CARE HOMES FOR OLDER PEOPLE
The Knoll Nursing Home 33 Preston Road Yeovil Somerset BA21 3AE Lead Inspector
Justine Button Unannounced Inspection 24th May 2007 09:30 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 Knoll Nursing Home DS0000066156.V340637.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 Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Knoll Nursing Home Address 33 Preston Road Yeovil Somerset BA21 3AE 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) 01935 421822 The Knoll Nursing Home Limited Mr Raymond Keyworth Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Elderly persons of either sex, not less that 60 years old, who require general nursing care. Up to three places for personal care. That a manager will be in post when the contracts of sale are exchanged and for a minimum of 6 months after this period. The manager is required to have a relevant nursing qualification and management experience and be on the current NMC register. A manager must be registered with CSCI at the earliest opportunity. This condition will be reviewed after 6 months of the date of issue. That Mr Ghuman will have registered on an accredited programme of study relevant to the management of health and social care by 1/7/06 Key inspection 25th May 2006 Two random inspections 18th October 2006 & 24th April 2007. 4. Date of last inspection Brief Description of the Service: The home is a converted house with a purpose built extension, situated a few minutes walk from the centre of Yeovil. Accommodation is on two floors. All the bedrooms are single occupancy. There are an adequate number of adapted bathrooms. There are two reception rooms and a conservatory area. There is a small dining area although this cannot accommodate all the people who live at the service. There are well-maintained gardens and patio area, which can be seen from the two main sitting areas. The home provides general nursing care for older people and can offer personal care for three people. The proprietor lives on the premises and has day-to-day contact with the service users. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Key inspection was carried out in line with the CSCI framework ‘Inspecting for Better Lives 2’. This unannounced key inspection was conducted over one day by CSCI Regulation Inspector Justine Button. During the inspection a number of the key standards were assessed. A number of tools were used during the inspection to assist the inspector make judgements for each outcome group. These tools included information received from the service prior to the inspection in the form of a pre-inspection questionnaire, review of care plans and documentation, discussions and feedback with people living at the service, staff, relatives and the management team. The care and support offered to people living at the service was observed. At the time of this inspection, 26 service users were living at the home. The inspectors were able to meet with the majority of service users and staff. Service users were positive about the care they received. Staff stated that they felt well supported. The registered manager was available throughout the inspection. A tour of the premises was carried out where all communal areas and the majority of bedrooms were seen. As part of this inspection, CSCI comment cards were sent to 20 service users and their representatives. At the time of this report 8 completed comment cards were received from service users. In addition 3 comment cards were sent to local GP’s who visit the home regularly. None of these were returned. Comments from service users were positive. The majority of service users indicated that the staff were kind and always listened. Since the last Key inspection in May 2006 three complaints have been received from the local community nurses and relatives of people living at the home expressing concerns about the care and support afforded to individuals. These complaint shave been investigated and reviewed via two Random inspection visits on the 18th October 2006 & 24th April 2007. The inspectors would like to thank service users, staff and the registered manager for their time and cooperation with the inspection process. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 6 The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well:
The Knoll provides a comfortable environment for older people who have nursing needs. Service users are cared for by registered nurses and care staff. The home provides 24 hour nursing care. The numbers of staff on duty are appropriate to meet the needs of service users. Service users and staff benefit from an effective and stable management team who promote an open and inclusive style of management. The home ensures that prospective service users are provided with the information they need to enable them to make an informed choice about moving to the home. During the inspection the inspectors observed staff interactions with service users. On the whole staff were heard communicating with service users in a kind and respectful manner. Service users appeared comfortable in their surroundings. Service users benefit from a wholesome and varied diet. The inspector was able to observe service users enjoying lunch. Meals, including special/soft diets were attractively presented. Service users enjoyed lunch in a relaxed an unhurried manner. Staff sat with service users and offered assistance where required. This was carried out in an unhurried and respectful manner. Service users spoken with stated that they liked the food. The manager needs to ensure that the menu board is displayed. The home ensures that service users have access to appropriate/specialised healthcare professionals. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 8 At the end of the inspection discussion took place with the manager and Mr Ghuman the provider. A number of issues were raised. The management had identified that a drug error had been made at the home. Appropriate action had been taken, however, the CSCI had not been informed of this error in line with Regulation 37. In addition an unusually high proportion of people at the home have pressure sores or wounds. The manager stated that a number of these were admitted from hospital with these sores. It was agreed with the manager that the CSCI would be informed, via the regulation 37 reporting system, when people were admitted with pressure sores in order that this can be kept under review. A number of the bed rails were seen to be lose such that there were gaps. These gaps cause an entrapment risk or risk of injury to the individual. In addition three entries were seen in the daily diary detailing one fall out of bed and two people who had limbs or body parts caught in ill fitting bed