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Inspection on 28/01/08 for The Close Nursing & Residential Home

Also see our care home review for The Close Nursing & Residential Home for more information

This inspection was carried out on 28th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE The Close Nursing & Residential Home Burcot Abingdon Oxfordshire OX14 3DP Lead Inspector Delia Styles Unannounced Inspection 10:30 28 & 29 January 2008 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Close Nursing & Residential Home Address Burcot Abingdon Oxfordshire OX14 3DP 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) 01865 407343 01865 407734 closenhome@aol.com Cavendish Close Limited Mrs Nyembezi Chipara Care Home 97 Category(ies) of Old age, not falling within any other category registration, with number (97) of places The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The continuing use of beds for service users with nursing needs in the remaining original building (formerly St Michaels and St Paul’s wings) is subject to review in 12 months from the date of this registration. 01 August 2006. The home may accommodate one younger adult between the age of 21 and 65. 5th January 2007 2. Date of last inspection Brief Description of the Service: The Close was originally a Tudor-style Victorian country house with two single storey wings, situated close to the market town of Abingdon and approximately 6 miles south of the city of Oxford. The home is set in 4 acres of grounds with access to the banks of the river Thames. An extensive new building project has replaced outdated and unsuitable facilities. The first phase of this project, Riverview, was completed in August 2005 and comprises a purpose-built two-storey building, with 20 en-suite bedrooms, offices, and new kitchen and laundry facilities serving the whole site. The second phase of building was completed in 2006, and involved the demolition of the original 2-storey house to create ‘The Willows’ unit, with 31 single en-suite rooms on two floors. The remaining older part of the home renamed the ‘Waterside’ unit, has accommodation for a further 46 residents in single and shared rooms. The range of fees is from £542 to £850 per week. The Close Nursing & Residential Home DS0000027175.V348401.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 1 star. This means the people who use this service experience adequate quality outcomes. This inspection of the service was an unannounced ‘Key Inspection’. A key inspection is one in which the ‘key’ National Minimum Standards (NMS) – those standards that the Commission considers to be the most important to residents’ well-being, are assessed. The inspection took place over two days – the 28th and 29th January – and lasted 14 hours. The inspection was a thorough look at how well the service is doing. It took into account information that CSCI has received about the service in the form of their Annual Quality Assurance Assessment (AQAA) and any information that we have received about The Close since the last inspection. The AQAA is a self-assessment of how well the home feels they are meeting the standards of care for people living at the home. All registered homes and agencies must send us their AQAA each year. During the inspection the inspector spoke to a number of residents, visitors and staff to get their views about the home. A tour of the home was undertaken and the inspector joined residents for lunch in two different parts of the home. A sample of residents’ care plans and records, medication records and staff recruitment files was looked at. The homes own quality audit report (April 2007) and the summary of the Residents/Relatives Questionnaire undertaken in October 2007 were also taken into account. This report summarises how well the home is meeting the NMS, through using the ‘Key Lines of Regulatory Assessment’ (KLORA). The KLORA sets out the sorts of evidence that best describes the standard (‘excellent’, ‘good’, ‘adequate’ or ‘poor’) of the care and facilities provided for people living at The Close. An judgement statement summarises each section (outcome group) in the report. The overall quality (‘star’) rating is arrived at through a ‘rules based’ approach, with the emphasis on three sections of the report that look at the safety and management of the home: Health and Personal Care, Complaints and Protection, and Management and administration. We would like to thank all the residents, visitors and staff for their time and help during the inspection process. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The information about the home – the Statement of Purpose and Service Users Guide – has been updated and re-written and is much more ‘user-friendly’ for people to read. The appearance of the older remaining part of the home – ‘Waterside’ – has been further improved with repainting, re-carpeting and fitting new curtains and blinds. A second full time maintenance person has recently been appointed so that day-to-day maintenance and repairs can be done more quickly, and there is additional time to devote to the upkeep of the grounds and gardens. A second part-time activities worker has been employed to assist the Activities Organiser. This should further increase the range of activities available to residents, both in organised groups and ‘one to one’ time with residents. Since the last inspection the home has complied with legal requirements for care homes with nursing by arranging for the collection and disposal of The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 7 unwanted and unused medicines from the home through a licensed waste disposal service. CCTV cameras have been put up