and act on what is said which is very positive. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 24 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 . The manager has been approved by the Commission as a fit person to run and be in charge of the home. Quality assurance, the safeguarding of service users monies and staff training all need some ‘fine tuning’ or improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been approved as a fit person by the Commission to run and be in charge of the home. She has successfully completed the Registered Managers Award. The home has in place a process for quality auditing . This system focuses on the National Minimum Standards for Older People. A discussion was held with The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 25 the manager and owner about the required improvements to this system where formal processes must be implemented to highlight conformance and non conformance and where needed corrective actions are put into place. It was explained that the Commission in the future will expect, care homes to undertake full self audits. It is felt that if the system was adequate major shortfalls would not be identified by the Commission as have been during the previous two key inspections. It is disappointing that to date the registered person has not contributed to the homes’ quality audit process as he should by; undertaking monthly unannounced inspections and compiling a report as described throughout Regulation 26. The safe keeping of three service users monies held by the home were checked. These were all found to be correct against balances. It was identified however, that the hairdresser and chiropodist are issuing a block receipt rather than individual ones to service users as they should. It is pleasing that improvements have been made concerning the safe keeping of service users’ money since the last inspection. During this inspection two signatures were seen to verify transactions and concerns about the lack of money given to one service user by their family have been reported to the social worker. The issue now resolved. A random inspection of service records was undertaken and was found to be in order. There were certificates available to demonstrate for example that the lift, hoisting equipment and fire fighting appliances have been serviced and were found to be in working order. There was also evidence of 5 year fixed electrical appliance testing and water testing. It was highlighted during the inspection by looking at records and speaking to the manager that, staff mandatory training is not up to speed as it should be in areas for example; infection control and first aid. A number of staff have either not received the training or received it over three years ago. The only evidence of fire training were certificates dated May 2005. The manager said that these were wrongly dated and should have been 2006. However, even if the date was correct, the number of certificates was not adequate in terms of the number of staff employed . Similarly, records show that not all staff have received fire drill training in the last twelve months. Agency staff records showed some had received training in 2003. Diligence is needed when checking agency staff to ensure that all of their training is up to date. The kitchen was not assessed during this inspection as Environmental Health carried out an inspection in December 2006. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 26 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 2 3 x x N/A 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 2 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 27 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 OP2 Regulation 5(1)(a)(b) Requirement The registered person and manager must amend the resident terms and condition documents to ensure that following; That the correct fee for any given financial year is correct. That the section which states that the home is registered with Dudley MBC be changed as it is registered with the CSCI. That any reference to NCSC is changed to CSCI. That all contracts/terms and conditions meet the requirements of the amended Care Home Regulations concerning terms, conditions and fees. 2 OP7 15(1) The registered person and manager must ensure that a care plan is produced for each resident. Timescale of 10/10/06 not met. The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 28 Timescale for action 01/03/07 30/01/07 3 OP7 15(1) This process must commence immediately as discussed during the inspection, starting firstly with those with the most complex needs and/ or who are at high risk. The registered person and manager must ensure that all service users needs including; dementia, behaviour, personal care, washing dressing, oral and denture care are accurately reflected in their care plan and that clear instructions are available for staff on how to deal with these. Timescale of 15/12/06 not met. This must also include pressure sore care, fluid balance regimes. 30/01/07 3 OP8 12(1)(a) (b) 4 OP8 12(1)a)b) 13(4)(c) The registered person and manager must make and maintain clear records to evidence that needs as described above (in care plan section) for instance, washing, dressing, and denture care etc have been/ are being met daily or to the required frequency. Timescale of 15/12/06 not fully being met. The registered person and manager must ensure that all fluid balance charts are scrutinised each day and totals of both in and out put made and recorded. For each resident who requires a fluid balance chart expert advice should be gained to determine what their approximate input and output should be each day. To ensure that at all times dehydration is prevented. This DS0000024978.V323860.R01.S.doc 20/01/07 17/01/07 The Brambles Version 5.2 Page 29 information must be included in their care plan and a referral made to their doctor if input or output becomes a concern. Although a timescale for full implementation has been given the manager and owner were informed of concerns regarding fluid input/ output mechanisms during the inspection and is it expected that this starts to be resolved immediately. The registered person and 15/01/07 manager must ask Social Services to review GT in view of the recent deterioration. This was highlighted during the inspection. 