CARE HOMES FOR OLDER PEOPLE
Close (The) The Close Littleton Panell Devizes Wiltshire SN10 4ES Lead Inspector
Roy Gregory Unannounced Inspection 18th September 2008 09:05 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 Close (The) DS0000028334.V369970.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. Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Close (The) Address The Close Littleton Panell Devizes Wiltshire SN10 4ES 01380 812304 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) theclose@hotmail.com Mr John Roche Mrs Aurora Roche Mrs Aurora Roche Care Home 12 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (12) of places Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st November 2007 Brief Description of the Service: The Close provides accommodation and personal care for older people with dementia. It is registered to accommodate 12 people, but the owners have opted to use two double rooms as large single rooms, so up to 10 people live at the home, each in a single room. The owner Mrs Roche is registered as the manager and the co-owner Mr Roche is closely involved with the home on a regular basis. The Close is a detached house set in its own grounds. The residents’ bedrooms are on the ground and first floors, connected by passenger lift. There is a sitting room, divided by arches from a dining room. From there, patio doors lead out to a garden area. Further shared space comprises a small former dining room and a conservatory, either of which may be used as a quiet area or for receiving visitors. The home is situated on the main road through Littleton Panell, a village south of Devizes. There are local shops, pubs and a GP surgery nearby, and it is on a bus route. The home has on-site parking. Bedrooms do not have en suite facilities, but all have wash hand basins. Commodes are provided in the bedrooms. There are six toilets for residents. There are three bathrooms, but only is equipped with a hoist and the others are little used. There are at least two staff working during the day. At night there is one waking staff member and another person who provides ‘sleeping-in’ cover. Fees payable are between £450 and £500 per week. Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. We visited The Close unannounced on Thursday 18th September 2008 between 9:05 a.m. and 4:35 p.m. and returned the following day from 9:20 a.m. to 4:20 p.m. During the inspection there was direct contact with a number of residents, in the communal rooms and individual rooms. This allowed for observation of care interactions, the service of meals and administration of medications. The entire home was toured. Mrs Aurora Roche, the registered manager, was available throughout the inspection time. We spoke with various staff on duty, including the deputy manager and housekeeper. There were discussions with Mr Roche, co-provider of the service, on each day, Records examined during the inspection included care plans and records of care, risk assessments, medication records, evidence of activities provided, accident records and records of staff training and supervision. Prior to the inspection visit, Mr Roche had returned the home’s Annual Quality Assurance Assessment, which gave some descriptive and numerical information. We also sent out a number of survey questionnaires. These were returned to us by the relatives or friends of six of the people living at the home, one member of staff, and a GP. During the inspection we met privately with the visitors to two people who live at the home, with a community staff nurse, and a community psychiatric nurse. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visits to the home. They take into account the views and experiences of people who live there. What the service does well:
The home’s assessment for a recently admitted person displayed a “personcentred” approach, identifying their “intact skills” to be maintained. The person’s care plan on admission was developed from this information. Mrs Roche conveyed a proactive approach to health promotion, including regular opportunities for movement and mental stimulation, combined with ensuring people ate and drank enough. Weight records were kept and, for some people, there were measured fluid intake and output charts. All residents
Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 6 received free chiropody treatment. The home also provided a visiting physiotherapist. A GP returned a survey form, indicating confidence in the care provided by the home, and satisfaction with the home’s level of liaison with the surgery. A visiting community staff nurse, who was familiar with the home, said she never had any concerns about the quality of care she had seen. Pressure area problems were few, which she considered a reflection of the home’s emphasis on stimulation, mobility and good nutrition. We saw that all care plans included pressure area risk assessments. We met a community psychiatric nurse visiting the home. She said the community mental health team valued the person-centred nature of care and stimulation provided by the home. She confirmed Mrs Roche’s assertion that the home aimed for minimal use of medication as a means of managing dementia. Examples of statutory care reviews, conducted by the mental health team, all noted that people’s families were very satisfied with the nature of care received by their relatives. All instances of giving care that we observed were skilled and patient. There was a high level of eye contact between residents and staff, and a lot of conversation. Members of staff gave people explanations of what they were doing, encouraged choice and gave praise. There were no “neutral” interactions, which for people with dementia are known to be unhelpful. When we arrived at the home, most of the residents were involved in a music and movement activity. A relative wrote in a survey about “The imaginative daily exercises and activities”. We saw that members of staff took up opportunities for conversation with residents, both one-to-one and in small groups. People were helped in orientation to the time of day, day of the week and the weather. Daily care records included many references to the activities people had joined in, and how they had responded. There was life history information to help inform about people’s likely areas of interest. A visitor told us their friend was assisted to telephone them whenever they wanted to. The same person said what they liked about the home was that their friend could continue their lifestyle without having to fit around the home. Similar comments were received through the survey: “The Close is a small community with a real ‘home’ feel to it. Small number of residents means staff get to know everyone well and everyone is treated as ‘one of the family’.” And, “The home exudes family atmosphere”. All care staff sometimes assisted with meal preparation as part of their duties, although Mrs Roche took a central role. There was a varied menu and good knowledge of individual preferences and dislikes. Meals were well presented and appeared to be much enjoyed. In the survey, all respondents indicated that meals were ‘Always’ enjoyed. One relative wrote, “Meals are varied and freshly prepared. Consideration is given to likes and dislikes”. Another added comment was, “The food is excellent and X has gained weight having lost it in hospital.” Nutritional needs were addressed in care plans. For example, a person’s swallowing capability had been referred for GP attention, and drink
Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 7 thickeners were now being prescribed. We saw that two people in particular liked to help in the kitchen, both with food preparation and with washing and drying up. This was a valuable way of enabling people to continue familiar patterns of daily living and to experience a measure of independence. The home is an extended family home and as such, has a number of attractive and homely features. Furniture and soft furnishings were of good quality. People were seen to use many parts of the home and garden as they chose, including the kitchen with supervision. Standards of cleaning around the home were good, with no offensive odours. All the visitors we spoke to, including professionals, commented on this, and all survey responses said the home was ‘Always’ fresh and clean. Two visitors, when talking about choosing The Close for their relatives, said separately that the absence of odour, relative to other homes they had visited, had been a definite reason for finalising their choice of home. The home has a small care staff team. They maintain a presence of two staff on duty through the day, often with Mrs Roche in addition. One person is on duty through the night, with an additional member of staff “sleeping in”, who can be called on if needed. Both Mrs Roche and the deputy manager worked alongside care staff and gave a lead to different areas of practice. Mrs Roche kept a book that recorded when members of staff, singly or in pairs, had been given time to explore and reflect on practical care issues, empathy, and appreciation of diversity, including use of role play. This was good practice. Staff meetings were also used in part to consider various training issues, and how the needs of individual people in the home were being met. We saw that there was an effective handover of information between shifts. Six out of nine staff had achieved NVQ (National Vocational Qualification in care) to level 2 or above and the deputy manager was nearing completion of NVQ level 4. What has improved since the last inspection?