rails. Whilst there were no serious injuries in these incidents the management must ensure the safety of people at the home who use this type of equipment. The management agreed to review all the bed rails at the end of the inspection. The management need to ensure that there is system in place for checking the bedrails at regular intervals. The health and safety of people was also compromised via the use of wheelchairs. Four wheelchairs were observed to have no footplates. Using wheelchairs without footplates can cause injury to the feet and lower limbs. All wheel chairs must be fitted with footplates and the management need to develop a system for periodically checking that these are in place. The home has yet to develop a system of regular staff supervision. Supervision allows staff and management the opportunity to discuss training needs or work practise/ employment issues. This system now needs to be developed in the near future. Staff supervision should be used as part of a quality assurance system. The home is currently researching which system to implement. Quality assurance will ensure that the home is delivering a service which the people at the home want and will ensure that the home can continue to develop and improve. The staff training records were viewed. Some gaps were observed in particular the lack of staff that had received training in first aid. Currently only two staff have received updating in this area. The management need to ensure that at least one staff member is available at all times who is able to deliver first aid. Induction for new staff does not currently meet with expected standards. The management need to research and consider implementing the “common induction standards”. It was identified that one aspect of infection control was not being adhered to. This related to the management of a urinary catheter. This may compromise the health of one individual at the home.
The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 9 Some activities are available at the home however none were available on the day of the inspection. The management stated that the activities organiser had recently left employment and that as such this area required further development. Two staff were to attend training in reminiscence and flexecise the week following the inspection. The post of activities organiser was being advertised at the time of the inspection. The storage administration and documentation of Medicines was viewed during the inspection. On the whole these were well managed. The medication for two people who were no longer at the home remained at the home in excess of the acceptable timescale. The management agreed to ensure that these were returned to pharmacy or destroyed as required. A number of the care plans for people living at the home were viewed during the inspection. The care plans seen had improved since the last key inspection. The plans however should be developed further. The care plans were not person centred nor was there evidence that the individual or their relative had been involved in the development or review of the plan. This would ensure that people living at the home received the care and support in the manner, which they would like. The plans were ambiguous in places and did not give clear guidance to staff on all the care needs of the individual. Assessments for some individuals had not been completed. Some of the assessments seen had not been dated or signed by the individual who had completed them. It was difficult to assess therefore if the assessments had been reviewed and if the plan of care would have needed to be changed to reflect any new needs. 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 Knoll Nursing Home DS0000066156.V340637.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 The Knoll Nursing Home DS0000066156.V340637.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, 2, 3, 4, 5. Standard six is not applicable in this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about moving to the home. The home takes appropriate steps to ensure that an individual’s assessed needs can be met by the home. Not all people who live at the home have a copy of the terms and conditions of their stay. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 12 EVIDENCE: The home has produced a Statement of Purpose and Service User Guide. Copies are made available to service users, prospective service users and their representatives. These documents are also displayed in the reception area of the home and include a copy of the home’s last CSCI inspection report. The registered manager provided the CSCI with pre-inspection information which stated that the home’s current fees are £470-600 per week. Fees are determined upon the assessed needs of an individual. Any ‘Free Nursing Care’ element awarded is incorporated into the fees and is not refunded to the service user. Extra charges are met by service users for newspapers, hairdressing, trips/outings, personal toiletries/items and special requirements. The home also makes additional charges for transport depending on the distance required. Not all people who live at the home have received a copy of the terms and conditions. People who are funded by the local authority do not have this document. In these cases the home has a financial agreement with the funding authority. This is not in line with the guidance issued by the Office Of Fair Trading. All people living at the home should have a contract between themselves and the home. This should detail things such as the room to be occupied and notice periods. This will ensure that all parties are aware of their rights and services to be provided within the fees charged. The manager or his deputy visit the majority of prospective service user and carry out an assessment to ensure that the assessed needs and aspirations of the individual can be met by the home. The care plan for the individual who had recently moved into the home was viewed this showed that the manager had completed a full pre admission assessment. This assessment was in addition to the assessment undertaken through the care management arrangements. Assessments from other professionals were also seen in care records. The home has in the past admitted people as an “emergency placement” The home needs to ensure that these admissions are kept to a minimum as they do not allow the individual the opportunity to make an informed decision about moving into the home and allow the home time to ensure that they can meet the needs of the individual. Prospective service users and/or their representatives are invited to visit the home prior to making a decision. Service users move to the home initially on a