around the building to improve the security of residents, staff and visitors. The staff training programme has been further developed and provides staff with regular opportunities to attend training that should improve their care and support skills for residents’ benefit. What they could do better: The standard of written records of resident’s care must be improved by making sure that they are written in enough detail to describe the support and care interventions that staff should provide to meet each individual’s assessed health, social and personal care needs. Risk assessments and regular evaluation of care should be reviewed and accurately recorded to show the extent to which the care provided continues to meet the changing needs of people. Though residents and their visitors generally report the standard of meals and menu choices as good, during the inspection we observed a number of factors that affected people’s enjoyment of their meals. For example whether they were seated comfortably and could manage their food easily. The home should review and improve the meal service to residents- presentation of food, staff assistance, and adequate spacing between mealtimes. The provider recognises that the old accommodation and facilities in part of the remaining ‘old’ part of the building is outdated and is unsuitable to meet the needs of more dependent residents. Some things, such as the small size of some rooms, the number of shared rooms and inadequate sitting and dining space in part of Waterside, can only be improved by a new building that the provider plans within the next three years. Additional staff training should be provided in caring for people with dementia and behaviours that challenge us to improve the understanding of staff and further develop ‘person-centred care’ for all residents. Staffing levels meet minimum levels but must be reviewed and increased to allow flexibility and enough staff to cover for colleagues’ time off for sickness, training, annual leave and social and recreational care of residents. The home was again experiencing problems with the hot water and heating systems to the oldest part of the home – Waterside (this was also the case at the inspection in January 2007). The home did not inform us about this problem as required or the actions they had taken to rectify it (Regulation 37), to maintain the temperature of the environment for residents. The home must inform the Commission of any illness, death or any event affecting the well being of residents. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 8 The hot water temperature in one area of Waterside was excessive and there was a potential risk of scalds to residents. Staff must monitor, record and take action to keep the hot water close to the recommended safe temperature. Because of the breakdown of the central heating in Waterside, portable heaters were in use. Risk assessments and notices to alert residents and visitors to the problems were not in place, although the system had been affected for at least 2 days. Safety procedures and temporary changes to care routines should be posted and explained, so that residents and staff are aware of the actions that are to be taken to maintain their safety and wellbeing. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Standard 6 is not applicable because the home does not provide intermediate care. Quality in this outcome area is good. People who come to live in this home have good information about the home in order to make an informed decision about whether the home is likely to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has produced a new colour brochure and updated the Statement of Purpose and Service Users Guide since the last inspection. The written information is much more ‘reader-friendly’ and less technical than the earlier versions. The homes own ‘Resident’s Relatives Questionnaire analysis shows people chose The Close for ‘care, atmosphere, décor & surroundings, gardens, reputation and location’. All of the people who completed questionnaires said they would recommend The Close and that they found the brochure informative and answered all their questions. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 11 However, we consider that the description given in the colour brochure of the accommodation Waterside (the oldest part of the building) is misleading in that it states there is ‘an extensive choice in accommodation’. And Waterside has ‘46 single en-suite and companion rooms’; the 7 companion (double) rooms are not of an adequate size for two people and the ‘en-suite facilities’ consist of a shared washbasin unit. Many of the single rooms are also small and not suitable for people who use disability aids or wheelchairs. The shortfall in the size and facilities in parts of Waterside are discussed later in this report. The home manager or her deputy assesses all prospective residents’ care needs. The inspector looked at a sample of 4 residents’ pre-admission assessments. These were completed in a commercially produced care record format and also included a brief social history of the person. They appeared to give sufficient information from which staff could draw up initial care plans. All residents have a ‘trial’ four-week stay to see if the home meets their expectations. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 10 Quality in this outcome area is adequate. Residents’ written plans of care do not consistently record their assessed care needs and preferences and the extent to which staff interventions have met their needs. Though improving, the variable practice regarding the planning and delivery of care means that not all residents can be sure that their nursing and personal needs will be met. The systems in place for residents’ medication management and medical care are good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of 6 residents’ care records was examined in detail. There has been limited improvement in the standard of record keeping since the last inspection, with a variable standard across the 3 different units in the home. There were omissions or lack of clear instructions about how specific aspects of care are to be carried out, and/or the effectiveness of the interventions, in each of the plans looked at. For example, wound care plans and evaluation of healing (such appearance of the wound, accurate measurement and any signs of infection) had not been updated for periods of 1 or 2 months. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 13 Nutritional risk assessments are incomplete and there is insufficient written information for staff to follow about how to improve the nutrition for those assessed as ‘at risk’. Staff were monitoring the food and fluid intake of 3 people ‘at risk’ of malnutrition but the records were dated wrongly and there were no entries since the preceding evening. On one unit, it appeared that staff had run out of charts, so no records for dietary intake had been made over at least a 12-hour period. The local GP practice has produced protocols for care one of which includes nutrition: they consider that prescribed dietary supplements are rarely indicated and peoples normal diets can be adapted and improved by simple measures. However, one of the care plans seen stated that the person should have pureed diet and ‘build-up’ drinks but there was no information on the food/fluid chart to show the detail of the content or quantity had been offered or eaten by the individual. This indicates that staff may not have accurate assessment information on which to base their evaluation of whether the person’s condition or care needs have improved. Two residents were very unwell at this time and were not expected to live. There were no specific care plans for ‘end of life’ care and no indication about their spiritual needs or how their family and friends will be supported at this time. There is little information about residents’ social and psychological care needs in the care plans, or about how these will be met. These are important aspects of care, especially for those residents with short-term memory loss and confusion or for those people who do not wish to join in group activities with other residents, so that they do not become isolated. As was the case at previous inspections, individual staff members when asked about residents’ needs and care usually were knowledgeable about them. The shortfall in care plans and record keeping were discussed with the nurses in charge on 2 units and with the manager at feedback. Accurate and sufficiently detailed care records must be maintained to reflect the changing care needs of residents so that staff have enough information to provide the level of care required. There is evidence that specialist equipment needed by residents, for example pressure relieving mattresses and seat cushions, is available. Doctors from the local Berinsfield Medical Centre provide medical care for residents: a GP visits routinely twice a week and additional urgent calls are made to see residents if necessary. The home has computer broadband connection so that the visiting doctors are able to access and update residents’ medical records on-line and amend prescription orders with the pharmacist, so that residents’ current health status, and treatment can be more effectively assessed by the GPs. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 14 The home manager meets with a doctor from the medical centre every 3 months to discuss any issues about the medical service and communication with staff in the home. This demonstrates that the home liaises effectively with health professionals to maintain and develop the clinical care for residents. Examination of a sample of residents Medication Administration Record (MAR) charts showed that these were well maintained and up to date. The manager confirmed that she has recently done an internal audit of medication records. The home uses the ‘monitored dosage’ system of medication – residents’ tablets/capsules are put into individual cassettes with doses for each day for a week. A qualified pharmacist dispenses medicines from the local Berinsfield doctors’ surgery. The pharmacist has also provided training in medication for nursing staff - ‘Managing and Administering Medicines in the Care Home’. The homes systems for the storage, administration, disposal and recording of medications appear to be safe and meet the needs of the residents. A requirement was made at the last inspection to meet the legal requirement for the safe disposal of unwanted medications has been met. Staff were kind, patient and respectful towards residents. However, there were several instances where staff had overlooked residents’ discomfort or need for assistance. In particular, it was noted that positioning of people in wheelchairs and length of time that some residents are left sitting in wheelchairs meant that they were uncomfortable and could not manage to feed themselves properly at dining tables. There is much more cultural and racial diversity amongst the staff group compared with the residents - almost all residents are of white British racial and ethnic origin. The homes own questionnaire survey to residents and relatives, and comments made during the inspection, whilst very positive about the caring and kind staff, indicate some difficulties with communication between staff, residents and their families, because for many staff English is not their first language. The home has tried to address this by offering English language classes to staff and by trying to recruit more staff from the local community. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. The arrangements for regular organised activities within the home and community for the majority of residents are good. However, the needs of more dependent residents require the involvement of all staff to ensure that residents have a range of opportunities to participate in stimulating and motivating activities that meet their diverse abilities. The home continues to develop and improve in this area. The food in the home is of satisfactory quality but improvements should be made to the service, timing and presentation of meals so that mealtimes are an enjoyable and social occasion for all residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a part-time activities coordinator who works 30 hours a week, Monday to Friday from 11.00 am to 17:00 pm. An activities assistant has just been appointed and works 15 hours a week, Monday to Friday from 13:30 to 16:30. The coordinator said that the new person is already helping to improve the social and recreational opportunities for residents, especially in providing more ‘one to one’ time with those residents who do not want to join in organised or group activities and could become bored or isolated in their own rooms. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 16 Planned activities and entertainments were well advertised in the reception area and on notice boards in each unit. Three volunteer workers come to the home regularly (weekly or fortnightly) to play board games with residents, entertain with guitar playing, and to lead a religious service (monthly). A Church of England minister attends the home every month and the Roman Catholic priest and representatives of other Christian denominations visit the home to lead regular services. The homes own questionnaire analysis (October 2007) showed that favourite activities were ‘pottery classes, religious services and Holy Communion, anything musical – singing, visiting guitar player, outings on the coach and walks in the garden’. Specific requests for other activities to be provided were ‘Salvation Army, flower arranging, film shows, going to the pub, someone coming in to read to them’. Additional requests were that more seating areas in the grounds should be created to enable residents and relatives and visitors to sit out in the garden in the summer and enjoy the beautiful grounds. Also, that the access path to the riverside should be improved to make it more ‘wheelchair friendly’ and more outside exercise and walks in the grounds during the good weather. The activities organiser and her assistant achieve a commendable amount of work with residents, and care staff are involved if they have sufficient time. However, the social needs and abilities of residents with increased physical and memory problems need individual assessment and ‘ad hoc’ opportunities for meaningful and enjoyable pastimes. This is a large home, (which, when full has 96 residents accommodated in 3 separate buildings) and needs more staff to be available and have the skills to meet the social and recreational care needs of residents including evenings and weekends. Visitors evidently feel ‘at home’ and were welcomed by staff. Feedback to CSCI from relatives and visitors, observation during the inspection and the home’s own questionnaire analysis confirmed that visitors always feel welcome. One person wrote: ‘They [the home] provide a welcoming, caring atmosphere’. A visitor said ‘They always look after me and make me feel at home when I come’. Residents’ and visitors’ comments about the food and mealtimes in the home were generally very positive. The homes questionnaire analysis (October 2007) showed that all the responses were ‘good’ or ‘very good’. Observations of meal service and presentation were made during the inspection and the inspector joined residents in Willows and in the main dining area of Waterside at lunchtimes on the 2 consecutive days. Meals are freshly prepared in the purpose-built kitchen in Riverside and transported in heated trolleys to each unit. Food was hot at the point of The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 17 service but the plates were cold (this was the case on both days of the inspection). Residents who needed to wait for staff assistance or prompting to eat their food or who need a lot of time to eat, had food that had gone cold and looked unappetising. The chef acknowledged this was a problem and said that the trolleys were not large enough to hold the hot food and plates together. However, they would put a second trolley into service to amend this. The lunch is a three course meal – soup or fruit juice to start; a choice of 2 main course dishes and dessert, with tea and coffee served at the end of the meal. The Monday lunchtime meal was tomato soup or grapefruit juice, followed by fish fingers, baked beans and chips, or gammon and fried egg; dessert was plum crumble (for diabetics), ice cream or Viennetta roll. It was noted that staff were not always sufficiently observant or skilled with the way they served and assisted people at mealtimes. For example, a person with visual impairment did not have her meal described to her or how the various parts of the meal were positioned on the plate and condiments were not offered and placed within reach. Two residents, who were only able to use one hand, did not have plate guards or non-slip mats under their plates to help them secure their food on their fork or spoon. A