Inspection on 31/08/06 for The Knoll Nursing Home

This inspection was carried out on 31st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Knoll Nursing Home 04/02/09

The Knoll Nursing Home 08/08/07

The Knoll Nursing Home 22/02/07

The Knoll Nursing Home 07/02/06

The Knoll Nursing Home 20/09/05

The Knoll Nursing Home 21/12/04

The Knoll Nursing Home 23/08/04

The Knoll Nursing Home 16/04/04

The Knoll Nursing Home 26/02/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

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

CARE HOMES FOR OLDER PEOPLE The Knoll Nursing Home 30 Leeds Road Greengates Bradford West Yorkshire BD10 9SX Lead Inspector Catherine Paling Key Unannounced Inspection 31st August 2006 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 DS0000019883.V308551.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 DS0000019883.V308551.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Knoll Nursing Home Address 30 Leeds Road Greengates Bradford West Yorkshire BD10 9SX 01274 619207 01274 620194 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) The Knoll Nursing Home Ltd c/o ADL plc Care Home 42 Category(ies) of Physical disability over 65 years of age (42), registration, with number Terminally ill (3) of places The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: The Knoll is a detached, converted Victorian property. The home is located in a residential area close to local amenities and on public transport routes. A long driveway leads to the home and there are parking facilities to the front of the property. There are gardens surrounding the home that are accessible to the residents. The accommodation is over four floors although residents only use the ground and first floors. A passenger lift goes to all floors. There are thirty-nine bedrooms in total; thirty-six single and three shared rooms. Eleven of the bedrooms have en-suite facilities. There are four communal bathrooms; three showers and ten communal toilets. There are three lounges on the ground floor. One has a conservatory area and two of the lounges are also used for dining. The home is registered to provide personal care with nursing for residents over the age of 65 years. There are three beds registered to provide palliative care. Information about the fees and any additional charges has not been given to the CSCI at the time of writing this report. Information about the services provided by the home in the form of a Statement of Purpose and Service User Guide is not readily available to current or future service users. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way care services are inspected. They are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example, Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes and copies of past inspection reports are available on our website – www.csci.org.uk Information about the home is gathered from a variety of sources, one being a site visit. Additional site visits may be made that will concentrate on specific areas such as health care or nutrition called random inspections. This visit was unannounced and carried out by two inspectors on 31st August 2006 starting at 09:30am and ending at 18:45. The inspection was completed on 5th September 2006 and feedback provided to the acting manager between 13:50 and 17:45. The purpose of this inspection was to inspect all the key standards, (the key standards are identified in the main body of the report), to assess how the needs of people living in the home are being met. The methods used included looking at care records, talking to residents, observing care practices in the home, talking to staff and management, looking at the environment and looking at other paperwork including staff and maintenance records. The home was asked to complete a pre-inspection questionnaire (PIQ) to provide additional information about the home. This had not been returned at the time of writing the report. A further copy of the PIQ was left at the home and the acting manager was asked to complete and return it to the CSCI by 3rd October 2006. Comment cards were left at the home for residents and their relatives. Four had been returned at the time of writing the report. What the service does well: The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 6 The home is in a secluded yet accessible setting with some of the rooms having attractive views across the valley and others overlooking the gardens. The communal areas are airy and spacious with large windows. Visitors are made welcome at the home and one said that the acting manager has made improvements at the home with drinks and fresh fruit available. Visitors are able to make themselves refreshments when they visit. Residents said that they could please themselves about getting up and going to bed. Overall residents also said that they thought the food is good at the home. Relatives and residents said that the staff were friendly and kind. During the inspection staff were observed to be kind and patient with residents. What has improved since the last inspection? What they could do better: An Immediate requirement notice was left with the nurse in charge following the visit of 31st August. The operations manager for the company was informed by telephone at the time of the inspection. The notice related to an issue of serious concern that had to be dealt with immediately and related to: Administration of medication: (a) Medication