The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 13 4 week trial period. This is to ensure that all parties are happy with the placement. This was confirmed by the most recent service user. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 14 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning system is in need of further development to ensure that all service user needs are addressed and all staff can easily access the information they need. The home has links with other health professionals to enable service user health needs to be met. Personal support is offered in such a way as to maintain the privacy and dignity of service users. EVIDENCE: The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 15 Four care plans were viewed in detail during the inspection. In addition the care plans relating to wound management were viewed for all individuals for whom this was applicable. Improvements in the care planning system have been made since the last key inspection, which was conducted in May 2006. All people living at the home now have a range of assessments through which care needs are identified. Care plans are in place for any identified needs. The majority of the assessments and care plans had been reviewed on a monthly basis or as required by deterioration in the individual’s health. A minority of the assessments or care plans however had not been reviewed. In addition for at least one person not all the necessary assessments had been completed. Staff need to ensure that all the care plans and assessments are in place. This will ensure that staff are aware of all the needs of that individual and that appropriate care is delivered. The majority of the plans were written in plain English some statements were slightly ambitious. Statements such as “encourage plenty of fluids” “give recommended diet at all times” need to be clarified. Statements such as these do not give clear guidance to staff as people with a urinary catheter for example would require more fluids than a individual with kidney problems. For one person who was living at the home and whose care plan was viewed had lost weight. This had been identified however it could not be confirmed if appropriate action had been taken and that there was no additional weight loss as staff had not complete a weight for several weeks. Service users or their representatives are not currently involved in the development or review of the plans of care. This issue has been raised at previous inspections. The comment cards received from relatives all stated that they were informed of any changes in their relatives condition and that communication between relatives and staff was good. The involvement of individuals and/or their representative in the plan of care would help towards this communication and ensure that care and support is delivered by staff in the way in which the individual would prefer and take into account the individuals likes and dislikes. In addition the management need to consider how the implication of the Mental Capacity Act will impact on the care planning process. Following a complaint to the CSCI, issues with regard to the care and management of wounds were raised with the management in a random inspection in April 2007. The home currently has a higher than expected incidents of pressure sores. Any person now returning or being admitted to the home has a full assessment of their skin integrity and any wounds; pressure sores or bruising is noted. The registered manager stated that a number of people had been admitted to the home from hospital with pressure sores. It was agreed with the manager
The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 16 that the CSCI would be notified via a regulation 37 form of any person entering the home or returning from hospital with a wound or pressure sore. This will allow the situation to be monitored and any issues raised with the PCT if required. Since the inspection in April 2007 wound management has improved and all wounds are now documented appropriately. Photographs and wound sizes are documented. This allows for staff to monitor the progression of the wound to ensure that the correct dressings are being used. The home has recently sought the advise from the community nursing service to ensure that they are giving the correct care and treatment in this area. Since the last random inspection staff have been more proactive in ensuring that people who have or are at risk of pressure sores have a regular change of position. This aids in the healing or prevention of pressure sores. People who are at risk or who have pressure sores have appropriate pressure reliving equipment. Although care plans require some additional improvement, the inspector was able to see evidence that the home was proactive in seeking the input of appropriate professionals. This included input from district nurses, GP’s, Social workers & palliative care specialists. The home has also made referrals for input from a tissue viability nurse and dietician. Service users who were able to express a view were very positive about the care they received. Staff interactions with service users were noted to be very warm, professional and respectful. Interventions were observed to be ‘unhurried’. Staff were heard explaining interventions to service users before carrying out. Service users appeared relaxed and comfortable throughout the day. This was confirmed by the feedback forms returned by other people living at the home and relatives. The homes procedures for the management and administration of medication was examined at this inspection. The home uses the monitored dosage system (MDS) with pre-printed medication administration records (MAR). Medicines are administered by the registered nurse on duty. Medicines were found to be securely stored. MAR charts were generally good. For one person who is a diabetic and on insulin there was evidence to state what the expected blood glucose levels should be and what action staff should take if levels were outside this expected range. This was in line with good practise. Controlled medication was viewed. This was administer and stored in line with correct procedures. The medication for two people who were no longer at the home was observed to be still with in the home outside of the expected timescales. For one person this medication had been dispensed in Feb 2007. The manager agreed to review this matter. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 17 The temperature of the drugs fridge was recorded regularly and was within safe limits. One drug error had been recorded at the home. This had been dealt with appropriately by the management however the CSCI had not been informed of this incident. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 18 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. This judgement has been made using available evidence including a visit to this service. There are some activities on offer although this area needs to continue to be developed. People living at the service are able to meet and welcome visitors. Some people at the home require help and support to make choices. Staff need to consider developing this area in light of the Mental Capacity Act Meals are varied and nutritious. EVIDENCE: The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 19 The home’s service user guide states, “we offer a range of activities” and “ an organised activity programme is on offer”. The homes activities organiser has recently left employment. Due to this activities at the home have been reduced. The care staff and the management have completed some activities and these included a recent trip to a local pub for lunch. No activities were on offer on the day of the inspection. Staff spoken to during the inspection stated that they try to do some activities with people living at the home but were “sometimes too busy”. Some staff were due to attend some training in reminiscence and flexercise the week following the inspection. This will increase the skills of the staff to deliver activities. The home has large and attractive gardens with an accessible patio area. The weather on the day of the inspection was warm and sunny. No person living at the home was offered the opportunity to sit out in the sun shine. Given the lack of other activities available on the day of the inspection this may have been a nice alternative for some and would not of required a large amount of staff time. The management stated that they were aware of the shortfall in this area and were currently in the process of recruiting to this post. Visitors were seen and all said that they felt welcomed. Satisfaction with the care of their relatives was expressed. This was confirmed in the feedback forms obtained. Comments included “The staff are kind and keep my father as comfortable as possible” All meals are prepared and cooked on the premises. Copies of a two week menu were made available to the inspectors. The menu appeared wholesome and varied. Lunch was observed during the inspection. Lunch on the day of the inspection included sausage, mashed potatoes and vegetables with onion gravy. A choice of ham salad was available. Fruit flan and ice cream was then served. Special diets are catered for. The inspectors observed soft diets being served to those with an assessed need. These were seen to be attractively presented. Sweets were available for those requiring a diabetic diet. Tea and coffee and cold drinks are available through out the day. In addition there is a range of snacks available. The snacks include foods that are suitable for those people who have problems with swallowing, require high protein intake to aid healing or require high calorific intake to prevention weight loss. These include supplements prescribed by the GP, milkshakes, yoghurts and fruit. People living at the home were not aware of what was to be served for lunch. The home needs to consider advertising the menu in accessible format within the home. People who live at the service stated that the meals were of good quality and enjoyable. Staff were observed assisting service users in a manner which was relaxed, unhurried and respectful.
The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 20 The home does have a dining area however this is not large enough to accommodate all people living at the home. The home is currently planning an extension. The plans include a larger dining room. This would improve the meal time experience for those living at the home. The kitchen was seen during the inspection and this was clean and tidy. People spoken during the inspection stated that choices were available with regard to times that wanted to get up and go to bed, this was not documented in the plan of care Staff were observed asking people where they would like to sit within the lounges. Some people who live at the home have some memory loss and dementia. The management need to consider how the Mental Capacity Act due later this year will impact on peoples rights to make choices about the care and support they receive. How the individual makes choices and decisions will have to be documented in the plan of care. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 21 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. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure. It could not be confirmed if this was accessible to people in the home. People living at the service are protected from abuse with the homes policies and procedures and practice. EVIDENCE: Since the last Key inspection in May 2006 three complaints have been received from the local community nurses and relatives of people living at the home expressing concerns about the care and support afforded to individuals. These complaint shave been investigated and reviewed via two Random inspection visits on the 18th October 2006 & 24th April 2007. Following the inspection the management has addressed issues raised. No complaints have been received by the home. The home has a complaints procedure, which is on display within the hallway of the home. Feedback forms received by relatives state that they were all The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 22 aware of how to make a complaint. All respondents stated they felt that their concerns would be acted upon. Staff are made aware of the home’s whistle blowing policy and information on ‘elder abuse’. These documents are made available in the homes policy and procedure file. Staff recruitment is robust. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 23 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of décor in the home has improved and improvements are ongoing. Service users live in a comfortable & clean environment and have access to a range specialised equipment. The home takes appropriate steps to reduce the risk of the spread of infection in all but one area. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 24 EVIDENCE: A tour of the building was conducted during the inspection. The home was clean and tidy on the day of the inspection. The bedrooms seen showed a degree of individuality with personal possessions being evident. There are two communal lounges and a small dining room. All areas were well used by people living at the home during the inspection. The gardens were pleasant and well maintained. The inspector observed that substantial work has been undertaken to improve the environment of the home. At this inspection a number of the bedrooms had been decorated. This has included the splitting of the double rooms to make them single occupancy. People living at the home and relatives stated that they like The Knoll because of its homely feel. The provider, Mr Ghuman has submitted plans to the local planning department for an extension. Following the extension all communal areas will be redecorated. The home takes appropriate steps to reduce the risk of the spread of infection. Hand washing facilities are appropriately sited throughout the home and staff have access to protective clothing. It was observed however during the inspection that for one individual who has a urinary catheter the drainage system required at night was reused. In addition the end of the system was left exposed to the sir. This is not in line with good practise and infection control guidelines. Grab rails, ramps and nurse call points are appropriately sited throughout the home. Recent purchases now ensures that the home has an adequate number of mobile hoists and stand-aids. Moving and handling belts and slide sheets are also available. The home has a good supply of adjustable beds. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 25 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and skill mix are appropriate to the numbers and needs of current service users. The home follows appropriate staff recruitment procedures. Some staff require additional training in order to complete their roles. EVIDENCE: At the time of this inspection, 26 service users were living at the home. Staffing levels are currently adequate to meet the numbers and assessed needs of the 26 service users at the home. The registered manager informed the inspectors that staffing levels would be increased to reflect any increase in service user numbers or any increase in assessed needs. Copies of a two-week staffing rota were made available to the inspectors. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 26 As a minimum, one registered nurse is on duty during the day and night with the following care staff; 5 in the morning, 4 in the afternoon, 4 in the evening and 2 at night. Staff spoken with during the inspection did not raise any concerns about staffing levels. In addition there are a range of ancillary staff available on a day to day basis. The manager of the home has sufficient managerial time which is not included in the staffing numbers as previously stated. The owner of the home lives on site and is available on a day to day basis. Staff have received manual handling, fire training ,food hygiene training and dementia care. Staff spoken with during the inspection were positive about the training opportunities available to them. Staff also indicated that they had received appropriate training to enable them to meet service users’ assessed needs. Only two staff however has current first aid certificates. The home needs to ensure that there is a staff member available on all shifts to deal with any emergency situation. Thirteen staff currently have an NVQ qualification. This equates to approximately 85 of staff. An additional three staff are currently undertaking this qualification. The home currently offers new staff an induction programme. This induction is conducted over one/two days. The induction is in a format of a tick list and does not meet current standards. The home should needs review the “common induction standards” and implement these with in the home for new staff. Two staff member has been employed since the last inspection. The recruitment files for these individuals were examined. They contained all appropriate information as required in Schedule 2 of the Care Homes Regulations 2001. Enhanced CRB checks and POVA checks were also in place. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 27 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, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users and staff benefit from a management team who promote an open and inclusive style of management. The home’s procedures for ensuring the health & safety of service users and staff are currently not adequate in all areas and this compromises the health and safety of people living at the home. Arrangements to safeguard people’s finances are adequate. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 28 EVIDENCE: The home is managed by Mr Keyworth. Mr Keyworth is a registered general nurse with experience in caring for older people. The manager Mr Keyworth has been registered with the CSCI for approximately 12 months. During the registration process it was agreed that Mr Keyworth would have to undertake a managerial qualification. Due to issues with the training provider this qualification has not been undertaken. Mr Keyworth and Mr Ghuman stated that they would be researching a new provider in the near future. Prior to the inspection Mr Keyworth had a period of time of personal leave. Following the inspection the CSCI were informed, by Mr Ghuman, that Mr Keyworth would not be available to manage the home for an unspecified period of time. During this period the deputy manager with support form Mr Ghuman would be covering this role. It has been agree that Mr Ghuman will continue to keep the CSCI informed with regard the managerial arrangements at the home. Service users and staff spoken with stated that they found the manager and the owner supportive and approachable. The views of staff are sought through regular staff meetings. Last meeting was conducted on the 21/05/07 Minutes are maintained. Formal meetings for service users are not currently conducted. The home manages small amounts of ‘pocket monies’ for service users where requested. Records of transactions were examined at this inspection. Receipts are obtained for all purchases. The home currently invoices individuals for additional services provided for example hairdressing or newspapers. Relatives or individuals currently pay monies into “The Knoll pocket money account” from which the invoices for additional services are deducted. This is a non-interest bearing account. Individual balances are kept. The records for this account were viewed during the inspection and seen to be correct. There is currently no system for regular staff supervision. Supervision is the opportunity for the staff member and the management to meet and discuss aspects of care practice; philosophy of the home and career development needs. The management need to implement this system in the near future. The home does not currently have a quality assurance system in place. Effective quality assurance should be based on seeking the views of all parties including staff members people living at the home and interested stakeholders. Staff supervision and meeting for service users would be a valuable tool in a quality assurance system. The management must now consider implementing a quality assurance system.
