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Inspection on 08/08/07 for The Knoll Nursing Home

Also see our care home review for The Knoll Nursing Home for more information

This inspection was carried out on 8th August 2007.

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.

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

What the care home does well

Care is provided in a clean, tidy home. Some of the rooms have attractive views across the valley and others overlook the gardens. The communal areas are airy and spacious with large windows. Residents are able to bring in their own possessions to personalise their rooms and make them more homely and `theirs`. Visitors can come to the home at any time. They said that the home had friendly, welcoming atmosphere and the staff kind and friendly. They were satisfied with the services and care provided to their relatives and said that staff kept them informed of any changes. They felt that the staff did their best in what were sometimes difficult situations, particularly where people are forgetful or have a memory problems. The time spent observing people showed that staff were patient, took time to make sure they were comfortable and paid attention to what they said.

What has improved since the last inspection?

Staff are now being provided with regular training and the support manager said that this will continue.

What the care home could do better:

Requirements to improve practice have been made and can be found at the end of this report. Management and support systems have been put in place by the provider but the poor progress made towards meeting requirements from the last inspection would indicate they are not working as well as they should be. Steps must be taken to make sure that the home is effectively managed and run in the best interests of people living there. In order to make sure that health, safety and well being of people living in the home is promoted and protected areas where swift attention is needed include: * Making sure care plans provide detailed information and guidance to staff about an individual and how to meet their needs. * Making sure staff work with the care plans and follow the instructions provided, for example giving high calorie snacks or thickened drinks to people needing them. * Making sure that if records of care, diet and fluids given to an individual are kept that they are accurate and kept up to date. * Making sure that the systems for dealing with medications are safe and people receive their medications as prescribed by their doctors. * Making sure that there are always enough staff on duty to meet people needs. * Not using abbreviations in peoples records as this could lead to misunderstandings.

CARE HOMES FOR OLDER PEOPLE The Knoll Nursing Home 30 Leeds Road Greengates Bradford West Yorkshire BD10 9SX Lead Inspector Nadia Jejna Key Unannounced Inspection 8th August 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Knoll Nursing Home DS0000019883.V344176.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.V344176.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 *** Vacant *** 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.V344176.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2007 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 areas to the front of the property. There are gardens surrounding the home and sitting areas have been provided that are accessible to 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 services provided by the home in the form of a Statement of Purpose and Service User Guide is available from the home to current and future service users. At the time of writing this report the weekly fees are £384.44. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was made by two inspectors on 8 August 2007 lasting 9 hours. The home did not know that this was going to happen. The purpose of this visit was to make sure that the home was being managed for the benefit and well being of the residents. During the visit residents, their visitors and staff were spoken to. Other records in the home were looked at such as staff files, complaints and accidents records. One inspector spent two hours directly observing the care being given to two small groups of residents in two different communal areas. One hour was spent in each area. Before the visit was planned the provider was asked to carry out a quality assessment of the service stating what they did well, what was in place to prove this, what improvements had been made over the last twelve months and what was planned for the year ahead. This document is called the Annual Quality Assurance Assessment and will be referred to in the report as the AQAA. Other information asked for included what policies and procedures are in place, when they were last reviewed and when maintenance and safety checks were carried out. The last inspection was in February 2007. This showed that some improvements had been made which meant better outcomes for people living in the home. However not all of the requirements made at an inspection in August 2006 had been met. This visit was to look at what progress had been made since then. Since the last visit there have been concerns about how the care provided to people who develop pressure sores. The provider is working with CSCI and the local authority adult protection team to deal with this and improve outcomes for people. Concerns have also been raised about staffing levels, especially at night. Feedback was given to the support manager on 16th August 2007. This was during a meeting held at CSCI office in Rodley to discuss concerns about staffing levels and what action had been taken in response to an immediate requirement as a result of the concerns. A letter from the provider on 15th August 2007 said that appropriate measures had been taken to make sure that the health and safety needs of people would be met at night. What the service does well: Care is provided in a clean, tidy home. Some of the rooms have attractive views across the valley and others overlook the gardens. The communal areas are airy and spacious with large windows. Residents are able to bring in their own possessions to personalise their rooms and make them more homely and ‘theirs’. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 6 Visitors can come to the home at any time. They said that the home had friendly, welcoming atmosphere and the staff kind and friendly. They were satisfied with the services and care provided to their relatives and said that staff kept them informed of any changes. They felt that the staff did their best in what were sometimes difficult situations, particularly where people are forgetful or have a memory problems. The time spent observing people showed that staff were patient, took time to make sure they were comfortable and paid attention to what they said. What has improved since the last inspection? What they could do better: Requirements to improve practice have been made and can be found at the end of this report. Management and support systems have been put in place by the provider but the poor progress made towards meeting requirements from the last inspection would indicate they are not working as well as they should be. Steps must be taken to make sure that the home is effectively managed and run in the best interests of people living there. In order to make sure that health, safety and well being of people living in the home is promoted and protected areas where swift attention is needed include: * Making sure care plans provide detailed information and guidance to staff about an individual and how to meet their needs. * Making sure staff work with the care plans and follow the instructions provided, for example giving high calorie snacks or thickened drinks to people needing them. * Making sure that if records of care, diet and fluids given to an individual are kept that they are accurate and kept up to date. * Making sure that the systems for dealing with medications are safe and people receive their medications as prescribed by their doctors. * Making sure that there are always enough staff on duty to meet people needs. * Not using abbreviations in peoples records as this could lead to misunderstandings. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 7 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 DS0000019883.V344176.R01.S.doc Version 5.2 Page 8 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.V344176.R01.S.doc Version 5.2 Page 9 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 and 3. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home makes sure that peoples needs can be met by carrying out an assessment before agreements are made about moving into the home. EVIDENCE: A revised Statement of Purpose and Service User Guide has been produced. A copy was sent to the CSCI. Feedback was given to the person in charge about additional information that would help people to decide if the services provided would be right for them. For example: * Making it very clear what needs could be met by the numbers and skills of staff on duty. * When the home might have to say they cannot meet somebody’s needs or might need to ask a person to move elsewhere. For example if their behaviour and actions might place other people living in the home or staff at risk of injury. * What the homes policy is around escorting people to hospital for appointments and in emergencies. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 10 The AQAA said that people are welcome to visit and look round the home at any time. During the visit some visitors called at the home looking for a place for a relative. They were welcomed by the nurse and shown around. The pre admission assessment for the most recent admission to the home was looked at. Their relative had been to look round the home on their behalf. One of the nurses had visited them in hospital. The pre admission assessment had enough detail for the home to know whether or not they could meet their needs. The person said that they were satisfied with the care and attention they had received. Information from people living at the home and their relatives said that: * They had been given enough information. * They were generally satisfied with the services provided. * The staff were very friendly, helpful and caring. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 11 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 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s personal and health care needs are being identified but this is not always shown in the records kept and there is the risk that appropriate advice and support from other healthcare professionals will be asked for. There is a risk that people will not receive their medications as prescribed by their doctors because the systems for dealing with medications are not robust. EVIDENCE: The support manager said that changes to the way plans are presented and produced are being made. This is to make them easier to read and to make sure that there is detailed guidance about how to meet individuals needs. Seven care plans were looked at. Some were handwritten and had been in place for over two years with changes added to the plan or commented upon in the evaluations. The support manager had renewed some of the care plans and these had been typed and were much easier to read. The new care plans contained more information about the person and how to meet their needs. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 12 Information in the AQAA said that all people are ‘treated individually in the same manner and without prejudice.’ Having more detailed information in the care plans about individuals abilities, strengths, needs, weaknesses, likes, dislikes and preferences would support this statement. Abbreviations were being used regularly. Only one out of four staff asked was able to explain what one of the abbreviation’s used was. Abbreviations like this should not be used as it can lead to staff not understanding the guidance and people’s health care needs might not be met. Guidance provided in care plans was not always being followed. For example staff had an idea of who needed thickened drinks because of swallowing problems but it was seen that one person needing this did not get it. Some of the records kept were not up to date. For example care charts showing what people had had to eat and drink or when their position in bed had been had gaps of 6 hours or more. This would indicate that no care or attention had been given or that staff did not have time to complete them. The support manager said staff were attending to peoples needs and did not always remember to fill in the records. She said she would deal with this immediately and also make sure staff received instructions about the importance of accurate record keeping. Accident records showed that one person had fallen sixteen times in four months. An entry on their care plan said ‘because of increasing dementia it is not safe to leave (resident named) to get in and out of chair or bed. Constant supervision is needed to prevent falls.’ The manual handling assessment went on to say ‘not sitting in recliner as putting legs over the side and not safe to sit in an ordinary chair.’ This record was not dated but signed. However on the day of the visit this resident was in a recliner chair. When asked why staff said it was to stop her getting out of the chair and falling. The reasoning behind the use of these chairs must considered and risk assessed and not because there are not enough staff on duty to monitor and supervise these people. The falls prevention team had not been contacted for advice about this person. This has been a requirement from previous inspections. The support manager obtained contact details for the falls prevention nurse and has left a message for them to contact her. At least five people sit in recliner chairs or ‘Kirton’ bucket style chairs. These prevent them from getting out of the chair without help. It has been raised at past inspections that these types of chair are a form of restraint and risk assessments around why they are being used should be carried out. The consent of the person involved and or their relatives should be obtained. The accident forms looked at did not show when the person was last seen or by whom. Adding this information has been recommended at previous The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 13 inspections. If somebody is on the floor in their room it provides an indication of how long they could have been on the floor. Medication records were looked at. There were some gaps indicating that medicines had not been given. The home uses a blister pack monitored dosage system and it showed that these tablets were missing. Other medication records showed that some people had gone without their regular prescribed medication for just over one week. Notes on the charts showed that it took nearly a week before prescriptions for these had been obtained and sent to the pharmacy. This information has been passed to the CSCI pharmacy inspector. When feedback was given to the support manager, she said that steps have been taken to deal with medication issues. Training has been arranged for the nurses and they will attend 1 to 1 formal supervision sessions around medication. An in depth audit of all medication systems is also going to be carried out. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 14 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 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are helped to stay in contact with their family and friends and visitors are welcomed to the home at any time. But there is a risk that residents social care needs will not be met because of the poor provision of social activities. EVIDENCE: An activity organiser has been employed but during the visit she was working as a carer to cover for staff shortages. Information received and seen on duty rotas showed that this is a regular occurrence. There are no regular planned activities other than a ‘Motivation Session’ every Wednesday and entertainers at regular intervals. The ‘Motivation Session’ took place during the visit and people appeared to enjoy it very much. The support manager said that when more staff had been recruited the activity organiser would be able to concentrate on her role and that the work she had done so far had been very good. She has been making sure that there are ‘Lifestyle Diaries’ in place for each person living in the home. These provide a background life and social history, along with information about past employments, family links, hobbies and interests. This information can then be used to plan meaningful activities for them. These documents are kept in separate file. Some had been completed and others were a ‘work in progress’. Some files had a short ‘pen The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 15 picture’ of the individual which would be useful as part of the care plan to provide a ‘picture’ of the person at the centre of it. Information from people using the service and their relatives said that more social activities and social stimulation could be provided. What was seen as part of the SOFI observation confirm this. The pictures on the television sets in the large lounge/conservatory were poor and would not be easy to watch for long periods. The support manager said that these would be replaced in due course. It was hoped that with fundraising efforts they would be able to buy a large cinema type TV. People can choose when to get up, go to bed, where they want to eat their meals and spend their time. Some like to stay in their own rooms most of the time and others prefer to sit in the lounges. Visitors said they could call at any time and were made to feel welcome. The atmosphere in the home was warm, welcoming and friendly and it was clear that staff had good relationships with people living in the home and their relatives/visitors. The daily menu is written on a chalkboard near the dining room. Carers said they ask people in the morning what they would like for lunch. This arrangement works for people who can communicate. During the visit it was seen that staff decide for those who cannot communicate. The care plans do not always provide information about people’s dietary likes and dislikes and alternative ways of communicating and finding out what they want to eat could be used, for example using photographs of foods and meals. Lunchtime was observed. The atmosphere in the dining room was jolly and people were talking to each other and having a laugh and joke with