was given out to the residents without reference to the medication administration record (MAR). Medicines were recorded as given some time after completion of the round. (b) Medicines for four residents were pre-dispensed and taken to the residents in unlabelled containers. This unsafe practice must cease and safe practice must be followed as set out in the Royal Pharmaceutical Guidelines for the safe administration of medicines in Care Homes and in the Nursing and Midwifery Council Guidance for the The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 7 Administration of medicines. Copies of both these documents were left at the home. Following the visit of 5th September 2006 serious concerns were raised about the number of nursing staff on the day shift for numbers of residents currently at the home. The acting manager was the only full time nurse on the day shift. The only other nurse currently rostered for day duty is a part time RGN. The practice of this nurse is in need of update and she can therefore provide only very limited support to the acting manager. This provides insufficient nursing staff to meet the needs of the residents. The acting manager has no previous managerial experience and as the only nurse on shift when she is on duty has no dedicated managerial time. She needs effective support in order to fulfil this role. These concerns were shared with the operations manager for the company and also detailed in writing to the responsible individual for the company. The statement of purpose and service user guide must be produced in a format that is user friendly so that prospective residents and relatives have access to information about the home to allow them to make an informed decision about living at the home. Care plans must be provided for all residents and must provide information and detail about their care needs. Wherever possible relatives and/or their relatives should be involved in the development of these plans. This should make sure residents receive a consistent and appropriate level of care at all times. Observed medication practices were poor and there were also issues with the overstocking of some medication. Policies and practice must be reviewed to make sure that they are safe and staff must receive appropriate training. There is little to do during the day for the majority of residents and some said they were bored. The registered provider must make sure that staff receive the training they need to properly care for the needs of the residents, for example in dementia care and adult protection. Some practices at the home put residents at risk of cross infection. The laundry is dirty and in need of cleaning and refurbishment. Staff need training and/or update in the control of cross infection. Detail of the shortfalls can be found in the body of the report. A number of requirements have been made and are at the end of the report. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 8 The registered provider has been asked to provide an improvement plan to detail what actions will be taken to improve services at the home. 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 Knoll Nursing Home DS0000019883.V308551.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 Knoll Nursing Home DS0000019883.V308551.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4. (Standard 6 does not apply) Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. Residents and their families have access to some information to help them make a choice about the home. Residents needs are assessed before they are admitted to the home but people with needs outside of the homes registration categories are admitted and staff have not received appropriate training to meet those needs. There is a risk that these specialist care needs will not be met. EVIDENCE: A copy of the inspection report for February 2006 was in the reception area. A combined statement of purpose and service user guide dated June 2006 was also in the reception area. This document was a combination of typed and handwritten information and difficult to follow. Not all of the required information was included, for example, a description of services to be The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 11 provided; the range of needs to be met; the criteria for admissions; staff qualifications. Information about training and the organisational structure was not clear. The document was not in plain English and not reader friendly. The home’s registration categories must be reviewed, as it was clear that the majority of residents fall in the category of older people rather than physical disabilities over age 65. From looking at care plans it was also clear that some of the residential residents had dementia and this had been the main reason for admission into care. A visitor said that their relative had come to live at the home one month earlier. The visitor had looked round the home and been given all the information they asked for and a brochure. The resident had come to look round and met people who lived and worked in the home before making the decision to come and stay. They both said that a nurse had visited them in order to do a pre admission assessment. They were both happy with the services provided and said that the staff were friendly and kind. The resident said they had settled in to the home very well. The Knoll Nursing Home DS0000019883.V308551.