The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 29 The following records were examined: FIRE – Records indicated that appropriate checks were being carried out on the home’s fire detection and fire fighting equipment. Regular training is conducted for all staff. Emergency lighting is tested monthly. SERVICING – A full range of servicing had been undertaken. Certificates were seen for the home’s electric hard wiring and gas supply. Hoists were serviced by an outside contractor in accordance with LOLER regulations. ACCIDENTS – The home maintains records relating to accidents at the home. The manager does not complete an analysis of accident records to identify any traits. Bath hot water outlets are thermostatically controlled to reduce the risk of scalding. Those checked at this inspection were found to be within the acceptable limits BEDRAILS- are in use for those service users with an assessed need. There is a system of assessing and maintaining all rails to ensure they are safe. This however has not been completed since 15/03/07. The daily diary was viewed. This showed that three incidents had occurred at the home relating to ill-fitting bed rails. These incidents included one fall from a bed where bed rails were fitted and two incidents of people having body parts trapped in the rails. The bed rails in use during the inspection were examined. A number of these were observed to be ill fitting such that they had gaps, which could entrap body parts. These bed rails could seriously compromise the health and safety of the individuals using this equipment. The issue was highlighted to the manager at the end of the inspection who agreed to review this as a matter of urgency. Guidance issued by the Medical Devices Agency should be used when considering the fitting of bed rails. WHEELCHAIRS- At least four wheel chairs were observed during the inspection to be without footplates. Some of these wheel chairs were in use on the day of the inspection. Using wheelchairs without footplates can cause injury to the occupant of the chair as lower limbs can become caught as the chair is being pushed. The management nee to ensure that all wheelchairs have footplates fitted and that there is a system in place for regularly checking that the chairs are safe. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 30 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 1 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 1 X 3 1 3 1 The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5 (1) (b) Requirement It is required that all people living at the home should have a copy of the terms and conditions of their stay at the home. This issue has been raised at previous inspections. 2. OP7 15 (1) It is required that a system be developed which ensures that service users or their representatives are involved in the development and/or review of their care plan. This requirement is outstanding from previous inspections. This requirement was reviewed during this inspection. Previous timescale 30/12/06 23/07/07 Timescale for action 23/07/07 3. OP30 18 (1) ( C) (i) It is required that the home reviews the current system of induction for new staff to ensure that it meets skills for care
DS0000066156.V340637.R01.S.doc 30/07/07 The Knoll Nursing Home Version 5.2 Page 32 4. OP30 18 (1) (a) 13 (4) 5. OP33 24 6. 7. OP36 OP38 18 (2) 13 (4) (a) (c) 8. OP38 13 (4) (a) (c) guidelines. It is required that the home ensures that an adequate number of staff have a first aid certificate. It is required that the home research, develop and implement a quality assurance system, which is based on seeking the views of stakeholders. It is required that the home should develop and implement a system of staff supervision. It is required that the management ensure that illfitting bed rails do not compromise the health safety and well being of people living at the home. It is required that the management ensure that the health, safety and well being of people living at the home is not compromised by the non use of footplates on wheelchairs. 30/08/07 30/08/07 30/08/07 30/06/07 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that the care plans are developed further to ensure that they give clear guidance to staff and that ambiguous statements are avoided. It is recommended that the management inform the CSCI of all people entering the home or returning from hospital with wounds or pressure sores. It is recommended that any medication belonging to people no longer at the home is destroyed or returned to the pharmacy within excepted timescales.
DS0000066156.V340637.R01.S.doc Version 5.2 Page 33 2. 3. OP8 OP9 The Knoll Nursing Home 4. 4. 5. OP14 OP15 OP26 It is recommended that the management consider the Mental Capacity Act and how people living at the home will be supported to make decisions and choices. It is recommended that consideration be given to displaying the menus in an accessible format. It is recommended that the practise of reusing night catheter bag drainage systems be reviewed to ensure that they meet with infection control and good practise guidelines. The Knoll Nursing Home DS0000066156.V340637.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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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