resident who needed to be fed her pureed food was assisted adequately by a carer, though the resident was not always allowed enough time to swallow the teaspoonfuls of food, or offered sips of water periodically to help them empty their mouth. Timing of ‘mid-morning’ hot drinks and biscuits to residents in part of Waterside (served at 11.45) was too close to the lunchtime meal (soup was served at approximately 12.15) and meant that residents were not ready to eat a full meal. Lunchtime is from around 12 to 13.30, mid afternoon tea approximately 3 pm and the last full meal of the day between 5 and 6 pm. This means there is more than 12 hours between the evening meal and breakfast next day. The timing of meals and snacks should be reviewed to make sure that residents are offered food and drinks at regular intervals and adequately spaced throughout the day. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. The home has a satisfactory complaints system and there is evidence that generally residents’ and their visitors feel that their views are listened to and acted upon. However, further improvements should be made to ensure that all staff listen to and know how to act on residents’ concerns. Changes made to improve practice as a result of complaints investigations should be monitored to ensure that residents are protected from recurrence of the same issues. The home’s induction and training programme for staff about adult safeguarding issues help staff to identify and protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has updated its Statement of Purpose and Service User Guide since the last inspection and these include information about how to make a formal complaint. Relatives and visitors spoken with said they would know how to make a complaint if this was necessary. One person confirmed that they had made a complaint and this had quickly been looked into and the matter resolved. The homes complaints record showed that they have received 5 complaints since the last inspection – 2 relating to residents’ accommodation in shared rooms, one about laundry and 2 from Social Services relating to poor standards of care and staff skills. One complaint was ongoing - the manager’s response was considered unsatisfactory and a further meeting is due to be held. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 19 The complaints log should be further improved by showing when the complaint was received, and a summary of outcomes of investigations and responses to complainants and whether satisfactorily resolved, to demonstrate a robust and timely complaints procedure is followed. The commission is aware of the 2 formal complaints raised through Social Services. We consider that some of the issues raised, such as the inadequacy of shared room accommodation (inadequate space for use of equipment, protection of privacy and dignity), inadequate care planning and evaluation of care, and lack of observation and attention to personal care details, are upheld to some degree by the evidence of this inspection visit. The fact that similar observations have been made by the inspector, in particular in the oldest part of the building, is of concern and indicates that the internal monitoring of care standards and practices by the homes managers are not sufficiently robust to give assurance that similar complaints will not recur. Formal review meetings are held with care managers and social workers, residents and their representatives (for residents whose fees are paid in part by Social Services) to discuss the resident’s care and any concerns. Residents and relatives meetings are held in the home every 3 months that give further opportunities for people to raise any concerns or complaints. All new staff have training about how to spot potential abuse of residents and all staff have mandatory updates in adult safeguarding matters. There was evidence that two days training were provided in 2007 and updated information about the Oxfordshire Social Services Safeguarding policies and procedures. Staff have also attended training about the Mental Capacity Act and the implications for how the home cares for and supports the right of all residents to continue to take decisions over their own lives whenever possible and to be included in such decisions at all times. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of cleanliness is good and the décor and furnishings and facilities in the new buildings provide residents with comfortable and attractive accommodation. However, there are considerable shortfalls in standards in the older building. This means that, despite the programme of redecoration and refurbishment that has improved the appearance of the accommodation, many of the rooms and facilities are inadequate and residents’ dignity, privacy and choice is compromised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new purpose built wings – River View and The Willows – completed in 2005 and 2006 respectively, provide a high standard of accommodation for residents in single en-suite rooms. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 21 A programme of refurbishment in the existing older part of the home – Waterside – has improved the appearance of communal rooms and corridors and residents’ own rooms considerably. New colour schemes, carpeting and soft furnishing, and replacement of old and worn-out furniture have created a fresh and lighter environment for residents. There are 16 single en-suite bedrooms in Waterside and 15 double rooms, one with an en-suite. The National Minimum Standards (NMS) for Care Homes for Older People state that ‘where rooms are shared, they are occupied by no more than two service users who have made a positive choice to share with each other. When a shared place becomes vacant, the remaining service user has the opportunity to choose not to share, by moving into a different room if necessary’. There was evidence that the home has responded to individual resident’s and families complaints where the residents who share are ‘not getting on’ together and/or one or both people are having disturbed nights. The homes questionnaire analysis included a suggestion for ‘single rooms for all residents’: the provider’s response was to administer questionnaires to all residents currently sharing a room for their opinions. The room sizes and the layout of the communal rooms and bathrooms in the older parts of the home (formerly St Michaels and St Paul’s wings – now ‘Waterside’) make it more difficult for staff to ensure that residents’ privacy and dignity are always protected. For example, one lounge area is a long narrow room and residents’ armchairs have to be arranged around the edge of the room, leaving little space between. Residents who need help at mealtimes and/or who have to be moved with the aid of a hoist, cannot be assisted by staff in a way that best protects their dignity in this confined space. People in shared rooms do not have en-suite toilet facilities and may have to use a commode in the room at night. However, Mr Halton has informed us that as a result of ‘the extensive surveys of all the residents and their families who use shared rooms’ showed that ‘they are happy with the way the home protects residents’ privacy and dignity and with the care in particular’. Mr Halton said that reducing the occupancy of Waterside by converting all shared rooms to single rooms was not an option. The limitations in the environment for residents accommodated in Waterside effectively means that there is an inequality of provision for almost 50 of all the people living at The Close. The registered person, Mr Halton, acknowledges that the older part of the Close is outdated and unsuitable to meet the needs of more dependent residents and says that there are plans to replace the Waterside building within the next 3 years, but these have not been finalised to date. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 22 The standard of cleanliness and tidiness throughout the home was very good overall and is commendable given the size of the home. Two exceptions were the lounge in River View where the lounge carpeting has numerous stains and chair arms and backs looked grubby and there was a strong and very unpleasant odour of urine in one area of Waterside dining room. There had been problems with heating and hot water system on Waterside that started on 25/01/08. An electrician and the facilities manager were on site on 28/01/08 morning to fix the problem. Portable room heaters were provided where residents were in their own rooms. There were no risk assessments or information available to alert staff to the safe use of heaters and the temporary arrangements in place for accessing hot water and ensuring that room temperatures were maintained to a comfortable level for residents. Some rooms were cool – a spot check of one room temperature was undertaken and found to be 19ºC at 5 pm on day 2 of the inspection, so was likely to fall below this over night - the convector heater in this shared room did not appear to be working but staff said it has a thermostatic cut out that works when room has reached the required temperature. It was not clear whether the temperature control could be adjusted to increase the heat output. The manager requested that care staff checked that residents’ room temperatures were warm enough. A random check of the hot water in a Waterside bathroom showed that it was between and 55-57ºC, above the safe recommended level of close to 43ºC and a potential risk of scalds to residents. It was felt this might have been a result of the temporary boiler problems. A repeated check next day showed that the water was still too hot, ranging between 47 and 55ºC. The facilities manager was informed and took action to check and adjust the temperature control valve. The hot water temperatures at all outlets accessible to residents must be regularly checked and adjusted as necessary to reduce the risks to residents. Radiator covers in the same bathroom and an adjacent toilet had damaged painted surfaces exposing the MDF so cannot be cleaned effectively; the covers should be replaced or re-sealed. The laundry was clean and tidy. One machine was out of order and the maintenance manager was arranging for its repair. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Staffing levels are consistent and the organisation recognises the importance of training for staff so that they have the skills to meet the health and welfare needs of residents. There are some gaps in the training that should be addressed to ensure that all staff develop a person centred way of delivering care and support. The homes recruitment procedures are satisfactory and protect residents from people who are not suitable to be employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and their relatives were complimentary about the qualities of the staff describing them as kind, caring, friendly and hard working. A staff member said she felt that staffing numbers had improved since the last inspection, though there is still a problem with the level of sick leave and delayed returns from annual leave. Visitors spoken with said that there had been fewer changes in staff in recent months and this was an improvement because they had got to know the staff well and so had confidence that the staff understood and knew the needs of their relatives. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 24 One person expressed a concern that ‘staff are a little too busy to stop and talk and to develop a real relationship – I would hope that staff would find enough time sometimes to stop and talk with [my relative]’. As stated earlier, some comments related to communication difficulties with staff – ‘owing to the fact that many of the staff are not native English speakers, there are communication difficulties from time to time’. A copy of the duty rota for all staff from 12/01/08 to 25/01/08 showed that there are a total of 4 registered nurses (RNs) and 14 care staff from 8 am to 1 pm; 4 RNs and 10 care staff in the afternoons and evenings; and 2 RNs and 7 carers overnight (9 pm – 8 am). The maximum occupancy for the home is 97; at the time of the inspection there were 91 residents. The rotas showed that the home maintains a consistent number of staff on duty, based on a formulaic approach to staffing that provides a ratio of 1 staff member to 5 residents in the mornings, 1 to 6 in the afternoons and evenings and just 1 to 10 overnight. Given the size of the home and dependency of residents, staffing numbers and skill mix are not always sufficient to meet the needs of people living here in a way that is ‘person-centred’. There are just 3 RNs who regularly cover the night shifts: 2 staff work a pattern of 5 nights on duty followed by 2 days off. The third night RN works 4 nights a week. On the duty rotas seen, it was apparent that night RN staff often start work at 5 pm and work through the night – an 18-hour shift. The total hours worked each week by 2 of the RNs is therefore in excess of 65 hours. Working excessive hours is potentially harmful to the health and wellbeing of the individual staff and to the residents in their care through the increased risk of accidents and errors. The home must review and amend its staffing numbers and skill mix to allow sufficient flexibility to cover absences for training, sickness, annual leave and the additional time needed for social and recreational care of residents at all times. The homes AQAA information states that out of a total of 58 care staff, 4 have National Vocational Qualification (NVQ) Level 2 or above and a further 6 carers are working towards this. This means that the home is considerably below the required target of 50 of care staff to have an NVQ Level 2 qualification. The manager confirmed that this is an area where they hope to improve by increasing the number of staff who undertake NVQ training in all areas of care and support. Discussion with the manager, nurses and the homes records of training provided evidence of the employers’ commitment to training and development of staff. The home is part of a group owned by the proprietor and benefits from having a training consultant who organises in-house training for staff. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 25 Mandatory training, for example, health and safety, fire safety, adult safeguarding and moving and handling, are included in a matrix timetable, so that it is clear when each staff member has received training and requires annual update or refresher sessions. Records showed that there had been additional training in a range of topics relevant to the care of residents, for example, introduction to caring for people living with dementia, the Mental Capacity Act, First Aid, continence care, care planning, and infection control (in relation to MRSA and c.difficile). Because there are a significant number of residents who have dementia it is important that all staff have sufficient knowledge and understanding to provide appropriate ‘person-centred’ care for those affected, and to manage their needs in situations where they living with other residents who have different disabilities and needs. It is recommended that staff have more in-depth training about dementia and dealing with behaviours that may challenge them. Examination of a sample of 4 staff members’ recruitment and training files showed that the home has a satisfactory recruitment procedure that ensures that the appropriate checks and references are obtained so that people who are unsuitable to work with vulnerable older people are not employed. The Close Nursing & Residential Home DS0000027175.V348401.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 and 38 Quality in this outcome area is adequate. The management of this home provides a good standard of leadership. Residents and their families and representatives’ views are sought and taken account of by the management team through the quality assurance systems in place. Further work should be undertaken to monitor staff practices and record keeping ensuring that the policies and procedures that support the health and wellbeing of residents are adhered to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered home manager, Ms Sithole has considerable experience of working in and managing care homes for older people. She has worked at The Close for five years and became the registered manager in 2004. She has academic qualifications in higher education (nursing) and a BA degree in The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 27 Health Service Management. She has completed the Registered Managers Award. There are regular quarterly residents meetings and the proprietor sends out quality questionnaires to relatives annually to get feedback from residents and their visitors about the services provided in the home. The manager confirmed that the proprietor undertakes regular monthly ‘registered provider visits’ (required under Regulation 26 of the Care Standards Act and Regulations) to ‘spot check’ residents’ staff and visitors’ opinions