CARE HOMES FOR OLDER PEOPLE
Cedars (The) Angel Lane Shaftesbury Dorset SP7 8DF Lead Inspector
Mike Dixon Unannounced Inspection 2nd November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 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. Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Cedars (The) Address Angel Lane Shaftesbury Dorset SP7 8DF 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) 01747 852860 01747 852722 The Community Health Association of Shaftesbury Limited Mrs Helen Goodbody Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (27) of places Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The above registered numbers refers to 26 service users and 1 additional service user as stated in this condition, and known to the Commission, to be accommodated in the ground floor bedroom near to the front door (Room 26) for the duration of the service user`s stay at The Cedars. This arrangement is agreed on the basis of the letter sent by the registered person to the Commission, dated 15/12/2004, in support of the application for variation received by the Commission on 10/12/2004. 25th February 2005 Date of last inspection Brief Description of the Service: The Cedars is a converted and extended detached premises close to the centre of Shaftsbury. It provides accommodation for 26 service users on the ground and first floors and has a fully enclosed courtyard style garden in addition to an open garden to one side and car parking at the front of the home. A condition of registration, allowing an additional service user to be accommodated at ground floor level, is no longer valid as the situation allowing a shared room arrangement is no longer applicable. A new certificate, showing the correct, revised figure of 26 will be issued in due course. The Cedars is registered to provide nursing care for older people, including those with dementia type illnesses. It is owned by the Community Health Association of Shaftsbury, a charitable company limited by guarantee. The running of the home is overseen by the Board of Trustees and the day-to-day management is in the hands of Mrs Helen Goodbody who is a state registered nurse. Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The main purpose of the inspection was to review the home’s progress in addressing requirements and recommendations that arose out of the complaint investigations that took place at the Cedars earlier in the year. The purpose was also to review progress with implementing requirements from the previous inspection report. The inspection was conducted in three parts: the first day was an unannounced visit when three inspectors spent time assessing the home’s management of the care needs of service users and observing practice. On the second day, the pharmacy inspector reviewed the medication system at the home. On the third day, two inspectors returned by appointment to observe practice further and to review the home’s staffing, staff training and health and safety arrangements. During the course of the visits the inspectors spoke with the majority of the twenty-two service users who were living at the home, the Manager, Deputy Manager and several staff members and four visitors. Prior to the inspection, the home gave comment cards on behalf of the Commission to a variety of people who have a connection with the home. Responses were received as follows: ten from relatives, five from healthcare professionals and two from social care professionals. An inspector also spoke with one healthcare professional by telephone. Questionnaires were given to thirty staff members and fourteen responses were received. In May, June and July of this year the Commission received complaints from a person who chose to retain their anonymity about the care of service users, staffing levels and the management of the home. The complaints were investigated jointly under adult protection procedures by the Commission, Dorset Social Care and Health and the Primary Care Trust. Most of the concerns were either partially or wholly substantiated. In August the Commission received a further complaint from a former staff member regarding the management and the lack of facilities available to staff to care for service users and this was not substantiated. Several requirements and recommendations were made of the home as a result of the investigations and those that have not yet been implemented in full are included at the end of this report. The home has received guidance and advice from officers of Dorset Social Care and Health Contract Monitoring Team and the Primary Care Trust to assist the management in addressing the concerns that have been raised during the preceding few months. The management of the home has produced a number of action plans in response and has begun to take measures to better safeguard service users. In most cases the home has not met the timescales set for complying with requirements; the Commission acknowledges that this has been difficult to achieve for a number of reasons including a period of ill-health of the Manager.
Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 6 What the service does well:
The inspectors were able to ascertain through observation and discussion on the two days of the inspection that for the most part staff had a good understanding of many aspects of service users’ care needs. Staff know how to provide personal care to service users in a manner which respects their privacy and dignity. Several examples of staff members assisting service users safely to transfer from bed to chair or chair to bed were observed. Staff have the necessary resources to promote the comfort of service users, many of whom suffer from incontinence and/or fragile skin. Service users who were able to express a view said that they were happy at the home. Most of the comments made by relatives or friends of service users about the home either verbally or in writing were favourable. One visitor said: “the staff are very good and kind, very friendly, they always have a smile on their face”. There are several examples of the home communicating well with doctors, nurses and other specialists to obtain the healthcare provision that service users need. Most of the health and social care professionals who have regular contact with the home and made their views known to the inspectors had a favourable impression of the care provided by the staff. The home has systems for managing residents’ medicines and the records seen indicated that they are given as prescribed. Many aspects of the storage and administration of medication arrangements are in accordance with professional guidance. Visitors are always made welcome by the staff and they are free to visit whenever they wish. For the most part staff communicate well with relatives and friends and include them in assisting with service users’ care, where feasible. There is a relaxed daily routine at the home and a programme of activities is in place which provides some opportunity for leisure pursuits such as singing, listening to music, quizzes and exercise. The home’s equipment, facilities and services are regularly maintained. The home is generally in a good condition; it is kept clean and free from unpleasant odours. Staff have protective clothing and follow hygiene procedures when going about different tasks. Bedrooms contain the majority of recommended items of furniture; they are “personalised” with pictures, photographs and other features of interest. There are enough nursing, care and ancillary staff members on duty to enable them to look after service users and carry out catering and domestic duties. The home is working towards a situation where most of the care staff will have achieved NVQ level 2 within the next year. There is a training programme in progress which assists staff to gain the skills to do their work safely and
Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 7 professionally. In most respects the home’s system of recruiting new staff complies with regulations and good practice guidance. Staff were noted to be enthusiastic about their work and several have worked at the home for a number of years. Interactions between staff and service users were on the whole very respectful and encouraging. Those persons responsible for the organisation of training for the care staff were highly committed to promoting high standards of competence. What has improved since the last inspection?
There were nine requirements from the previous inspection report; the home has implemented three of them in full, four of them mainly or partially and has not met a further two. There were also nine recommendations, four have been addressed in full, one has been partially addressed and a further four have not yet received attention. In most cases a risk assessment is now completed prior to the fitting of bed rails and a consistent format for the completion of such assessments is in use. Care plans make reference to the monitoring of tissue viability where a high risk to service users’ health has been identified. Service users’ records now record information as to the wishes of service users following their death, including funeral arrangements. Most staff members have received training from an external training provider on the topic of adult protection and the prevention of abuse; an appropriate record of such training is maintained. The “whistleblowing” policy now makes reference to external agencies that can be contacted by staff. Prospective new staff members complete a full previous employment history on the application form. One-to-one supervision of care staff has commenced. Fail-safe thermostatic valves have been fitted to wash-hand basins in bedrooms and bathrooms to prevent service users from scalding themselves with hot water. As noted in the introduction to the report, a number of requirements and recommendations were made of the home following the complaint and adult protection investigations that were conducted at the home earlier this year. The management have implemented the requirement to provide two registered nurses on duty during the daytime on each day of the week and to ensure that three staff members are on duty throughout the night. The management have recruited a Registered Mental Nurse who has now commenced working at the home, as recommended. Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 8 The management have stopped admitting new service users to the home whose reason for admission is to receive palliative care. The home has sought advice from an external specialist in the event of service users experiencing problems with swallowing or a significant loss of weight. Referrals are being made to the service users’ general practitioner in the event of staff noting a medical problem. Good standards of service users’ personal hygiene are being maintained. What they could do better:
Twenty-one requirements and twelve recommendations have been made as the result of this inspection, including those that have been repeated from the previous inspection report. The majority of these items concern the care and welfare of service users and the clinical skills and leadership of the registered nurses. In some respects the shortfalls are about documentation; good record-keeping is important to encourage a consistent approach from staff and to avoid a situation where care practice is open to interpretation by different members of staff. The home must be more thorough with the assessment of prospective service users to ensure that only those people whose care needs can be met are admitted to the home. Both the mental and physical health care needs of service users must be comprehensively assessed and reviewed. Improvements are needed with the writing of care plans and the carrying out and recording of risk assessments so that staff have clear instructions and guidance. Improvements are also needed with the nutritional screening of service users and the monitoring of their weight gain or loss. In order to ensure better protection for service users the home needs to implement a more effective means of investigating and monitoring incidents and accidents, including the referral of service users to their general practitioner in the event of an injury and the setting out of clear action plans where service users are at risk. The home should ensure that service users and/or their representative are kept informed of any substantial change to the care plan and are given the opportunity to read and where feasible sign the revised documentation. The home should check with the Nursing and Midwifery Council (NMC) if the procedure adopted by the home in respect of determining the issue of resuscitation accords with recommended guidance on the subject. Some improvements to the medication policy, storage, administration and recording systems are necessary to provide better protection for service users. The home should review the activities programme in the light of the individually assessed psychological and social needs of service users. The daily plan of care should take into account such needs, ensuring a more holistic
Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 9 approach to service users’ care needs. Where appropriate, the home should keep a record of the times when individual service users eat their meals to assist with the monitoring of dietary provision. Food items should be pureed separately so that they retain a resemblance to the original product. In order to comply with fire regulations linen cupboard doors must be kept shut when not in use. The home must conduct an annual evacuation of service users or demonstrate through the fire risk assessment the appropriateness or otherwise of involvement of service users in fire drills. Both new and existing service users’ should be asked whether or not they would like an alternative type of lock fitted to their bedroom door which allows them to safely lock the door from the outside with a key and a suitable record should be kept. The Manager must ensure that agency staff who regularly work at the home have received adult protection training. A police/POVA check must be conducted via the Criminal Records Bureau on foreign workers before they commence working at the home. All policies and procedures regarding adult protection should be kept in an accessible place at all times. The registered nurses must receive updated training on tissue viability/wound care, the management of nutritional needs of older persons and palliative care, including pain control. Registered nurses should consider accessing clinical leadership courses, such as those provided by the Royal College of Nursing. One-to one supervision must be extended to include registered nurses to ensure that there is suitable oversight of the nursing and care needs of each service user. With regard to the registered nurses, a training strategy should be drawn up which reflects the demands made by the nursing needs of the service users. A specific plan should then be developed and delivered by competent trainers. There should not be a reliance on “cascade” training. Arrangements should be put into place to monitor how staff are putting training into practice. The management must introduce an effective quality assurance system which is based on the views of service users, their representatives and other people who have an interest in the home. Such a system would assist the home to evaluate the progress it is making in meeting its aims and objectives. The management should review the index system for the home’s policies/procedures and review the documentation to ensure that the guidance reflects expected practice. 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.
Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 10 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 Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The home does not carry out sufficiently comprehensive preadmission assessments to demonstrate that it can meet the care needs of prospective service users. EVIDENCE: The home carries out a pre-admission assessment on prospective service users or receives information about them from an external agency. The inspectors looked at four examples of assessments and found that there were several gaps in the documentation for three of them. In one case the home had not made an evaluation of the information supplied by another agency and had not recorded details of potential areas of risk. In another case there was no conclusion to the assessment, no signature of the person who carried it out (or when) and no indication as to where the information for the assessment had come from. Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Each service user has a care plan but there is insufficient information to provide clear guidance to staff about the meeting of personal, health and social care needs. The risk assessment process and accompanying documentation is in need of improvement in order to better protect service users. Shortcomings with the assessment of nutritional needs and evaluation of weight loss mean that the home is not able to demonstrate that service users’ health care needs are being consistently met. The home has systems for managing residents’ medicines and the records seen indicated that they are given as prescribed; the medication policy, some documentation and monitoring of records need improving to protect service users. Staff treat service users with respect and dignity and for the most part carry out personal care tasks in a manner which ensures service users’ comfort and safety. Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 13 EVIDENCE: Each service user has a set of care records which comprise a care plan, assessments covering a range of topics, including nutrition, tissue viability, manual handling, risks regarding the prevention of falls, treatment plans and visits from healthcare professionals. The inspectors looked at eight examples of care records in depth and at several others in less detail. Whilst acknowledging that the records contain a lot of information, in some important areas there are gaps and elsewhere the information is not displayed in a way that is readily accessible to the reader. The care plans do not clearly set out the tasks expected of care staff in relation to personal care; nursing interventions are not consistently clearly documented, social care needs and a corresponding plan of care are lacking in detail and the mental health assessments have limited practical application. In one case there was no risk assessment for the fitting of bed rails for a service user and in another instance the assessment did not reflect the type of bed rail that was in place. Elsewhere, there was no documented risk assessment where a problem with aggressive behaviour for a service user had been noted. The manager and deputy manager have recognised the shortfalls and in between the two days of the inspection visit have begun to revise the system of care planning. The recent appointment of a Registered Mental Nurse is also an indication of the home’s intention to reassess the psychological well-being of service users who suffer from dementia. For the most part discussion with staff and observation of practice indicated that staff had a good understanding of service users’ care needs. This was not “backed up” by robust record-keeping. Several examples of such shortfalls were noted, including the lack of a suitable care plan for service users with diabetes. The documentation relating to the monitoring of falls is another illustration of this particular problem: risk assessments are not consistently updated/reviewed following falls and guidance to staff on action to take to prevent a reoccurrence is not transferred to the care plan from the risk assessment. In one case the information contained in the risk assessment contradicted what was written in the care plan. The audit of accidents is limited to recording the number that occur each month, without an analysis of findings or identification of required action to minimise falls. The arrangements for the investigation and monitoring of incidents is also in need of review, as noted in the course of the adult protection investigation conducted by Social Care and Health in August of this year. During the current inspection an example was seen in a care record of bruising to a service user’s arm, with no accompanying explanation of the cause or evidence of investigation into the incident or referral to the GP.
Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 14 Care records make reference to contact with and visits from healthcare professionals, including GPs, diabetic liaison nurse, psychiatrist and community psychiatric nurse. Views expressed by health and social care professionals in comment cards received by the Commission prior to the inspection were mainly positive about the home’s performance, e.g. one person said that there was “generally a good standard of care and committed staff”. Another person commented adversely on the home’s failure to consistently follow advice about a service user’s care. The assessment of service users’ nutritional needs and the monitoring of weight is an area which continues to give cause for some concern. Advice contained in care plans is vaguely worded (the use of such terms as “adequate” or “good” in relation to fluid or food intake) and does not always reflect an understanding of the nutritional needs of older people, e.g. a comment to the effect that the lack of mobility of a service user means that he/she requires less diet. There is no clearly set out rationale for the frequency of weighing and no criteria in place or guidance on action to take in the event of sustained weight loss. An example of substantial weight loss for one service user was noted by Dorset Care and Health Contract Monitoring Team in November and there was no action plan in place to address the matter. The home has suitable equipment and facilities to enable staff to transfer service users safely and promote the comfort and well-being of service users who have fragile skin and/or suffer from incontinence. Apart from one occasion on the first day of the inspection, the staff were observed to carry out a range of tasks in a competent manner, using standaids and hoists. Particular attention was paid to safeguarding service users’ privacy and dignity at these times. In view of the mental frailty of the majority of service users it was difficult to ascertain their views on the manner in which they were being looked after. Those who were able to comment said that they were happy with the care which they received. Staff engaged with service users in a positive and reassuring way. Visitors who spoke with the inspectors spoke highly of the staff. One said: “the staff are very good and kind, very friendly, they always have a smile on their face”. Comment cards received from friends or relatives were mainly favourable; one included the view that the service user in question was “very well cared for”. Two people considered that they were not consulted about their relative’s care. The findings of the pharmacy inspector are contained in a report which has been sent to the home under separate cover. Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 15 There is an activities programme but it could be developed so that it takes better account of the individual circumstances of service users. Visiting arrangements are very good, enabling service users to maintain contact with friends and relatives. The arrangements for monitoring dietary intake of service users are in need of improvement so that the home can more readily demonstrate the meeting of service users’ needs. EVIDENCE: The daily routine moves along in a relaxed manner which helps to create a calm atmosphere. Staff endeavour to assist service users with personal care tasks at intervals which accord with service users’ wishes and circumstances. A notice board in the front hall displays information about regular weekly activities and forthcoming events over the Christmas period. An activities organiser visits the home on three afternoons each week and conducts quizzes, exercise sessions and “singalongs” in a group or does some one-to-one work with service users in their own room. The normal arrangement is for staff to assist some service users to the lounge on the ground floor in the late afternoon to participate in an activity. For the greater part of the day service users remain in their bedroom and although there is interaction between staff
Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 16 and service users there is no evidence of planned activity which reflects the individual circumstances and needs of the service users. There are twice weekly visits from the hairdresser and celebration of Holy Communion takes place once a month. Visitors informed the inspector that they were always made welcome by the staff and that they were free to visit whenever they wished. It was evident that the staff took steps to encourage visits from relatives and to include them in assisting with service users’ care, where feasible. A few service users receive daily or very frequent visits. One relative complimented the staff on arranging a celebration party for his wife and himself on the occasion of their sixtieth wedding anniversary. This positive view of the home was confirmed in the comment cards received from relatives or friends of service users prior to the inspection. Information about visiting arrangements is included in the home’s service user’s guide. Service users’ nutritional needs, likes and dislikes are documented on a chart that accompanies the drinks trolley and fluid and food intake charts are kept. On the first day of the visit it was noted that fluid intake was not consistently being recorded and that the charts did not cover a 24 hour period; improvements had been introduced by the time of the second visit. The home has been taking action in the recent past to address concerns about nutritional issues: some service users have been referred to the dietician; a staff member has attended a relevant course and will be passing on information to the staff group; in January 2006 dieticians will be visiting the home to provide staff training. Two visitors commented favourably on the home’s achievement in improving the dietary intake of their relative since her admission; as regular visitors to the home they have witnessed the serving of meals and consider the food quality to be very good. The home has a six week rotating menu, the content of which is periodically reviewed. The majority of service users enjoy a “normal” diet, in some cases meals are pureed where swallowing difficulties are anticipated or encountered. A few service users have supplementary nutritional provision where specific concerns about diet have been identified. Choice is limited with regard to meal content; in effect, service users’ likes and dislikes are known and alternatives are offered if they don’t like a particular dish or item. An inspector observed the serving of lunch on both days of the inspection when it was noted that the majority of service users required assistance with eating. The arrangements appeared better organised on the second day which may be the result of there being more staff on duty. On the first day, puddings were still being served after two o’clock; this in itself is not a problem provided that there is some rationale about the spacing of meals for individual service users (the serving of tea commences at four thirty in the afternoon).
Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 17 The inspectors spoke with several service users about the quality of the food. It was difficult to gain an accurate picture of the situation in view of the mental frailty of most service users. The majority who expressed a view said that the food was good; on the first day of the inspection one person said that they did not get enough to eat but on the second day said that the food quantity was sufficient. From observation, service users appeared to enjoy the meals as most of the content was consumed. With regard to presentation, on the second day the potatoes and carrots were pureed together, the resulting item resembling swede, which could be “off putting” for some people. It is preferable if all vegetables are pureed separately. It was also the case that there was no green vegetable on that occasion; the menu indicated that cabbage would be included. On the positive side, the cottage pie itself that was served for service users requiring a soft diet was well presented. Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Whilst the home has made improvements by developing staff training, the measures currently in place for responding to incidents are not sufficiently comprehensive to offer full protection to service users. EVIDENCE: The home has adult protection and “whistleblowing” policies and procedures which comply with guidance and a copy of the Dorset County Council “No Secrets” code of practice. Not all policies/procedures were in evidence on the day of the inspection, although these have been seen on previous inspection visits. The Trustees of the Association and the majority of the staff members have now attended the protection of vulnerable adults training session provided by Dorset County Council. Not all agency staff who regularly carry out shifts at the home have received adult protection training; following the investigations that were carried out earlier this year, a requirement was made of the home to ensure that this was put into place. In view of the continuing concerns that the Commission, Dorset Social Care and Health and Primary Care Trust have regarding the home’s shortcomings with responding to and monitoring incidents and accidents, it is not possible to say that the home is fully protecting service users at present. Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,23,24 and 26 The premises are well maintained, clean and free from unpleasant odours, overall providing a pleasant environment for service users. Safety is compromised by the failure to ensure that all fire doors are kept in a closed position. The equipment and facilities offered by the home are suited to the needs of the service users, ensuring that their care needs can be met. Whilst the size of most bedrooms limits the options for layout and furniture distribution the accommodation is sufficient for the purpose. EVIDENCE: The physical environment is generally well maintained, the condition of decoration and floor coverings is kept under review. A programme of improvement and upgrading is under way; on the first day of the inspection fail-safe thermostatic controls were being fitted to all washhand basins in bedrooms to limit hot water temperatures. Fire safety measures and checks are mainly in accordance with the requirements and guidance from Dorset Fire and Rescue Service. The servicing of the fire precaution and emergency
Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 20 lighting systems takes place on a regular basis and most routine checking measures are occurring, as required. The inspector noted that the linen cupboard doors on both floor levels were left open for the greater part of the morning, contrary to fire regulations, a point that has been noted on a previous inspection visit. An assessment of the premises and facilities was conducted by a trained occupational therapist last year. The report concluded that the home met the standard and that the home’s design was suited to the needs of the service users. The report made minor recommendations regarding wheelchair access from outside the building. The home has a range of equipment to enable staff to safely transfer and assist physically frail service users, including mobile hoists, standaids, wheelchairs, slide sheets and bath hoists. Storage space is very limited; equipment is stored in bathrooms and the hairdressing room, giving a cluttered appearance. All rooms have a nurse call point with an extension lead. The inspectors observed a few examples of transferring service users in bedrooms; staff were just able to conduct the operation with the existing layout and design of the rooms. Whilst all bedrooms meet minimum size requirements, the need to use mobile hoists to transfer service users is made difficult by the limited available space in most rooms. A variety of beds are in place, including some specialised beds suited to the provision of nursing care for those service users who require them. Bedrooms contain the majority of items of furniture recommended under this standard; in some cases there are fewer items either through lack of space or where the service user is confined to bed, e.g. the provision of two comfortable chairs. Bedrooms are “personalised” with pictures, photographs and other features of interest. As far as it was possible to ascertain service users appeared to be happy with the layout and appearance of their room. Locks on bedroom doors are of the type that enable a service user to safely lock their door from the inside but does not provide the option of allowing service users to lock the door with a key from the outside. There is an outstanding recommendation on how the home should address the issue which applies to current as well as prospective service users. The premises were clean and free of unpleasant odours. Suitable cleaning materials and equipment were in evidence, as were protective gloves and aprons. Staff were observed to follow hygiene procedures when going about different tasks. Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 There are sufficient numbers of staff on duty to enable the home to meet the care needs of the service users. The home is making progress towards building a care staff team which holds nationally recognised qualifications. The recruitment practice is mainly comprehensive and only needs minor adjustment to fully protect service users. Staff training is in place that covers important areas for the promotion of health and safety and good care practice. The training programme of the registered nurses is in need of development in order to improve the quality of nursing care. EVIDENCE: Following a complaint investigation earlier this year the Commission has required the home to increase the number of trained nurses on duty during the daytime so that there are two nurses every day of the week. Recently the home has improved the skill mix of the team by appointing a Registered Mental Nurse. There was also a requirement that the Manager allocate herself twenty hours per week when she was not one of the registered nurses, carrying out “hands-on” work. The expansion of the registered nurses team has recently enabled the Manager to focus more on management duties. Staff numbers as a whole have been expanded by recruiting care assistants from abroad. A small but significant number of shifts are covered by agency staff; for the most part this applies to night duties. For the four week period looked at by the inspector, ten different agency staff members worked at the
Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 22 home but many of the shifts were covered by a small number of staff who worked at the Cedars regularly. The number of care assistants on duty during the daytime varies from between six and eight. The high dependency needs of most service users makes such staffing levels necessary. From observation and comments received from staff and other interested parties, staffing arrangements are generally satisfactory. As noted earlier in the report in relation to catering, the serving of the midday meal places particular demands on staff resources and may require some adjustment of personnel to better serve service users’ interests. The inspectors looked at the records of three recently appointed staff members and found that for the most part the correct procedures and checks had been carried out. The one exception concerned a staff member recruited from abroad; although a police check had been conducted in her country of origin where she had just left, no police/POVA check had been carried out in the United Kingdom via the Criminal Records Bureau. The measures conducted by the home in relation to recruitment include the completion of an application form, the recording of the previous employment history, conducting an interview and taking up of two references. It is the home’s policy to encourage care staff to undertake preparation for NVQ level 2, once they have successfully completed a probationary period. Some staff go on to achieve NVQ level 3. At present four staff members have completed level 2 or 3, eight staff members are preparing for level 2 and two for level 3. An induction programme is in place for all newly appointed staff. For care staff induction is spread over a three month period and develops into a foundation programme, covering topics in more depth, in accordance with National Training Organisation specifications. Designated care staff take a leading role with the implementation of this programme and records are kept. The areas that are covered mainly relate to health and safety, including manual handling, infection control and first aid, in addition to the promotion of sound principles of care practice. The training and development of the registered nurses falls within the remit of the Manager and Deputy Manager, although individually each person has the responsibility to keep up-to-date with current practice in accordance with the requirements of the Nurses and Midwifery Council. One of the key findings of the multi-disciplinary team investigating complaints and adult protection issues earlier this year was the lack of clinical expertise and leadership in certain areas, particularly in relation to service users’ nutritional needs, pain control, prevention of falls and monitoring of incidents and accidents. The resulting advice to the management of the home was for the registered nurses to obtain training and guidance from external professionals and professional bodies. In the action plan submitted by the home the Manager has stated that
Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 23 information and application forms have been requested regarding a clinical leadership course for herself and professional development courses for other registered nurses. Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,36 and 38 The lack of a formal quality assurance system limits the extent to which the home is able to demonstrate that it meets the expectations of service users and achieves its stated aims and objectives. Care staff are now supervised but registered nurses have yet to follow the same model. Whilst many aspects of health and safety are in good order the home is not yet taking all the necessary steps to provide a safe environment. EVIDENCE: A requirement for the home to implement a quality assurance system has been made in successive inspection reports since 2003. In view of other priorities during the five month period prior to this inspection it is understandable that the management has not had the time to pay attention to this topic. According to the manager’s action plan the matter will be addressed in the early part of 2006.
Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 25 Formal one-to-one supervision for care staff has commenced and a record is kept of the outcome. Similar supervision arrangements are not yet in place for the registered nurses and it important that this is implemented in the near future. Registered nurses meet each week to discuss clinical, care practice and training issues and this is also an opportunity for staff to provide support and guidance to each other. From comments expressed by staff to the inspector in their written responses, the staff are of the view that they can readily approach the manager or deputy manager if they have a problem. Servicing of the home’s facilities and equipment is undertaken on a regular basis and records are kept. Water quality testing has been carried out and final results of water checks are awaited, following completion of works to the plumbing. Controls to limit hot water temperatures to wash-hand basins as well as baths have now been installed. Staff training on topics relating to Health and Safety is under way; most staff members have now covered areas such as manual handling, first aid, fire, infection control and food hygiene. The one area where further clarification is needed concerns fire drills; these exercises are carried out quite frequently, but it is not clear to what extent service users are involved. The fire risk assessment is quite a comprehensive one and could be expanded to determine the need or not for such involvement. The main concerns regarding health and safety are about the home’s failure to monitor accidents and incidents and to demonstrate the taking of preventative action to minimise reoccurrences. These matters have been dealt with in more detail earlier in the report under Standards 7 and 8. Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 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 x 1 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 2 13 4 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 2 x x 3 3 3 x 3 STAFFING Standard No Score 27 3 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X 2 X 2 Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 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 OP3 Regulation 14(1) Requirement Timescale for action 15/01/06 2 OP7 12(1) 13(4) 3 OP7 15(1) Pre-admission assessments must be completed accurately in full, or reasons stated for omissions of sections; they must be signed and dated. Assessments must state where information to complete them has been obtained from and indicate whether or not the service user has been consulted. Previous timescale of 31/3/05 not met. This requirement has been amended. A risk assessment must be 15/01/06 completed prior to the fitting of bed rails. The assessment must take account of all relevant points and demonstrate the suitability for the measure in question. It must indicate who has been consulted and when this took place. Previous timescale of 30/4/05 not met. Care plans must clearly set out 28/02/06 tasks expected of staff in relation to the meeting of service users’ personal, health and social care needs.
DS0000020499.V263307.R01.S.doc Version 5.0 Cedars (The) Page 28 4 OP7 12(1) The registered person must demonstrate that each service user who suffers from dementia and/or a related mental disorder has had a full assessment of his/her mental health nursing and care needs by a health care professional who is qualified in that field and that there is ongoing monitoring of service users’ mental health needs, including a periodic review by a suitably qualified person Call bells/cords must be positioned so that they are within reach of service users in their bedroom, unless other arrangements are determined by the carrying out of a comprehensive risk assessment in which case there must be clear guidance as to how the safety and well-being of the service user in question will be monitored. Where assessment or an incident has indicated a potential risk to service users and/or staff from a service user who may become aggressive, a risk assessment must be conducted and recorded without delay and must include guidance/advice to staff on action to take and indicate how the matter in question is to be monitored. The assessment must be linked to the care plan. 31/01/06 5 OP7 13(4) 15/01/06 6 OP7 13(4) 15/01/05 7 OP8 12(1) A nutritional assessment must be 28/02/06 conducted on each service user on admission. Where a risk to the service user’s health is identified a clear plan of care must be set out which details the action to be taken and how the matter will be monitored. The assessment must be kept under
DS0000020499.V263307.R01.S.doc Version 5.0 Page 29 Cedars (The) regular review. This requirement arises out of a complaint investigation and has been partially met. 8 OP8 12(1) Each service user must be weighed on a regular basis and a record kept, taking into account the wishes of the service user in question. The frequency of weighing must be determined by risk assessment. This requirement arises out of a complaint investigation and has been partially met. 9 OP8 12(1) Bruising or other unexplained injuries sustained by service users must be referred to the GP without delay for assessment. Incidents that affect the wellbeing of service users and accidents must be investigated without delay, in accordance with the home’s own procedures, unless the nature of the event indicates the need for referral to Social Care and Health under adult protection procedures. An audit of incidents and accidents must be implemented to assist with the monitoring of such events. This requirement arises out of an adult protection investigation and has been partially met. 11 OP8 13(4) 15/01/06 Risk assessments must be reviewed following an accident or serious incident; revised guidance/advice must be transferred to the care plan An audit of accidents must be implemented in sufficient detail to demonstrate an evaluation of