staff. Care staff served meals from a hot trolley using their knowledge of people’s likes, dislikes and appetites. It took a long time to serve the main course to everybody and there did not appear to be any systems in place for making sure that all people regardless of where they were eating had been served. One person in the dining room was not served dessert until the inspector pointed out that others had finished theirs and were ready to leave the room. The support manager said she would make sure this did not happen again. People who could communicate were offered an alternative if they did not like what was offered. One person was offered a variety of desserts, ice cream or fruits when they did not want the dessert on the menu. If care plans accurately showed what peoples dietary preferences were this range of choice could be offered to all people. People said they enjoyed their meals and the pace of the meal was relaxed and unhurried. People who needed help to eat were offered it discreetly on a 1 to 1 basis. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 16 The last inspection of the kitchen by the Environmental Health Department in May 2007 said that the outcome was good and awarded 4 stars on the ‘scores on the doors’ system. At the time of the visit the dishwasher was broken and staff were washing up manually. This was very time consuming and crockery that had not been properly cleaned was seen. If the machine remains out of action when care staff have to fulfil kitchen duties they will be kept away from their caring role longer than necessary and there is the risk of cross infection and contamination of crockery not being properly cleaned. The support manager said that that quotes for repairing the machine had been requested. Hot drinks are served at regular intervals but for people who needed help to drink the delay between it being poured and help being given meant that drinks are often lukewarm for them. The support manager said she would look into this. Information from surveys said that often there was limited choice at teatimes, especially for people needed soft or pureed foods. The support manager said that new menus have been produced that will improve choices offered for all people. They have been produced by head office but can be altered by the home to reflect people’s choices and preferences. The support manager said that the cook would talk to people and find out what their views were. Information from the AQAA said that good contacts have been made with local churches and the Salvation Army. Regular services are held in the home for people who wish to attend. Other people have maintained links with their own churches. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 17 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): People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies are in place to make sure that people are safe. People know who to speak to if they have any concerns. EVIDENCE: The AQAA said that the home has a complaints policy and people are actively encouraged to make complaints without feeling uncomfortable or that the complaint will not be acted upon. It said that over the last twelve months there have been three complaints. A comment made on a relatives survey said ‘they encourage a feeling of safety and contentment to their residents. They try very hard to ‘get it right’ for each resident.’ Most said that they knew who to speak to if they had any concerns. The complaints file was looked at. There were records for five concerns, two of which had been received after the AQAA was completed. They were about various issues relating to standards of care provided, concerns about staffing levels and supplies of incontinence products. These had been investigated and responded to by the provider. There is one outstanding complaint that has not been fully resolved yet. This is a concern that was referred to the local authority adult protection unit by the tissue viability nurse regarding the care provided to people who developed pressure sores and the way they were dealt with by the nurses in the home. The operations manager for the organisation has been working with the adult The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 18 protection team, CSCI and healthcare specialists to investigate this and put systems in place to make sure that if pressure sores develop they are properly dealt with. The AQAA said that one of the things they could be better would be to remind staff they are at liberty to contact CSCI or adult protection directly if they witness abuse of people living in the home. Staff would be supported to do this if the home has a ‘whistle blowing’ policy to protect staff. Information in the AQAA about policies and procedures does not include asking if one is in place. The AQAA said that staff have had training around adult protection. Training records seen confirm that most staff have had this training. During the SOFI observation and through the day the French doors to the conservatory were open because it was a hot, sunny day. Because they are next to the front door visitors and contractors were using it as the entrance and were not signing in or letting staff they were in the building. This could be a security risk to people living in the home. The support manager was made aware when feedback was given and said she would look at ways this could be dealt with. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean and tidy home. EVIDENCE: The home was clean and tidy and there were no smells. People said that their rooms were kept clean. They were happy with their rooms and it was clear that many of them had brought in their own belongings to make them more homely and ‘theirs’. One of the relative’s surveys said that ‘The home is clean, there are flowers in the general areas and every effort is made to make people feel as though it is their home.’ The provider carried out an audit of the home in June 2007. In their report they have identified where repairs are needed. They also said that plans were being made to upgrade the building generally. These plans include providing a walk/wheel in shower room that can be used by people of all abilities. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 20 In the large lounge some of the armchairs are heavily stained with food and drink spillages and need cleaning. The ceiling fan was being used as it was very hot and sunny on the day of the visit. However, the fans mechanism was rocking and looked unsafe. This was pointed out to a member of staff who said the fan was not normally used and turned it off. It must be checked to make sure it is in safe working order. The fire safety officer has been in contact with the providers and will arrange to meet them at the home to review progress made with work recommended at the last fire safety inspection. There had been agreements in place about making smaller fire compartments but this does not appear to have been done yet. Sheets and towels are sent out to a commercial laundry. Before they are sent they must be counted and put in special bags. Soiled linen is placed in water soluble red PVC bags and has to be washed and dried before it is sent. This means dirty laundry is tipped on the floor to be sorted and bagged which poses the risk of contamination and cross infection. The support manager was advised to look at this practice and make sure appropriate action is taken to reduce the risk. The movement of the heavy bags should also be risk assessed and appropriate action taken to protect people involved with this. The laundry floor has been painted to make it easier to wash and keep clean. There are now two washing machines with sluicing facilities. But only one of the two dryers is working. This can make it difficult to deal with all the laundry during the hours the laundry assistant works Monday to Friday. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are not always enough staff on duty to meet the needs of people living in the home and for the size and layout of the building. EVIDENCE: Information was received before the site visit about staffing levels being reduced, especially at night. A phone call to the home confirmed that two staff were on duty at night from 11pm to 7am for twenty seven people. There were concerns that two staff would not be able to meet the care needs of people as well as health and safety issues, especially with regards to safety in the event of a fire. A letter from CSCI detailing the concerns was sent to the provider on 1st August 2007. The fire safety officer was contacted and visited the home on 6th August 2007 to review fire safety and staffing levels at night. His findings were detailed in a letter to CSCI and the support manager. On the day of the site visit duty rotas looked at confirmed that two staff had been left on duty and an immediate requirement about staffing levels was left with the support manager to forward to the provider. A letter explaining the reasons why it had been made and what action they had to take as a result was sent to the provider on 10th August 2007. In response to this the provider has reviewed the situation and made provision for an extra member of staff to ‘sleep over’ and be available in the event of emergencies. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 22 Staff rotas showed that there were five staff on duty in the mornings and four in the afternoon/early evening. One of these would always be a trained nurse. Staff work extra shifts to make up numbers on the rota but information received said that at times this did not happen. Ancillary staff are employed for kitchen, cleaning and laundry duties but their hours are being rearranged and in some cases reduced. This means that at times care staff are taken away from their role to carry out these duties. This has been raised at previous inspections and requirements made. The provider must make sure that at all times there are enough staff on duty to meet the needs of people living in the home. Information from surveys returned to CSCI, staff surveys carried out by the home and looking at the minutes of staff and relatives meeting showed that there were concerns about the numbers of staff on duty and that the home was often ‘short staffed’. Comments from the relatives meeting included concerns about the lounge areas being left unattended for long periods of time. On the afternoon of the visit this happened and the inspector had to find staff to attend to somebody who was trying to get up from their chair unaided and was at risk of falling. Two staff files were looked at. They showed that all the necessary pre employment checks are being done. A newly appointed member of staff, who was visiting the home, said she was waiting for her criminal record bureau check to come through before she started work. In the meantime she was attending courses run by the company and was looking forward to joining the team. Information received from the provider before the inspection said that they had employed a training and development coordinator and training programme was being reviewed. This person was contacted before the inspection. They had attended training courses to enable them to present training and education sessions to staff. To further help with this they had attended ‘train the trainer’ courses such as moving and handling and basic food hygiene. They were very keen and committed to this role and were going to attend more courses relevant to the topics needed. A training audit had been carried out and plans were being put in place to make sure all staff had received appropriate training for the roles they were to perform. New staff are being provided with induction training equivalent to the Skills for care common induction standards and the organisation has invested in training books to support them. Six staff have achieved NVQ level 2 or higher. This amount of training for care staff is a positive step forward and must continue. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 23 As a result of the multi agency meetings about people who developed pressure sores and the issues identified around medication earlier in this report there is a question about the skills and competency of the nursing staff. The provider must make sure that they receive training appropriate to their roles and responsibilities and that they are aware at all times of their personal and professional responsibilities as set out in the Codes of Practice issued by the Nursing and Midwifery Council. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of a regular manager means that there has been no consistent leadership and guidance in the home. The management support systems put in place by the provider are helping to monitor outcomes for people living in the home and identify where improvements still need to be made. EVIDENCE: The home has not had a registered manager for the last year. The acting manager from the last inspection has chosen to be the deputy manager and the organisation is actively looking for a suitable person to take on the role and responsibilities of manager. At the meeting with the support manager on 16th August 2007 it was said that a suitable candidate had been found and it was hoped they would start work in six to eight weeks time. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 25 The providers have arranged for acting and temporary managers to run the home and provide guidance and leadership supported by the operations manager. In the last twelve months there has been an acting manager, a temporary manager and now the support manager. The lack of consistent leadership in the home has had an effect on the way services have been provided to people. Progress in meeting requirements made at previous inspections has been slow and few areas where improvements have been made were identified during this visit. The support manager had been at the home for four weeks and said that they were going to start auditing and monitoring the quality of services provided. They had been working with staff to review routines of working to make them more efficient, to look at how care was being provided to people and to improve the standard of records kept. The providers Quality File was looked at. This contains information such as the business plan, dates planned for quality audits and their outcomes when completed and copies of reports from other agencies such as the Environmental Health Department if they have visited. In June 2007 and audit against the National Minimum Standards for Care Homes for Older People identified where improvements needed to be made. Most of these areas had been identified and requirements made at previous CSCI inspections. A meeting for residents and their relatives was held in May 2007. The notes showed that some of the relatives were concerned about the staffing levels and poor social stimulation/lack of regular planned activities. Every six months a survey is carried out which asks residents and their relatives about their views of the services provided. The most recent was done in July 2007. The results had been summarised and presented in a graph, which was not easy to understand. It did not clearly show what people were happy or unhappy about and there was no detail about what action was going to be taken as a result of the survey. Information from the AQAA said that all required maintenance and safety checks of equipment and installations had been carried out but no dates were given. During the visit a carer was heard reminding somebody that their wedding ring had been given to the home to hold in safekeeping. The ring was found in a brown envelope in the safe but no receipt had been issued to the person as acknowledgement. Where valuables are given to staff for safe keeping a proper record must be kept of the item including the date it was handed over and details of who the item belongs to. A procedure must be introduced to make sure residents belongings are safe. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 26 Bedrails are used in the home but the records kept do not give enough detail about the type used, the fitting of the equipment and how often it will be checked, who is responsible for doing the checks and where the outcomes will be recorded. The risk assessments for using bedrails must also take into account individuals’ choice and consent to their use. If they are not able to do this their relatives or representatives must be involved with decisions made. The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 27 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 X X 2 The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 15 Requirement In order to make sure that peoples’ personal, social and healthcare needs are identified and met the care plans must be more detailed and informative. They must provide staff with clear guidance about how to meet individuals’ needs. The provider must make sure that all staff are aware of and follow the guidance in these plans. Timescales of 01/02/06 and 04/12/06 not met. The last timescale of 31/08/07 was not due at the time of the visit. It was agreed to extend this timescale. 2. OP8 12, 13 In order to make sure that people’s health care needs are met steps must be taken to make sure that appropriate professional advice and support is requested. For example the falls prevention team for people at risk of falling and the GP and dietician for people at risk of losing weight. DS0000019883.V344176.R01.S.doc Timescale for action 30/10/07 30/09/07 The Knoll Nursing Home Version 5.2 Page 29 Steps must be taken to make sure that if urine and blood samples are requested by healthcare professionals they are obtained and set to the appropriate surgery/hospital. In order to evidence that this is being done records must be kept. Records monitoring care provided such as changes of position, food and fluid intake must be kept up to date to show how the risks are being managed and that actions taken by staff. This will help to identify when further input from other health care professionals may be needed. Written agreements and consents must be in place when forms of restraint, such as the use of Kirton chairs are used. A thorough risk assessment must be carried out before considering their use. Timescales of 06/11/06 and 30/06/07 not been met. 3. OP9 13 In order to protect people and 30/09/07 make sure they are given medication as prescribed by their doctors the provider must make sure that safe systems are in place for the ordering, receiving, storing and administration of medications. The policies and procedures must be in line with