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. Care plans are poor and the lack of detailed information about individuals’ needs provides the opportunity for care needs to be overlooked. Staff do not make use of the care plans. Some medication practices are unsafe and place residents at risk. Service users are treated with respect and their dignity is upheld. EVIDENCE: A sample of four care plans were looked at in detail. The relatives of two of these residents and the visitor of a third were spoken with. Care plans were in place for most residents. However, it was found that for the two most recent admissions the only information available to staff was the pre admission assessment and the daily records. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 13 Staff said that they did not get time to look at the care plans. One of them had a good understanding of residents’ needs and the support they needed. Visitors said that they were aware of the care plans and had been involved with an annual review of care. The care plans looked at contained some individualised information about the residents but the majority was generalised and could have related to any resident in the home. The care plans were based more on medical needs and the activities of daily living rather than looking at individual strengths and weaknesses and the specific intervention needed by staff to make sure that personal, health and social care needs are met. Serious concerns were identified in the following areas: • Nutrition and hydration – there was no information about what individual food preferences, likes and dislikes were. For residents at risk of losing weight and those who had lost weight there was no information about how meals would be enriched, how often nourishing snacks and drinks would be given. The food diary and intake charts kept by staff showed that three meals a day were given between the hours of 08:00am and 17:00. The record showed that snacks and drinks were only given four times over 24 hours and that there was a gap of at least 17 hours between the evening meal and breakfast and that total fluid intake for a 24 hour period did not exceed 1 litre, even when there was detail in the care plan about elimination for one resident who was at risk of developing urine infections and needed to drink 2 litres of liquid or more per day. • One of the residents, who had fragile skin, was immobile and at risk of developing pressure sores did not have any care plans at all detailing how these areas of risk should be looked after. A resident who had received grazes to their shins following an accident did not have a care plan detailing how the wounds would be looked after. The grazes did not have any dressings on them and their visitor said that they were not getting any better. A care plan about what to do in the event of the residents death said that they were not for active resuscitation – but it did not state who had been involved with making this decision and the nurse in charge did not know what the homes policies and procedures (if any) were about this subject. There was no information about what type of dementia people had, how it affected them and how to best meet their needs. This was even the case for one resident who had been seen by the community psychiatric nurse (CPN) who left detailed notes for staff on how to approach them, speak to them and provide personal care. DS0000019883.V308551.R01.S.doc Version 5.2 Page 14 • • • The Knoll Nursing Home • A resident whose pre admission assessment showed that they were prone to eye infections and had a rash to their face did not have any care plans showing how staff were to monitor these problems and what treatments were in use. The manager who had left had devised the assessment tools currently being used. The quality of the information asked for and recorded was poor. Several residents were being cared for in Kirton or ‘bucket’ style chairs. Care plans seen for two residents nursed in one of these chairs showed that risk assessments around using these chairs had not been carried out. The relative of one resident said its use had been discussed with them and they felt their relative was safer and at less risk of falling but this agreement was not recorded. There were no signed consents seen. The moving and handling assessment was brief and basic and did not provide details about how to move residents safely and what type of equipment should be used to protect the resident and staff. Daily record documents were in all care plans but these were not always filled in daily, staff said these should be completed by the day shift and the night shift. Two of the plans seen had entries dated 28.8.06 for the day shift and no further entries until the day of 30.8.06. On the visit of 31 August serious concerns were identified around the nurse in charge’s practices when administering medications to residents. In the morning they gave residents medications without making any reference at all to the medication administration record (MAR) and did not sign any of the charts until half an hour or more after the last tablets had been given. The inspector found the MAR charts in the reception office and asked the nurse if they wanted them after asking if all residents had had their tablets. They replied yes as they had not signed them yet. When asked about their practice they said their practice was safe. They were reminded about safe practice and responsibilities under Nursing and Midwifery Council (NMC) and Royal Pharmaceutical Society (RPS) guidelines. At tea time the same nurse was seen taking medication upstairs. When asked who it was for they said for the four people in their rooms upstairs and they were holding four bun cases stacked on top of each other. The top one had three tablets in it and it could be seen there were tablets in the one underneath. The nurse was challenged again about safe practice and they said they knew what the tablets were and who they were for. An immediate requirement was made around making sure that safe practice is followed at all times when dealing with and administering residents’ medications. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 15 There were gaps in the medicine administration record (MAR) where staff had not signed or used code letters to show whether or not medication had been given. The policy for medications was in the MAR charts file. This was not to the RPS guidelines. Examples of areas that were missing included action to be taken in the event of an error in administering medication; how to deal with drug alerts and hazard warnings and how to deal with prescribed oxygen. Oxygen was in use and signage in areas where it was used did not provide all the safety information required but merely stated that it was in use. The previous manager had written to general practitioners (GPs) asking them to state what medications they would be happy for nurses to use as homely remedies and copies of their responses and instructions were with the resident’s MAR charts. This is good practice. The treatment room on the third floor was looked at on the visit of 5 September 2006. There was a large stack of catheter equipment. The acting manager said that items like that are sent even when not requested on repeat prescriptions. It was established that repeat prescriptions are not signed in the home and she did not know that this should be done. There was overstocking of many items of medication for example bottles of lactulose, including some for residents no longer at the home and boxes of insulin that was dispensed in March, July and August as well as some brought in by the family of the resident concerned There was a box of paracetamol labelled for staff and a record book to use if any were given out. A policy should be available about giving staff medication. There were five boxes of a prescribed medication issued on 28 June 2006, which had not been given. The acting manager said they were waiting for advice on how to administer this drug. She said that the manager, who left three weeks ago, was dealing with it. There were two bottles of Haloperidol liquid that had been dispensed in February and April 2006. The acting manager was not aware of how long liquids can be kept after they have been dispensed into other bottles. It appears that there is an issue with tablets not in the Monitored dosage system (MDS) not being given as prescribed which may have contributed to the large build up of stocks. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 16 The acting manager was asked about how medication was disposed of. She was not aware of the ‘denaturing kit’ that should be supplied for dealing with the destruction of controlled drugs. It was evident that policies and procedures were in need of review and that trained staff are in need of training and update. Residents and visitors said that staff were kind, caring and respected their privacy. Examples given were knocking on doors before entering rooms. However, some domestic staff were seen entering rooms without knocking. At least eight visitors were spoken with during the visit and they all said the staff were nice, kind and caring and they were generally satisfied with the care their relatives received. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The more able residents are able to make choices about their day-to-day lives. Staff need to work at ensuring less able residents are encouraged to exercise choice wherever possible. Residents are supported in maintaining contact with their family and friends. Visitors are welcomed at the home. Residents have little to occupy them through the day and there is poor provision of planned activities. Poor records of food served to the more highly dependent residents make it difficult to establish whether a varied and nutritious diet is being provided. EVIDENCE: Residents said that they enjoyed the meals. Visitors said that they could visit at any time and were always made to feel welcome by the staff. Some said they were offered a drink if staff had time The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 18 but that they could go into the kitchenette area and make themselves a drink whenever they wanted to. No mid morning drinks were served to residents and there were no glasses of juice or water in front of or available to residents. Residents individual social, cultural and religious needs were not identified in appropriate care plans. There were no clear plans about meeting individuals social care needs. There were psycho-social care plans, the purpose of which was not clear. They provided a mixture of information that could apply to any resident such as encourage to speak to others and join in with activities. A resident who speaks very little English did not have a care plan showing what the best communication methods would be and there was no information about how their religious