DS0000020499.V263307.R01.S.doc 31/01/06 15/01/06 10 OP8 13(4) 15/01/06 12 OP8 13(4) 31/01/06 Cedars (The) Version 5.0 Page 30 findings and action to be taken to minimise reoccurrences. 13 OP9 13(2) The manager must ensure that 31/12/05 nurses follow the home’s procedures and accurately record the administration or reason for non-administration of medicines at the time they are given and should introduce a system for monitoring records. An additional or larger CD 31/12/05 cupboard must be obtained so that all CDs can be stored correctly. 31/03/06 All staff members, including agency staff, must receive training of at least two hours duration in adult protection matters and procedures. It is preferable that training is delivered by an external training provider with particular expertise in this field. This requirement was in the previous inspection report and was amended following an adult protection investigation to include agency staff (timescale for compliance 30/9/05). The requirement remains in place because agency staff have not yet received training. 16 OP19 23(4) Linen cupboard doors must be kept shut when not in use, in accordance with the written instructions on the label on the door. Police/POVA checks must be conducted via the CRB on all prospective new staff members, including foreign workers who have just arrived in the United Kingdom. The registered nurses must
DS0000020499.V263307.R01.S.doc 14 OP9 13(2) 15 OP18 13(6) 15/01/06 17 OP29 19(1) 15/01/06 18 OP30 12(1), 18(1)(c). 31/03/06 Cedars (The) Version 5.0 Page 31 receive updated training on tissue viability/wound care, the management of nutritional needs of older persons, disphagia, and palliative care, including pain control. 19 OP33 24 There must be effective quality assurance and monitoring systems based on the views of service users and other stakeholders. Previous timescales not met, most recently 31/5/05. 20 OP36 18(2) 31/01/06 All registered nurses must receive one-to-one supervision on the basis of one session every two months. A record of the outcome of the session must be kept. This requirement has been amended to reflect the fact that supervision for care staff has commenced. Previous timescale of 30/4/05 was not met. 21 OP38 23(4) The home must conduct an annual evacuation of service users or demonstrate through the fire risk assessment the appropriateness or otherwise of involvement of service users in fire drills. 31/03/06 31/05/06 Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 32 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 OP7 Good Practice Recommendations The registered person should ensure that service users and/or their representative are kept informed of any substantial change to the care plan and are given the opportunity to read and where feasible sign the revised documentation, providing evidence of such consultation. The registered person should ensure that care plans consistently include reference to the monitoring of tissue viability where a high risk has been identified through assessment. The assessment format should be modified to identify how the score rating has been arrived at in order to assist staff with the subsequent monitoring of the topic. The home should follow guidance from the Royal Pharmaceutical Society: The policy should be updated with the recommended additions or amendments. There must be clear instructions for when to give “when required” medicines, and for any medicine that is crushed, with the MAR chart or in the care plan. The registered person should check with the NMC if the procedure adopted by the home in respect of determining the issue of resuscitation accords with recommended guidance on the subject. The registered person should review the activities programme in the light of the individually assessed psychological and social needs of service users. The daily plan of care should take into account such needs, ensuring a more holistic approach to service users’ care needs. The registered person should keep a record of the times when individual service users eat their meals to assist with the monitoring of dietary provision. Food items should be pureed separately so that they retain a resemblance to the original product. All policies and procedures regarding adult protection should be kept in an accessible place at all times. The registered person should make a note in service users’ care records, evidencing that service users have been
DS0000020499.V263307.R01.S.doc Version 5.0 Page 33 2 OP8 3 OP9 4 OP11 5 OP12 6 7 8 9 OP15 OP15 OP18 OP24 Cedars (The) asked whether or not they would like an alternative type of lock fitted to their bedroom door which allows them to safely lock the door from the outside with a key. Where this option is not feasible, owing to the mental frailty of the person in question, a risk assessment should be in place which supports the decision made by the registered person in this regard. 10 11 OP30 The manager should undergo training in the clinical supervision of staff. Registered nurses should consider accessing clinical leadership courses, such as those provided by the Royal College of Nursing. The registered person should review the index system for the home’s policies/procedures and review the documentation to ensure that the guidance reflects expected practice. 12 OP33 Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 34 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 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 Cedars (The) DS0000020499.V263307.R01.S.doc Version 5.0 Page 35 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