the Royal Pharmaceutical Guidelines and reflect current good practice and legislatory requirements. Staff dealing with medication must receive appropriate, The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 30 certificated training. Timescales of 01/09/06 and 30/06/07 have not been met. 4. OP12 16 The registered provider must 30/12/07 make sure that residents are consulted about their social interests and a suitable programme of activities arranged for them. The needs and abilities of residents must be taken into account. The registered person must 30/12/07 make sure that after the meeting and visit with the fire safety officer happen any works recommended after are carried out within the timescales agreed with the fire safety officer. In order to prevent the risk of 30/09/07 cross infection steps must be taken to review the ways laundry is dealt with before it is bagged and sent out to the commercial laundry. In order to protect people and make sure that their health, safety and well being are maintained and their needs are met. The provider must make sure that there are enough staff on duty at all times. Peoples needs and dependency levels must be taken into account. Steps must be taken to make sure that care staff are not taken away from their caring roles to carry out domestic duties. 8. OP30 18 In order to make sure that staff are trained and competent to meet the needs of people living in the home the provider must DS0000019883.V344176.R01.S.doc 5. OP19 23 6. OP26 13 7. OP27 18 08/08/07 30/10/07 The Knoll Nursing Home Version 5.2 Page 31 make sure that the training programme is updated and developed. It must make sure that all staff, including qualified nurses, have the knowledge and skills to maintain the health, safety and well being of residents and themselves as well as training around specialist healthcare needs of residents such as dementia, stroke etc. The provider must make sure that the qualified nurses receive training appropriate to their roles and that they are aware at all times of their personal and professional responsibility and accountability as set out in the Codes of Practice issued by the Nursing and Midwifery Council. 9. RQN 24 In order to demonstrate how the quality of services provided to people will be improved and how the requirements detailed in this report will be met the provider must forward and improvement plan to the CSCI. In order to make sure that equipment in the home is being properly maintained the provider must inform CSCI of the dates when maintenance and safety checks were carried out. In order to maintain the health and safety of people who have been identified as needing bed rails, the provider must make sure that full and detailed risk assessments of why they are being used are carried out. The assessments must include what type is being used, how they are fitted, how often they are to be checked and who by. Records The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 32 30/09/07 10. OP38 13 and 17 30/09/07 must be kept. 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 OP1 Good Practice Recommendations In order to make sure that the information provided to people is clear and easy to understand the provider should review the Statement of Purpose and Service User Guide making sure that the information is in plain English and not repetitive. The document should: * Make it clear what types of peoples needs could be met by the numbers and skills of staff on duty. * When the home might have to say they cannot meet somebody’s needs or might need to ask a person to move elsewhere. For example if their behaviour and actions might place other people living in the home or staff at risk of injury. * What the homes policy is around escorting people to hospital for appointments and in emergencies. Abbreviations should not be used in the care plans or other records as it could lead to misunderstandings and peoples health care needs might not be met. In order to effectively monitor and audit accidents detailed records should be kept which provide clear information about what happened, who saw it happen, when the person was last seen and by who, what injuries were sustained, what action was taken and what the outcome was. In order to make sure that peoples social and leisure interests and needs are met the provider should make sure that residents are consulted about their social interests and a suitable programme of activities arranged for them. The needs and abilities of residents must be taken into account. 2. OP7 3. OP8 4. OP12 The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 33 5. OP15 In order to make sure that people receive their meals and hot drinks the provider should review practices around serving meals and drinks. In order to maintain good standards of hygiene in the kitchen the dishwasher should be repaired. 6. OP18 In order to protect people the provider should make sure that the adult protection policy and procedure complies with the Public Disclosure Act 1998, the Department of Health Guidance No Secrets and reflects the local authority adult protection procedures. Steps should be taken to make sure that all staff receive relevant and informative training that equips them with the knowledge to recognise abuse and act appropriately to protect residents. Steps should be taken to monitor people entering and leaving the building via the French doors of the conservatory. 7. OP33 In order to keep people informed about the outcomes of the quality assurance surveys the information should be presented in a way that can be easily understood and shows what action will be taken in response to answers and comments made. In order to make sure that the home will be managed effectively the provider should make sure that a suitably qualified and competent manager is appointed. In order to protect peoples valuables the provider should make sure that when items are taken into safekeeping written acknowledgement in the from of a receipt is issued to the individual. 8. OP31 9. OP35 The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Knoll Nursing Home DS0000019883.V344176.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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