needs would be met. The psycho-social care plan for a resident with severe dementia was totally inappropriate for their needs. It said that they may become bored due to the predictability of the days and for them to be assisted so far as reasonably possible. The guidance for staff was to assist them to join in and said that they were limited with regards to chatting, they could participate to a small degree but did not appear to like music from the organist. It said they liked to keep their hands busy and to use items brought in by the family. They were seen holding a bead frame throughout the day and this was the only type of stimulation seen for them. Staff interactions with residents varied. The activities coordinator ignored one resident who called out for a nurse while they looked through CD’s. When asked why they did not acknowledge the person they said this particular resident always called out and that other staff ignored it. Other staff spoke to the resident for a few minutes and this settled them and was what they wanted. Social stimulation throughout the day consisted of the TV in one lounge and music being played in another. The activities person played cards with a small group of able residents. Some residents said that there was not enough for them to do and although there was an activities organiser the activities offered were limited. This was reflected in records of activities for one week on July when there was evidence of a very restrictive range of activities involving only a small number of the more able residents. Activities included several trips to the local supermarket involving one resident; several entries of chatting with up to five residents on one day and two residents being pushed around the grounds. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 19 Staff did not have enough time to be able to interact or do anything with residents other than personal care tasks. A notice in the office said that an organist was due to come in to entertain residents in the afternoon, but they did not arrive. The acting manager said that there was no budget for entertainment and she and the previous manager had been paying for the entertainment themselves. The acting manager felt that she could not sustain this. The full time cook has worked at the home for a number of years with the part time cook providing cover for his days off. A kitchen assistant provides additional cover for two days and the two cooks work together for two days out of the week. This means that there are three days in the week where there is no additional support for the cook on duty. There was an inspection by the Environmental Health Department in June when no major issues were identified. There is a four-week rotational menu. The cook said that breakfast is served from 08:30 and usually finishes about 10:15; lunch from 13:15 and the evening meal between 16:30 and 17:15. Tea and biscuits are provided at suppertime. Lunch is a light snack, for example eggs on toast or soup and sandwiches. It was not clear if all residents got a bedtime drink, as these were not recorded in food diaries. One carer who also works on the night shift said that residents do get an early morning drink although these were not recorded either and several residents said that they had not had an early morning drink that day. None of the residents got a mid-morning drink on the day of the visit. Overall, the indications are that fluid intake is poor. Residents were drinking out of badly stained plastic beakers which should be replaced. Liquidised meals are served with all the components mixed together, which does not allow for the different taste and textures to be experienced by the residents and is considered poor practice. The cook seemed to be aware of opportunities to fortify meals however the only snacks served to residents were biscuits with no home baking in evidence. The evening meal is the main meal of the day but staffing levels at this time consist of the chef and three care staff. The chef served meals to residents in the lounges and dining areas. He said he did this by choice to make sure the right people got the right meals. The three carers were giving meals to people in their rooms and helping those who needed help to eat. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 20 The chef does his part of the washing up and the care staff do the rest. This leaves two carers and the nurse on the floor. At 6pm on the first visit two carers were having their break leaving one carer and the nurse on the floor. This is inadequate to meet the needs of resdients. The Knoll Nursing Home DS0000019883.V308551.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Residents are confident that their concerns will be dealt with appropriately. EVIDENCE: Visitors said they knew who to speak to if they had any concerns. Two had spoken to the previous manager and the acting manager about concerns and would do so again if needed. They did not give details about the issues but said that they had been satisfied with the way they had been dealt with. One visitor had made a complaint directly to the CSCI and had been satisfied with the way that had been resolved. The complaints procedure was displayed on the notice board by the main entrance door. The acting manager was aware of the Bradford Social Services document ‘No Secrets’ which contains information about the multi-agency procedures for the protection of vulnerable adults and there was a copy at the home. She had not had any training in adult protection. Care staff had had some training in adult protection as part of undertaking their National Vocational Qualification (NVQ) in care. Staff were aware of the whistle blowing procedure which was displayed on the staff notice board. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Further refurbishment work must be done to make sure that a safe and comfortable environment has been provided for the residents. The laundry area was not adequate and provided the opportunity for cross infection. Some practices put residents at risk of cross infection. EVIDENCE: There are some areas of the home not currently used by residents. One isolated room is being used as a training room. The adjacent room and bathroom are being used for storage of combustible items. There was no fire detection in the bathroom. The bathroom and bedroom doors were not kept shut. Some of the communal toilets have wooden seats that are damaged and pose a cross infection risk. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 23 There were bars of soap in communal toilets and bathrooms presenting a risk of cross infection. Not all doors closed properly even those marked ‘fire door keep locked shut’. There is a nurse call system in the home. If residents are unable to use it due to mental or physical disability a risk assessment is carried out which states that hourly checks will be made at night. However, the fact that hourly checks should be made was not referred to in the safety or sleep care plans for one of the residents with severe dementia. The laundry area remains dirty as seen at the previous inspection. Leaves and other debris had collected in this area and snails were seen on the laundry walls. The flooring was damaged and in need of replacement. The only sink in this area was filthy. Soap and paper towels were provided. One machine was marked out of order and there was no easy access to the back of the machine for cleaning. There was what appeared to be a new fire door which was wedged open and when tested did not shut even though it is marked ‘fire door keep shut’. The whole area was very dirty and must be cleared out to allow for proper and effective cleaning. There was a linen store in this area, which did not have fire detection, and the door was not shut. There was a sign in the home which stated that ‘heavily soiled or urine soaked sheets are to be sluiced/dried off and then put into bags’. There was conflicting information from staff as to whether hand sluicing was done. The handling of foul linen must be kept to a minimum and effective infection control procedures should mean that hand sluicing does not take place. There was a room off the hall, which appeared to be used for the storage of wheelchairs and a hoist but had one dining table. There were also staff belongings, including bags and coats, on top of the sideboard. The staff notice board was in this room. Four residents were moved into this area for their lunch. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. The numbers and skill mix of staff are not sufficient to meet the needs of the residents. Staff have not received appropriate training about specialist care needs of residents and there is a risk that these will not be met. Recruitment practices do not consistently protect residents. EVIDENCE: Staffing levels were not adequate. There was only one full time nurse on day duty who was the acting manager. The only other nurse on the day shift was part time and could offer only limited support. Following the second day of the inspection the serious concerns about the nurse staffing levels were shared with the operations manager for the company who advised that she could not authorise the use of agency nurses to provide temporary support. She said that a nurse had been employed and it was hoped that she would start at the home within the next two to three weeks. The serious concerns regarding the nurse staffing levels were followed up in writing to the operations director following completion of the inspection. Residents and visitors said that often there was not many staff around especially in the afternoons and evenings. Some of the comment cards received after the inspection also raised concerns about the number of staff and in particular the need for support for the acting manager. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 25 There is ancillary support for staff but this is not provided over the seven day period. Although the chef is on duty at teatime the care staff are involved in collecting pots and washing up after tea. There are no laundry staff after 14:00 on weekdays and none at the weekend with no cleaners from early afternoon and none rostered for Saturday or Sunday. The numbers of carers currently employed at the home are not sufficient to meet the needs of residents and they should not be involved in non-caring duties. Carers were very clear and knowledgeable about their role. They were enthusiastic about what they had learned through NVQ training. A small number of individual files were looked at for recently employed staff and overall recruitment practices were satisfactory with all the required checks being carried out. In the case of a recently employed nurse there was evidence of attempts to assess professional knowledge, which is good practice. However, there were no written responses from the nurse but comments from the interviewer such as ‘answered correctly’. There was evidence of induction for staff in the form of a list of topics all signed off with the same date. One member of staff who had worked previously at the home, left and returned after several months but they had not formally reapplied for the job nor had criminal records checks been repeated. Information about planned training has been asked for in the PIQ. Staff need training in dementia care and adult protection as well as medication updates for the trained staff. The Knoll Nursing Home DS0000019883.V308551.