The home’s statement of purpose included the homes policy for emergency admissions, as previously required. Care plans were much improved from the previous inspection, when it was necessary to make a requirement about the content and quality of care plans. Plans were developed from assessment information and the home’s experience of looking after a person. They included guidance to details, such as attention to denture comfort and hygiene, and use of sunscreen in hot weather. Visitors to two residents told us they had been asked for information and opinions to inform care planning. One person wrote in a survey form, “They have taken great care to get to know XX and [their] particular problems and how [they] can be helped”. Following our previous recommendation, staff were now wearing disposable aprons only when it was necessary for the task in hand, rather than routinely,
Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 8 in order to enhance people’s dignity. There had been action on a requirement that people should be consulted about the gender of staff providing their intimate personal care. At our previous inspection we recommended people should be provided with more opportunities to access the local and wider community. Mrs Roche said she concentrated on those people who did not have many opportunities to go out with family or friends. People were quite often included in shopping trips, and there had been visits to Devizes carnival and to a village day at a neighbouring village, as well as a country drive, stopping for tea and cakes. One person went out to church and a minister visited the home monthly. A small number of teenagers from a local school came into the home twice a week, purely to talk with people. They achieved a good rapport. No rooms had en suite facilities. People had commodes in their rooms for night-time use. In line with a requirement made at the previous inspection, these were emptied, cleaned and returned singly, so a carer would always return a commode liner to the room where it belonged. Attention had been paid to gates that kept the garden secure from access to the busy road. Unlike at previous inspections, it was clear from the written rotas who was on duty, or sleeping in, at any time. Following a previous recommendation, Mrs Roche had made a positive link with the local co-ordinator for “Skills for Care”, which oversees provision of training to staff in the care industry. This had enabled access to training funds. It also ensured that when new staff are taken on, they will receive an induction that complies with the recognised standards. At the previous inspection there had been concern about care records being left accessible to unauthorised people. These were now kept in an appropriate place. What they could do better:
In 2006 it was strongly recommended to the management that they should take action to ensure radiators were guarded, or replaced by low surface temperature radiators. At the last inspection on 1st November 2007, it became a requirement that radiators and pipe work must be guarded so that residents would not be at risk of burn injuries. At this inspection, we found very little progress had been made on this safety matter. As this reflects on the management’s lack of attention to a statutory requirement, and relates directly to the safety of people in the care of the service, the home’s overall rating is assessed as poor under our rules for applying quality ratings. Accordingly, we are taking advice from our Regional Enforcement Team about means of securing compliance with the requirement. Initially, the providers are required to return an improvement plan, to show how statutory requirements are to be addressed. Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 9 The environment was further let down by inattention to worn and chipped paintwork on door frames, an issue noted in previous inspections and mentioned by visitors. There were makeshift notices on doors to help people to identify various rooms, which were just hand-written signs in poly-pockets. Whilst the idea was sound, only a little extra effort was needed to make something attractive, say by laminating, and the addition of pictures would be of real assistance to some people with dementia. The effectiveness of cleaning was compromised in some high-risk areas by flaking paintwork that could not be cleaned and that could harbour infection. For example, in toilets, boxing-in of pipes behind toilet bowls was in need of repainting. We require the home to undertake a systematic audit of high-risk areas, now and at regular intervals, so that these shortfalls can be identified at an early stage and made good. Some items in the laundry had been left in soak. Mrs Roche was advised that soaking is not regarded as a safe way to handle laundry items. They should be sluiced as necessary and washed right away. We found at the 2007 inspection that work had been done, as previously required, on developing an internal quality assurance system based on canvassing views and opinions of residents and their supporters. This has not been sustained. Mrs Roche in fact identified some particular issues on which she would like feedback. There needs to be a commitment to annual surveying of stakeholders’ views, to be used as the basis for forward planning. Mrs Roche and the deputy manager frequently observed staff and worked directly with them. The small staff team, in turn, had ready access to management. However, Mrs Roche said it had been difficult to maintain consistent one-to-one supervision of care staff. This should be programmed through the year, to supplement the good hands-on supervision already in place. Risk assessments would benefit from all being done in a similar format, to promote staff understanding and to demonstrate that appropriate people have been consulted in drawing up assessments. 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.
Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 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 Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. (The Close does not provide intermediate care, so key standard 6 does not apply). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose is kept up to date so that prospective residents and their relatives can know about the service. Efforts are made to ensure that as much information as possible is gained about prospective residents to ensure their needs can be met. Prospective residents and their families are encouraged to visit to see for themselves what is being offered. EVIDENCE: The assessment for the most recently admitted person showed how information had been gathered. It displayed a “person-centred” approach, identifying “intact skills” to be maintained, before going on to the difficulties the person encountered living in the community. The person’s care plan on admission was developed from this information. People’s needs, and how to meet them, were reviewed four weeks after being admitted, usually with input from a community psychiatric nurse. There was evidence of a high level of understanding between Mrs Roche and the community mental health team.
Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 12 The person’s relatives told us they chose The Close from among many homes they looked at because they considered the person’s move into care would be easier with the homely scale of environment and personal approach of staff that they saw when visiting. They were able to decorate and furnish the person’s room before admission, as a way of carrying over familiar features from one environment to another. They considered the initial information given, the assessment and contract details to be good. Four out of five respondents to our survey thought they had been given sufficient information to assist making a choice of home. The home’s statement of purpose included the home’s policy for emergency admissions, as required at the previous inspection. No emergency admissions had occurred since that inspection. Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 13 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 – 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s personal and health care needs were met through care planning. People were treated with respect and their right to privacy was upheld. Residents were protected by the home’s procedures for the safe handling of medicines. EVIDENCE: There was a care plan for each resident. These were concise, but covered identified social and physical needs. They included recognition of the aims of care interventions, for example, “that X will remain able to attend to herself” and, “That Y will be more orientated and free from distress.” A daily care record was kept for each person, which demonstrated that care plans were followed. Care plans included guidance to details, such as attention to denture comfort and hygiene, and use of sunscreen in hot weather. Plans were reviewed six-monthly, or more often in response to significant changes. They were much improved from the previous inspection, when it was necessary to make a requirement about the content and quality of care plans. Visitors to two residents told us they had been asked for information and opinions to
Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 14 inform care planning. One person wrote in a survey form, “They have taken great care to get to know XX and [their] particular problems and how [they] can be helped”. All residents were registered with the same local GP practice, although an alternative choice was also available. Individual care records included a log of all appointments with and attendance by health professionals. Mrs Roche conveyed a proactive approach to health promotion, including regular opportunities for movement and mental stimulation, combined with ensuring people ate and drank enough. Weight records were kept and, for some people, so were measured fluid intake and output charts. There was previously a requirement about ensuring good provision for diabetes management, but currently there were no residents with a diabetes diagnosis. All residents received free chiropody treatment. The home also provided a visiting physiotherapist. Urine tests were carried out at any time when a change of behaviour suggested a person might have acquired an infection, so GP attention could be arranged if necessary. A GP returned a survey form. They indicated confidence in the care provided by the home, and satisfaction with the home’s level of liaison with the surgery. There were no negative comments. A visiting community staff nurse, who was familiar with the home, said she never had any concerns about the quality of care she had seen. Calls on the community nursing service were appropriate and never too late to enable an effective intervention. On this occasion she was undertaking continence assessments. Pressure area problems were few, which she considered a reflection of the home’s emphasis on stimulation, mobility and good nutrition. The last incidence of pressure injury, to a person who must spend a lot of time in bed, had been successfully treated by February 2008. The person used pressure-relieving equipment provided by the community nursing service. We saw that all care plans included pressure area risk assessments. We met a community psychiatric nurse visiting the home. She said the community mental health team respected judgements made by Mrs Roche. They valued the person-centred nature of care and stimulation provided by the home. Some care records contained copies of correspondence between consultant psychiatrists and GPs. These might, for example, confirm changes in medication, which showed the home shared in multi-disciplinary assessments and influenced care strategies. The community psychiatric nurse confirmed Mrs Roche’s assertion that the home aimed for minimal use of medication as a means of managing dementia. One person’s records showed how a particular medication had been supplanted by a weaker one, which in turn had been reduced in use. For the same person, staff had noted approaches that helped the person cope with the aspect of their dementia, which had initially been the reason for giving medication, resulting in a personcentred care plan. Examples of statutory care reviews, conducted by the Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 15 mental health team, all noted that people’s families were very satisfied with the nature of care received by their relatives. We observed safe practice in the storing and administration of medicines. At any time, the senior member of staff on duty was the key holder. Most staff had undertaken a distance-learning course in the safe handling of medications. Mrs Roche carried out internal training and checks on individual competence. We saw that any use of “as needed” medication was recorded appropriately. Handwritten additions to administration records were counter-signed to show they had been checked for accuracy. An audit by the supplying pharmacist was expected. There was no current use of controlled drugs, but storage arrangements for such drugs were not up to