of the home and facilities. The proprietors arranged an independent external quality audit of the home in April 2007 (based on the National Minimum Standards for care homes for older people). A copy of the auditor’s visit and recommendations was provided at the inspection. It was noted that many of the auditor’s recommendations were implemented, but it is of concern that observations about the short fall in record keeping in relation to risk assessments and care plans in particular were still apparent at our inspection some 10 months later. We would agree with the auditor’s conclusions that there is a need for the managers of the home to undertake a robust system of monitoring to ensure that staff are consistently meeting the standards of care and support needed by residents. Security of residents’ care records and personal information is an issue raised by both the auditor and as part of a recent complaint against the home. This relates to Waterside, where residents’ care records are kept in wheeled, lidded lockable filing units – one is held in the small office area of one wing and the other by a large desk at the end of the large TV lounge. On both days of the inspection, there were adequate safeguards in place – the cabinet in the lounge was locked and the nurse on duty held the keys; the cabinet in the office area was lidded but not locked, but staff were available to challenge any unauthorised access. The manager confirmed the arrangements in place for safekeeping residents’ personal finances: that the home does not handle money for residents: relatives/representatives are invoiced for additional expenses or occasional ‘spending money’. No personal property is held in the homes safe. Oxfordshire County Council ‘money management’ arrangements are in place for 4 residents. All the remaining current residents have relatives or representatives who deal with residents’ finances on their behalf. The inspector looked at a sample of accident records and fire safety log book and found these to be correctly completed, showing that routine safety checks (for the fire equipment and alarm systems) were up to date. The home’s The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 28 policies and procedures are comprehensive and are reviewed at least annually. There are copies of these in each nurse’s station and the managers’ office. The home had not notified us of the hot water and heating problem as required or the actions they had taken to rectify it (Regulation 37), to maintain the temperature of the environment for residents. The home must inform the Commission ‘without delay’ of any illness, death or any event affecting the well being of residents. The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 29 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 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X 2 X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 17 (1) (a) Schedule 3 18 (1) (a) Requirement Service users’ plans of care must be sufficiently detailed and updated to reflect the changing needs and current objectives for their health and personal care. Ensure that at all times the numbers and skills of staff working at the home are sufficient and appropriate for the health and welfare of residents. The provider must supply to the Commission a report of actions to be taken to ensure that the part of the premises (Waterside) are suitable for the purpose of achieving the aims and objectives set out in the statement of purpose. Regularly monitor and adjust as necessary the temperature of the hot water in all areas of the premises accessible to residents to reduce the risk of scalds Notification must be given without delay of any event in the care home which adversely affects the well-being or safety of any resident Timescale for action 31/05/08 2. OP27 31/05/08 3. OP10 OP23 23 (2) 31/05/08 4. OP25 13(4) 31/05/08 5. OP38 37 31/05/08 The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 31 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 OP15 Good Practice Recommendations Review and improve the standard of food service, with particular attention to food presentation, maintaining hot and cold foods at the correct temperature, staff assistance, and the availability and spacing of mealtimes, snacks and drinks. Provide more advanced training for staff in care of people living with dementia * Ensure the prompt undertaking of risk assessments and dissemination of information about any temporary use of freestanding room heaters and take action to protect residents and visitors from accidental burns from unguarded heater surfaces and trip hazards from trailing flexes. NB This recommendation was also made at the last two inspections in January 2006 and 2007 * Ensure that temporary management actions for emergency situations (such as disruption to the heating and hot water supply) are disseminated to staff and notices posted to inform residents and visitors of the situation. The number of hours worked by staff should be monitored by managers and staff advised about the potential risks to their health and safety from working excessive numbers of hours without adequate rest periods. They should be reminded of their professional accountability under their codes of practice/conduct. Improve the internal systems for the formal monitoring and audit of standards of care and record keeping ensuring that staff consistently adhere to the homes policies and procedures. 2. 3. OP30 OP38 4. OP38 5. OP38 The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Close Nursing & Residential Home DS0000027175.V348401.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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