6 OP8 13(4)(c) The registered person and manager must fully review all risk assessments to include tissue viability, nutrition, falls, behaviour, moving and handling etc. These are then to be reviewed every month or earlier if incidents or changes occur. This process must commence immediately starting first with those service users who are most at risk. The registered person and manager must produce a signature and initial list of all trained staff who are competent to administer medicines to resident’s for identification purposes. The registered person and manager must ensure that the date of opening of all medicine containers are date labelled and any balances of medicines are carried over onto the new DS0000024978.V323860.R01.S.doc 5 OP8 12(1)a)b) 13(4)(c) 05/02/07 7 OP9 13(2) 25/01/07 8 OP9 13(2) 20/01/07 The Brambles Version 5.2 Page 30 9 OP9 13(2) 10 OP9 13(2) medicine chart in order to undertake medicine audit. Timescale of 15/12/06 not met. The registered person and manager must ensure that risk assessments are recorded for service users who self- medicate and be easily accessible to trained members of staff. Timescale of 15/12/06 not met. The registered person and manager must ensure that the medicine policy is reviewed and updated. Timescale of 15/12/06 not met. The registered person and manager must ensure that the medicine trolley is kept locked and secured when not in use and also when left unattended during a medicine administration round. Timescale of 10/10/06 not met. 25/01/07 01/02/07 11 OP9 13(2) 18/01/07 12 OP9 13(2) 13 OP9 13(2) 14 OP9 13(2) The registered person and manager must ensure that medicines for refrigeration are stored safely and securely at all times which must be locked when not in use. The registered person and manager must ensure that external and internal and eye preparations are stored separately. Timescale of 15/12/06 not met. The registered person and manager must ensure that all errors involving residents’ medication administration is reported to the Commission for Social Care Inspection as per DS0000024978.V323860.R01.S.doc 18/01/07 25/01/07 18/01/07 The Brambles Version 5.2 Page 31 15 OP9 13(2) 16 OP9 13(2) 17 OP9 13(2) 18 OP9 13(2) 19 OP15 16(2)(i) Sch4/13 Regulation 37. Timescale of 16/11/06 not met. The registered person and manager must ensure that staff sign the medication charts for the administration of medication or an appropriate code is documented to show the reason why medicine was not administered. Timescale of 10/10/06 not met. The registered person and manager must record the exact amount of medication administered is recorded on the medication chart for variable dose( for example; one or two). Timescale of 15/12/06 not met. The registered person and manager must ensure that the correct daily dose of Warfarin is recorded onto medication records to ensure residents medication records are accurate. The registered person and manager must ensure that there is a documented protocol and assessment available in service users care plans and also next to the medication records for medication (e.g antipsychotic and anxiolytic) prescribed on a when required basis. The registered person and manager must ensure that food/fluid intake charts are produced and put into operation for any resident who has lost weight, is nutritionally at risk or has a poor appetite. These must be completed over a 24 hour period. Timescale of 01/11/06 not met. 18/01/07 18/01/07 18/01/07 25/01/07 16/01/07 The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 32 20 OP18 13(6) 18(1)(a) The registered person and manager must ensure that all staff who have not to date receive abuse awareness training. Timescale of 01/12/06 not met. This to include staff who received training prior to July 2004 when the POVA list came into being. The registered person and manager must following the doctors instructions 8/1/07; Inform infection control of the advise given by the doctor. Inform relatives that precautionary measures are being taken concerning rashes on some residents. The registered persons and manager must expand on laundry procedures within the home to include directions for staff on how to segregate clean and dirty washing. The registered person and manager must seriously consider increasing staffing levels between 06.00 and 09.00 hours to ensure that service users needs can be met at a time of their choice and increase safety and supervision. A proposal regarding this must be provided to the CSCI. The registered person and manager must continue with recruitment processes for both days and nights to reduce agency usage. The registered person and manager must inform the CSCI when any new admissions to the DS0000024978.V323860.R01.S.doc 01/03/07 21 OP26 13(3) 15/01/07 22 OP26 13(3) 01/02/07 23 OP27 18(1)(a) 01/02/07 24 OP27 18(1)(a) 18/01/07 25 OP27 18(1)(a) 18/01/07 The Brambles Version 5.2 Page 33 home occur and highlight how staffing levels have been increased. The weekly/ monthly sending of staff rotas to the CSCI can cease immediately. The registered person and 25/01/07 manager must ensure that a new CRB is applied for, for JH. Induction and foundation 01/02/07 training to NTO specifications must be introduced (Now Skills for Care Standards). This is an outstanding requirement from 22nd November 2004. The proprietor must complete monthly Regulation 26 reports. This is an outstanding requirement from 22nd November 2004. The registered person and manager must continue with the quality assurance processes within the home to ensure that audits clearly identify conformance and non conformance and that records of corrective actions taken are made. The registered person and manager must ensure that the hairdresser and chiropodist issue individual receipts to each resident. The registered person and manager must ensure that all staff ( who require this)receive training or fresher training in the following; First aid. Moving and handling. Infection control. Food hygiene The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 34 26 27 OP29 OP30 13(6) 19(2) (11) 18&19 28 OP33 24 01/02/07 29 OP33 24 01/02/07 30 OP35 17(2) 01/02/07 31 OP38 18(1)(a) 01/03/07 Health and safety. Dementia training. 32 OP38 23(4)(d) (e)(4a)(5) This to include agency staff. The registered person and manager must ensure that ALL staff receive fire training and are included in at least one fire drill per year or as advised by West Midlands Fire Service. The registered person and manager must commence with a process to analyse all accidents and incidents on a monthly basis to determine who is at risk and any triggers or trends. 01/03/07 33 OP38 13(4)( c) 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Brambles DS0000024978.V323860.R01.S.doc Version 5.2 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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