current security standards. We saw kindly and respectful interactions between staff and residents. Conversations were inclusive. Following our recommendation at the previous inspection, staff were now wearing disposable aprons only when it was necessary for the task in hand, rather than routinely, in order to enhance people’s dignity. There had been action on a requirement that people should be consulted about the gender of staff providing their intimate personal care. All respondents to our survey said they considered ‘staff listen & act on what residents say’. Care planning records showed people’s personal preferences. One person was recorded as declining assistance with an aspect of personal care, on the basis of what they could do for themselves. They had agreed what staff would do, and records showed they continued to be offered greater assistance at each review, so the nature of care offered could be changed as needs or perceptions changed. A decision to use the twin rooms for single occupancy only, was a further measure by which the home sought to provide for privacy. Close (The) DS0000028334.V369970.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 – 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home was active in identifying and meeting people’s social, religious and recreational needs. People kept in contact with family and friends and went out into the community with support. People experienced a homely way of life, including how meals were served. They were able to exercise choices. EVIDENCE: When we arrived at the home, most of the residents were involved in a music and movement activity. A weekly session provided by a visiting physiotherapist was included in the home’s fees. We saw other instances of the use of a variety of music that fitted with people’s recorded tastes. A relative wrote in a survey about “The imaginative daily exercises and activities”. We saw that members of staff took up opportunities for conversation with residents, both one-to-one and in small groups. People were helped in orientation to the time of day, day of the week and the weather. When staff members took a break on the patio, where they retained a good view of the sitting room, some residents joined them and were made welcome. There were no current residents who smoked, but this could be accommodated by use of the patio. Two people took a walk together around the grounds. Their care plans showed this activity had
Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 17 been assessed for risks, and staff were aware how to retain awareness of where people went and for how long. Mrs Roche was skilled at activity and orientation work, such as developing the appreciation of things or reminiscence through use of pictures and objects. The home was well supplied with card and board games, which were used. In two people’s care records we saw evidence of participation in word and number games. Daily care records included many references to the activities people had joined in, and how they had responded. There was life history information to show people’s likely areas of interest. At our previous inspection we recommended people should be provided with more opportunities to access the local and wider community. Mrs Roche said she concentrated on those people who did not have many opportunities to go out with family or friends. People were quite often included in shopping trips, and there had been visits to Devizes carnival and to a village day at a neighbouring village, as well as a country drive, stopping for tea and cakes. One person went out to church and a minister visited the home monthly. There was a community volunteer scheme whereby a small number of pupils from a local school came into the home twice a week, purely to talk with people. We saw that the children were not left unsupervised. They achieved a good rapport with people, Mrs Roche having first given them input about how they could be involved and what was and was not expected of them. Visitors that we met felt comfortable to see their relatives and friends in any of the communal rooms or in the person’s bedroom. A conservatory provided a suitable venue for private visits. Mrs Roche said she had given guidance to a relative about developing a relationship with the person they visited. They were now visiting regularly and staying for lunch when they did so. A visitor told us their friend was assisted to telephone them whenever they wanted to. The same person said what they liked about the home was that their friend could continue their lifestyle without having to fit around the home. Similar comments were received through the survey: “The Close is a small community with a real ‘home’ feel to it. Small number of residents means staff get to know everyone well and everyone is treated as ‘one of the family’.” And, “The home exudes family atmosphere”. A visitor told us they had always permed their friend’s hair, and they continued to do so since their friend moved into the home, in the privacy of the person’s bedroom. People were encouraged to take their meals in the sitting/dining room. Some chose to sit with others at the table and some used individual tables over their knees, whilst remaining in an armchair. Where somebody needed assistance to eat, this was given discretely and with patience. All care staff sometimes assisted with meal preparation as part of their duties, although Mrs Roche took a central role. There was a varied menu and there was good knowledge of individual preferences and dislikes. Meals were well presented and appeared to be much enjoyed. There was a cooked option at teatime. In the survey, all
Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 18 respondents indicated that meals were ‘Always’ enjoyed. One relative wrote, “Meals are varied and freshly prepared. Consideration is given to likes and dislikes”. Another added comment was, “The food is excellent and X has gained weight having lost it in hospital.” Nutritional needs were addressed in care plans. For example, a person’s swallowing capability had been referred for GP attention and drink thickeners were now being prescribed. We saw that two people in particular liked to help in the kitchen, both with food preparation and with washing and drying up. This was a valuable way of enabling people to continue familiar patterns of daily living and to experience a measure of independence. Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. There is provision for receipt of and response to complaints. Staff and management understand and exercise responsibilities in respect of keeping residents safe. EVIDENCE: The home had provision for receipt of complaints, but none had been received within the procedure in the preceding year. Mrs Roche kept a record of minor issues and how they had been resolved. There was readily available information about a local independent advocacy service. In all the survey responses, relatives knew how to make a complaint. Mrs Roche said the way to do so is highlighted to people at the time of admission. The development of quality assurance, to systematically obtain feedback from the people who live in the home, would enable them to be more aware of the ways and means to raise any area of complaint. There was monitoring of people entering and leaving the home. Signed records confirmed that all staff were given copies of the “No Secrets” guidance to local safeguarding procedures, and the code of conduct for social care workers issued by the General Social Care Council. Mrs Roche said she encouraged staff to consider that any behaviour displayed by people needed to be seen as communication, in the context of their dementia or other medical conditions. A community psychiatric nurse confirmed she had had discussions with Mrs Roche and the staff group as a whole about balancing care and risk for a
Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 20 person whose lucidity varied. They had looked at issues in the light of the Mental Capacity Act. Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 21 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, 23, 25 & 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home offers a homely environment but maintenance lags behind the amount of wear and tear, which compromises both hygiene and safety; the home’s radiators are mainly uncovered. EVIDENCE: The home is an extended family home and as such, has a number of attractive and homely features. There is room for ornaments, books and so on, without them presenting as obstacles or clutter. The main sitting room looks through arches into the dining room, from which there are patio doors to the outside. Furniture and soft furnishings were of good quality. People were seen to use many parts of the home and garden as they chose, including the kitchen with support. Attention had been paid to gates that kept the garden secure from access to the busy road, as required at the previous inspection. Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 22 The environment was let down by inattention to worn and chipped paintwork on door frames, an issue noted in previous inspections and mentioned by visitors. There were makeshift notices on doors to help people to identify various rooms, which were just hand written signs in poly-pockets. Whilst the idea was sound, only a little extra effort was needed to make something attractive, say by laminating, and the addition of pictures would be of real assistance to some people with dementia. Rooms that were formerly used for two people to share were now being used for single occupancy only, so although registered for twelve residents, there were now a maximum of ten. The former double rooms therefore provided two people with very large bedrooms, with other rooms varying in size. A visitor described having redecorated a room prior to their relative moving in, so that it bore many similarities to their previous bedroom at home. Many other rooms were very personalised. The home had three bathrooms, but only one of these was used as a bathroom as it had assistive equipment. The other two were older-style bathrooms unsuited to residents’ needs, but the toilets in them were used. Also, one person used a bathroom as a dressing room, which represented continuity of how they had dressed and undressed in their own home. No rooms had en suite facilities. People had commodes in their rooms for night-time use. In line with a requirement made at the previous inspection, these were emptied, cleaned and returned singly, so a carer would always return a commode liner to the room where it belonged. However, as an extra precaution, Mrs Roche agreed to put numbers on liners, so that at exceptionally busy times, or with unfamiliar staff, they would not get mixed up. Standards of cleaning around the home were good, with no offensive odours. All the visitors we spoke to, including professionals, commented on this, and all survey responses said the home was ‘Always’ fresh and clean. Both visitors, when talking about choosing The Close for their relatives, said the absence of odour, relative to other homes they had visited, had been a definite reason for finalising their choice of home. A housekeeper worked five days a week, and care staff undertook essential cleaning at weekends. There was a cleaning schedule, and Mrs Roche routinely checked standards, such as cleaning of touch points (e.g. door handles, switches). The housekeeper had commenced working towards National Vocational Qualification (NVQ) in cleaning, but this had lapsed and ideally needed to be completed. The effectiveness of cleaning was compromised in some high-risk areas by flaking paintwork that could not be cleaned and that could harbour infection. For example, in toilets, boxing-in of pipes behind toilet bowls was in need of repainting. If a routine systematic audit of high-risk areas were carried out, these shortfalls could be identified at an early stage and made good.
Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 23 All laundry was handled by the home. There was a laundry building in the grounds, with appropriate machinery. Care staff were able to undertake laundry tasks within their duties. Some residents liked to assist tasks such as folding clean linen, but they did not go into the laundry for safety reasons. Some items in the laundry had been left in soak. Mrs Roche was advised that soaking is not regarded as a safe way to handle soiled items. They should be sluiced as necessary and washed right away. In 2006 it was strongly recommended to the management that they should take action to ensure radiators were guarded, or replaced by low surface temperature radiators. At the last inspection on 1st November 2007, it became a requirement that radiators and pipe work must be guarded so that residents would not be at risk of scalding. A programme to complete this work was to start with those radiators presenting most risk to residents. At this inspection, we found very little progress had been made on this safety matter. There was a risk assessment of uncovered radiators, but it took too little account of the risk of unwitnessed falling by older, less mobile people with fragile skin. In two bedrooms the uncovered feed pipes for radiators were adjacent to people’s headboards. Accordingly, we are seeking advice from our regional enforcement team regarding available measures to secure compliance with this requirement, as the home is not providing adequately for residents’ health and safety. At our request, the local environmental health department has also made a visit to the home and indicated the necessary works should be carried out. Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 24 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 – 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by trained, competent staff, who are encouraged to maintain a focus on the particular needs of people with dementia. Safe recruitment practices are in place. EVIDENCE: The home has a small care staff group. They maintain a presence of two staff on duty through the day, often with Mrs Roche in addition. Mr Roche also gets involved in supporting residents. One person is on duty through the night, with an additional member of staff “sleeping in”, who can be called on if needed. Unlike at previous inspections, it was clear from the written rotas who was on duty, or sleeping in, at any time. Mrs Roche reported that recruitment of staff was very difficult. A vacancy had been carried for several months. Other staff, and Mrs Roche herself, filled gaps in the rota, because Mrs Roche believed use of agency staff would undermine the consistency of care that people experienced. One staff member had been recruited since the previous inspection, but had left soon afterwards. Mrs Roche was aware of her obligations with regard to taking up security checks and references, as highlighted at the previous inspection. Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 25 One member of staff was a deputy manager. She was nearing completion of NVQ (National Vocational Qualification) level 4 in care. Both Mrs Roche and the deputy manager worked alongside care staff and gave a lead to different areas of practice. Mrs Roche kept a book that recorded when members of staff, singly or in pairs, had been given time to explore and reflect on practical care issues, empathy, and appreciation of diversity, including use of role play. This was good practice, although it was suggested that to preserve confidentiality, a separate book should be used for each member of staff. Staff meetings were also used in part to consider various training issues, and how the needs of individual people in the home were being met. We saw that there was an effective handover of information between shifts. Mrs Roche had made a positive link with the local co-ordinator for “Skills for Care”, which oversees provision of training to staff in the care industry. This had enabled access to training funds. It also ensured that when new staff are taken on, they will receive an induction that complies with the recognised standards. Existing staff had undertaken distance-learning courses in safe handling of medication, and working with people with dementia. All staff received infection control training. A trainer in moving and handling was currently being sought. Six out of nine staff had achieved NVQ level 2 or above. All instances of giving care that we observed were skilled and patient. There was a high level of eye contact between residents and staff, and a lot of conversation. Members of staff gave people explanations of what they were doing, encouraged choice and gave praise. There were no “neutral” interactions, which for people with dementia are known to be unhelpful. Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 26 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, 36, 37 & 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service has responded to many requirements made by the Commission, but the safety of radiators in residents’ accommodation has been neglected. Supervision arrangements for staff are in place and are being further improved. There is insufficient evidence of forward planning based on obtaining the views of people with a stake in the service. EVIDENCE: Mrs Roche allowed her registration with the Nursing and Midwifery Council (NMC) to lapse. It is not necessary to her role. She has continued her membership of the Royal College of Nursing, which she finds a valuable source of journals and other publications. She also said the NMC code of conduct was used to inform several of the home’s policies, including record management and medication procedures. She has made links with both Alzheimer’s Support
Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 27 and Age Concern. Mr Roche had commenced working towards NVQ level 4 in care but decided against completion, as he will not be developing a management role further. Mr Roche returned the Annual Quality Assurance Assessment (AQAA) to us, as all registered services are required to do. At the previous inspection there had been concern about care records being left accessible to unauthorised people. These were now kept in an appropriate place. We found at the previous inspection that work had been done, as previously required, on developing an internal quality assurance system based on canvassing views and opinions of residents and their supporters. This has not been sustained. Mrs Roche commented that feedback from people on various aspects of care provision issues would in fact be useful. There needs to be a commitment to annual surveying of stakeholders’ views, to be used as the basis for forward planning. Mrs Roche said it had been difficult to maintain consistent one-to-one supervision of care staff. However, the nature of personalised training, as evidenced in the previous section, went some way to meeting people’s supervision needs, and both Mrs Roche and the deputy manager frequently observed staff and worked directly with them. The small staff team, in turn, had ready access to management. Arrangements were booked for both the deputy manager and Mrs Roche to attend a course on staff supervision, so it was envisaged that a more systematic approach would become possible in 2009. The deputy manager was keen to programme individual supervision sessions for staff through the year. Mrs Roche would retain responsibility for annual appraisals. The home does not have any involvement with personal monies for residents. Expenditure on items such as hairdressing and toiletries is agreed with and invoiced to people’s advocates. With regard to health and safety, the outstanding matter of uncovered radiators has already been mentioned. Other issues were subject of risk assessment, including individual assessments about supervised or unsupervised access to the gardens. Risk assessments would benefit from being all done in a similar format. The community psychiatric nurse who visited during the inspection offered to give some guidance on this. We suggested that a member of staff should receive training in risk assessment in order to take a lead on this work. Mrs Roche undertook an annual review of all accident reports, as well as seeing each one after it was made. Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X 3 X 1 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X N/A 2 x 1 Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 29 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 OP9 Regulation 13 (2) Requirement The person registered must replace the controlled drug cupboard by a cupboard that meets with the current storage regulations (The Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007). The person registered must ensure that radiators and pipe work are guarded so that residents are not at risk of scalding. The programme to complete this work must start with those radiators most at risk to residents. (Unmet requirement, original date 01/05/08) The person registered must undertake a recorded audit of all areas that present a high risk to infection control, for example around toilets and wash hand basins, and make good any identified compromises of hygiene. The audit to be repeated at annual intervals. The person registered must maintain a system for evaluating
DS0000028334.V369970.R01.S.doc Timescale for action 31/12/08 2. OP25 OP38 13(4)(a)& (c) 31/12/08 3. OP26 13 (3) 30/11/08 4. OP33 24 (1 & 5) 30/11/08 Close (The) Version 5.2 Page 30 the quality of the services provided at the care home, which demonstrably provides for consultation with service users and their representatives. Actual collection of data to commence by the due date. 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 OP19 Good Practice Recommendations The registered person should ensure that areas in need of new paintwork are decorated. (This is a repeat of a previous recommendation). The person registered should provide improved signage to doors, suitable to the needs of people with dementia and in keeping with the environment of the home. The person registered should instruct all staff not to leave soiled laundry items in soak. The person registered should aim to produce all risk assessments within a similar format. 2. OP19 3. 4. OP26 OP38 Close (The) DS0000028334.V369970.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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