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. The management of the home is not organised. This results in practices that do not always promote and safeguard the health, safety and well being of the residents. EVIDENCE: The registered manager left the home a few weeks ago. The deputy manager has taken up the role of acting manager. She has no previous managerial experience and the available support from qualified staff at the home was limited. The ‘Quality file’ indicates that there is a system of in-house audits for example for the kitchen, medication practices and care plans. The most recent audits on the files were for July 2006, just before the manager left. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 27 A quality assurance survey was carried out in May 2006. The results have been included with the statement of purpose/service user guide and displayed on the relatives notice board in the entrance hall. They showed that overall people were satisfied with services provided. Accident records are kept but they would benefit from additional information: • The details of the accident and any resulting injuries, • If there was a suspected or actual head injury they did not show that neurological observations had been carried out • About the outcomes of the accident. • Who saw the resident last before the accident and at what time. An accident summary form was kept but the information on the form was not clear or legible. There was no audit of accidents to assist in the identification of any trends or issues that might need to be addressed. The ‘complaints analysis’ completed for July 2006 stated that there were ‘no official complaints regarding investigation since June 2005’. It is not clear from this statement if there had been any other type of complaints. Staff supervision records are held in the ‘Quality file’. These are confidential records of 1:1 meetings and should be held in individual files. Records of staff meetings indicate that the most recent meeting was held in June 2006 and the one before that was July 2005. A relatives meeting was held in June 2006 and the notes of this meeting indicated that these would be held every two months. No more recent records were seen. The operations manager visits the home regularly and provides notes of these visits to the CSCI. It is the policy of the home not to handle personal allowances for the residents. However there is an arrangement between a member of the ancillary staff and a resident where the member of staff does some shopping. Records are kept and include two signatures and receipts of all transactions. There was a lack of comprehensive and accessible policies and procedures for staff. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 2 2 X X 3 X 1 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 2 2 2 The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1)(c) Schedule 1 and 17(2) Schedule 4 Requirement The provider must provide up to date and accurate information relating to the home in a format that is accessible to residents and their representatives. This includes the Statement of Purpose and Service User Guide. This information must also be made available to the CSCI. Residents must not be admitted 30/10/06 to the home outside its registration category i.e. with dementia. Care plans must set out in detail 04/12/06 the action which needs to be taken by nursing and care staff to ensure that the health, personal and social care needs of the resident are met. Care plans must be drawn up with the involvement of the resident and agreed and signed by the resident wherever capable and/or their representative. Timescale of 01/02/06 not met The registered person must DS0000019883.V308551.R01.S.doc Timescale for action 08/01/07 2. OP4 14 3. OP7 15 4. OP8 12 & 06/11/06 Page 30 The Knoll Nursing Home Version 5.2 13(4)(5)( 7)&(8) make proper provision for the health and welfare needs of the residents to be met. A review must take place of the nutritional risk assessment currently used to make sure that there is accurate identification of those residents nutritionally ‘at risk’. Records must demonstrate clearly how that risk is to be managed. Timescale of 26/06/06 not met The current manual handling risk assessment must be reviewed to make sure that staff have sufficient information to safely assist residents. Forms of restraint, such as the use of Kirton chairs must not be used without thorough risk assessment. Advice and support about safe manual handling and moving should be sought from the appropriate healthcare professionals. The registered provider must ensure that there are detailed policies and procedures for the receipt, recording, storage, handling administration and disposal of medicines. Systems must be in place to make sure that staff adhere to these policies and procedures. Those staff involved in the administration of medication must receive regular update from an accredited trainer. The registered provider must consult residents about their social interests and about the DS0000019883.V308551.R01.S.doc 5. OP9 13(2) 01/09/06 6. OP12 16(m)(n) 04/12/06 The Knoll Nursing Home Version 5.2 Page 31 programme of activities arranged for them. Facilities must be provided for recreation taking into account the needs and abilities of the residents. 7. OP14 12(2)(3)& (4)(a) Timescale of 29/05/06 not met The registered provider must make sure systems are in place for all residents to be able to make choices and have control over their lives. A review must take place of the provision of food and drink to make sure that all residents receive suitable and nutritious food and an adequate fluid intake. Training must be provided for the chef to make sure that he is fully aware of the nutritional needs of the frail elderly. The provider must ensure that the home develops and implements an adult protection procedure which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets. All staff must receive relevant and informative training to equip them with the knowledge to recognise abuse and act appropriately to protect residents. 10. OP19 23 Timescale of 29/05/06 not met All threadbare carpets must be replaced. Timescale of 23/12/06 not met The registered provider must make sure that all areas used by residents are kept clear of staff belongings and are not used for storage. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 32 29/12/06 8. OP15 16(2)(i) 29/12/06 9. OP18 12(1)(a)1 3(6) 18/12/06 02/01/07 11. OP22 23 12. OP24 12(4)(a) Following risk assessment for those residents who cannot use the call bell system there must be details of how the is to be addressed within care plans. Records must provide evidence of the action taken. The registered provider must ensure that all residents’ bedroom doors are fitted with an appropriate lock, which allows staff to gain access in an emergency. Timescale of 31/05/05 not met The laundry area in the basement must be cleaned. The floor must be replaced to allow for effective cleaning. The hand-washing sink must be cleaned and protective clothing including gloves must be provided. The cracked wooden toilet seats must be replaced. The registered provider must review infection control practices with staff and consider additional training in control of infection for all designations of staff. Advice must be sought from the infection control nurse. The registered provider must review the staffing numbers and skill mix of qualified and unqualified staff to ensure that these are appropriate to the assessed needs of the service users, the size, the layout and purpose of the home, at all times. The number of staff and hours in respect of service user needs should be based on guidance recommended by the DS0000019883.V308551.R01.S.doc 30/11/06 02/01/07 13. OP26 13(3) 06/11/06 14. OP27 18(1)(a) 30/10/06 The Knoll Nursing Home Version 5.2 Page 33 Department of Health. Care staff must not be taken away from caring duties to carry out domestic tasks. There must be sufficient ancillary staff on duty at key times for example, for all meal times. 15. OP28 18(1)(a) Timescale of 24/05/06 not met The registered provider must 29/12/06 ensure that the minimum ratio of 50 trained members of care staff is achieved by 2005. Timescale of 03/07/06 not met The provider must make sure the 30/11/06 recruitment procedures used are robust enough to protect residents at all times. The provider must make sure 29/12/06 there is a training programme in place to make sure staff have the necessary skills to care for the residents. Care staff must provide written evidence of their induction training. In the absence of a registered 30/10/06 manager the registered provider must put contingency plans in place that safeguard the residents at the home. 16. OP29 19 17. OP30 18 18. OP31 9 19. OP33 20. OP33 21. *RQN The CSCI must be informed of these arrangements. 24A The registered provider must 11/12/06 produce an improvement plan setting out the methods and timetable of how they intend to improve the services provided at the home. 24 Policies and procedures must be 18/12/06 reviewed and available to staff to ensure staff have access to relevant and accurate information. Section 31 The registered provider must 03/10/06 DS0000019883.V308551.R01.S.doc Version 5.2 Page 34 The Knoll Nursing Home CSA 2000 23. OP37 17 24. OP38 13 and 17 25. OP38 23(4) complete and return the preinspection questionnaire. The registered provider must 08/01/07 make sure that all the required records are kept and are up to date. Records must be kept securely. Detailed accident records must 20/11/06 be kept which provide clear information about what happened, who saw it happen or when the resident was last seen and by who, what injuries were sustained, what action was taken and what the outcome was. As previously requested the 30/10/06 registered provider must produce an action plan with timescales for the issues raised within the fire safety report, as requested in the letter dated 03/02/06. 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 OP36 Good Practice Recommendations Supervision records should be kept in staff personal files. The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Knoll Nursing Home DS0000019883.V308551.R01.S.doc Version 5.2 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!